Fundamental Differences

[Eidolon Faer]

*shrug*

If the person in the post is a genius / saint, it's a good thing.

If the person in the post is a politically-appointed twit whose head rattles when you grab him by the lapels and shake him, then not so much.

Which is more likely?

[Lurker]

he complained about Medicare chopping reimbursement rates for a particular lipid panel assay routinely given to measure Cholesterol for those with other cardiac risk factors (ie. typical Medicare patients). The shift was from ~$35 to ~$6.

That test takes 1-2 minutes to administer and costs $4. That's not an average cost either. So it doesn't fit your example of Medicare reimbursing less than the cost of the test.

Fallakin,
Bush appointed plenty of Czars, too. The difference is Obama is appointing people who are experts in their field. In any case, it wouldn't be a single person on the IMAC board making decisions about Medicare, and it's a world of improvement over having Congress directly control it like they do now.

[Eidolon Faer]

...fascinating. Source, please? There are a bunch of different lipid panels, done by multiple methodologies. The one he talked about was not a point-of-care 1-2 minute one. I believe it was done by Electrophoresis.

I figured that the average member of the audience wouldn't really be interested in me going all Lab Geek on you.

[Eidolon Faer]

Speaking of which, point-of-care testing is something which can be both extremely good and extremely bad, and the recent movement towards it is being driven almost exclusively by medicare reimbursement policies. (It means using instruments in the doctor's office or patient's bedside, rather than having a proper "Lab" do the tests. The blood sugar meters used by diabetic patients are one good example. Cost-per-test is usually MUCH higher, but it's consistent between institutions, so Medicare reimbursements are at least slightly sane.)

I just hope the nurse who maintains the instrument does so properly. Otherwise God only knows what the number that meter spits out really means.

[Lurker]

...fascinating. Source, please?

Well, the only lipid profile that fit your description and was reimbursed by Medicare for around $6 is CPT 82465. It's given with this device (pdf warning) and costs around $4 according to this profit calculator from the supply vendor.

We agree on the problem for the most part. I just don't think it's as severe as you do, and I think the solutions Obama is putting forward will go a long way to solving your complaint about Medicare and how care is delivered in general. He is making a point of looking to institutions that work, like the Mayo Clinic, as examples of what to do for Medicare and the system at large.

[Klast Brell]

...fascinating. Source, please?

Well, the only lipid profile that fit your description and was reimbursed by Medicare for around $6 is CPT 82465. It's given with this device (pdf warning) and costs around $4 according to this profit calculator from the supply vendor.

We agree on the problem for the most part. I just don't think it's as severe as you do, and I think the solutions Obama is putting forward will go a long way to solving your complaint about Medicare and how care is delivered in general. He is making a point of looking to institutions that work, like the Mayo Clinic, as examples of what to do for Medicare and the system at large.

(go ahead Eidolon. Finish slamming the door shut on the trap)

Anyway. I think I can see a problem with talking only about the cost of the test itself. The test may cost $4. Even if the test was $0.00 such as the cost of measuring your weight on a scale or measuring your heart rate by feeling the pulse with fingertips on the wrist. Even of it was $0.00 there will still be a cost. The wages of the nurse who takes your pulse. wages for the doctor who interprets the result. The secretary who takes makes your appointment and files your medical records. The billing clerk who processes the insurance paperwork. The electricity to keep the lights on in the exam room and the cost of the building itself. All these things have to be added to the cost of the procedure. When you are getting your car fixed you pay for parts and labor. This test is a $4 part. Medicare will pay $6 for parts and labor. Will 2 bucks be enough to cover all the other expenses of the clinic or hospital?

[Eidolon Faer]

Trap, Klast? This isn't about a trap. This just happens to be a topic I have some direct knowledge of, and I'm trying to give the people here a little appreciation of some of the issues that don't make it into the soundbites on CNN. I figure the audience here is probably bright enough and politically-interested enough to care.

I'll take a look at the .PDF later tonight, Lurker, and see if I can find it. It might not be called "Lipid Panel" exactly... This is a very detailed breakdown of your cholesterol that the doctor would order when trying to figure out exactly what medications you need when he KNOWS your cholesterol is already high from the cheap screening test you're talking about. There's a lot more to it than just Triglycerides, HDL and LDL.

Apparently Medicare's answer is "Throw them on a generic Statin drug, and if they die, they die."

[Partha]

And apparently yours (and the Repulicans') is 'If they can't get insurance, let them die.'

[Lurker]

I'll take a look at the .PDF later tonight, Lurker, and see if I can find it. It might not be called "Lipid Panel" exactly... This is a very detailed breakdown of your cholesterol that the doctor would order when trying to figure out exactly what medications you need when he KNOWS your cholesterol is already high from the cheap screening test you're talking about. There's a lot more to it than just Triglycerides, HDL and LDL.

See if you can get the CPT code for the test you are talking about. Like I said, the only test that fits your description and had a $6 reimbursement was CPT 82465. If you are talking about a more elaborate test then the reimbursement must be higher.

[Eidolon Faer]

Hmm...apparently I forgot about at least ONE member of the audience here. My apologies for describing you as "bright," Partha.

Medicare, as a program, has some serious structural flaws which closely parallel the "Wal-Mart is teh S474N!!!111" arguments we've seen on this board for nearly a decade now. Using it as the model for an even larger government program is begging for problems. THIS Republican understands it quite clearly, and wonders why it's such a challenging concept for the Democrats here to grasp.

This is not to say I would oppose any possible national health care initiatives, but I'd rather maintain the status quo than actively make problems worse. I want a GOOD proposal that gets people the insurance they need.

In fact, I suspect that implementation of the stuff the big players in the current debate are suggesting will require Medicare to be dismantled entirely and rebuilt from the ground up, on a totally new conceptual framework. I also suspect this is something that Congress lacks the political will to do, and Obama lacks the political capitol to enforce.

Finally, I suspect that several of the politicians know this, and have a "plan" of their own: Spend two years wasting time and money on junkets and debates, achieve nothing, and then blame it all on the nearest convenient scapegoat when they eventually declare failure.

But then, I dearly hope that history proves me wrong.

[Lurker]

Nobody is suggesting we use Medicare as it currently operates as a model for the public option, since reforming how Medicare operates is one of the major aims of reform. Hundreds of billions in trimmed Medicare waste and a panel empowered to make real changes to Medicare will be part of the final package.

[Eidolon Faer]

Lurker.

I took a look at the .PDF you linked.

That's a brochure for a point-of-care instrument used in a doctor's office. Not anything remotely like what I remember from the conference. Heck, it's a CLIA-waived test, which means a monkey can do it. Point of care testing is another fairly sticky can of worms that gets very detailed, and has both good and bad aspects.

A useful article for understanding just how Medicare reimbursements have been a game of Calvinball can be found here, from the CBO.

Considerable evidence suggests that a reduction in payment rates leads physicians to increase the volume and intensity of the services they perform. Although their participation rates are currently very high, CBO also expects that some physicians will probably respond to continuing reductions in payment rates by declining to participate in the Medicare program.

[Ddrak]

That's actually illegal. If you accept Medicare's lowball payment, you can't bill the patient for the same procedure.

That's broken then. Medicare should provide a payment level and the amount doctors charge should be independent of that. Obviously if they charge more then they'll get less customers so supply/demand fixes it all. It also gives an opportunity for private health care to offer more value-added services on top of Medicare.

Creating a Universal Health Care system will effectively kick that crutch out from under Medicare.

If what you say is true then that sounds like a great incentive to create a better Universal Health Care system. What would your model implementation of such a system be?

Dd

[Lurker]

That's a brochure for a point-of-care instrument used in a doctor's office. Not anything remotely like what I remember from the conference.

You'd need to get the CPT code. Like I said, there's only one procedure that fit your description and rate. It doesn't matter much though since we agree there's a problem.

Medicare should provide a payment level and the amount doctors charge should be independent of that. Obviously if they charge more then they'll get less customers so supply/demand fixes it all. It also gives an opportunity for private health care to offer more value-added services on top of Medicare.

Supply and demand wouldn't fix anything. People would just buy additional insurance. We'd end up with the exact same situation we have with private insurance now. Here's a good Nate Silver post about why standard economic rules don't apply to health care. It's about profit, but I think it applies.

[Ddrak]

Supply and demand wouldn't fix anything. People would just buy additional insurance. We'd end up with the exact same situation we have with private insurance now. Here's a good Nate Silver post about why standard economic rules don't apply to health care. It's about profit, but I think it applies.

That argument doesn't apply on several levels:

1. The marginal utility argument only comes into play when the cost exceeds the amount a person can afford in a single uncommon event. If you're talking about small marginal extra payments ranging from nothing to something under $100 then people will absolutely shop around and ask questions about what they are getting for the money outlaid over the prescribed benefit rate.

2. The "people won't notice because it comes out before you see your paycheck" argument doesn't apply because it's an out-of-pocket expense. These are very visible and result in people taking notice of what each component of the insurance does and doesn't pay.

3. The usual "it's a mandatory expense" argument doesn't apply as you are comparing different providers, some of which should be able to make a zero co-pay option available, giving people the option of treatment but probably at some lower level of convenience or comfort.

The point of being allowed to charge more than the prescribed rate is to allow competition between people who want to offer non-essential services above and beyond the basic essential medical treatments.

Dd

[Lurker]

The point of being allowed to charge more than the prescribed rate is to allow competition between people who want to offer non-essential services above and beyond the basic essential medical treatments.

We're discussing rates for the same procedures, not extra services. There's already a private insurance market to enhance Medicare for services that aren't covered.

Medicare reimbursement rates need to be fixed. The entire system needs to move away from fee-for-service. I don't think letting providers charge whatever they want is the way to accomplish that.

[Ddrak]

We're discussing rates for the same procedures, not extra services. There's already a private insurance market to enhance Medicare for services that aren't covered.

Medicare reimbursement rates need to be fixed. The entire system needs to move away from fee-for-service. I don't think letting providers charge whatever they want is the way to accomplish that.

The same procedure doesn't mean the same level of service in performing that procedure. If you want to have the doctor come to you then I think the doctor has the right to charge extra despite it being the same procedure. If you want a private room for procedures that require hospitalization then I think the hospital has the right to charge more than a shared room. If you want your choice of doctor I think you can run the risk of having to pay more than the prescribed rebate and end up a little out of pocket. If you want 3 nurses looking after you while you munch caviar while the procedure is carried out then you can probably expect to pay more too.

The socialized part of the system should have fixed rebates. That's a low mark for the service fee. Making it illegal to charge more and have the patient pay the difference makes absolutely no sense. There's no good economic reason to restrict things in that way.

Similarly, moving away from fee-for-service seems broken to me (if I understand what you are saying). Heath care providers should not have their income dictated by a government because it discourages any of the natural competition and striving for excellence to attract the higher paying customers. Enforcing mediocrity in your health care system is a great way to grind it into the dirt. Right now only the insurance side is broken - breaking the actual care side to fix it isn't a good trade.

Dd

[Lurker]

Shared room vs. private room or multiple nurses feeding caviar isn't a procedure. It's a different service. Medicare or private insurance might only cover shared rooms and you'd have to pay more for coverage that allowed private rooms. I have no problem with that, but it isn't what's being discussed. We're talking about the rates for procedure 'x', whether that's a blood test or an x-ray or having your appendix removed.

You aren't understanding the argument against fee-for-service. Like the Mayo Clinic does, doctors should be paid for results, not for how many procedures they perform. You'd reward doctors and hospitals that had better results at lower costs. That wouldn't lower quality of care at all.

[Fallakin Kuvari]

Because so many people in hospitals have multiple nurses feeding them caviar...

[Lurker]

Take it up with Ddrak. It was his example.