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POLICY: Kinsley–Good grief! (with UPDATE)

Supposed voice of liberal moderation Michael Kinsely is out with a Washington Post op-ed called Before We Go ‘Single Payer’ which is just staggering. I thought Arnold Kling was bad in his misunderstandings, but I apologize to the libertarians on this one. Kinsley’s piece just doesn’t make sense, which indicates to me that he doesn’t understand what he’s talking about.

He accuses Krugman and Wells of ducking the rationing issue — they don’t. Instead they say it can be delayed by cutting out some administrative costs, but it will come in the end. You may not buy that argument, but it is a proven fact that admin costs are lower in single payer nations than they are here. Check the CMS cost data if you don’t believe me.

But then he wonders off into absurdity.

But anyone is insurable at some price — a price that reflects the cost he or she is likely to impose on the insurer. Adverse selection is only a problem to the extent that insurance is not really insurance but rather a subsidy.

Frankly I have no idea what he’s talking about with this “subsidy” stuff. If he means that some people pay more in premiums than they receive in benefits and some pay less, then that’s what insurance is. But I have a simple way of correcting his notion that everyone is insurable at a price. Let’s give Kinsely a pre-existing condition, and send him out into the individual market. He’ll change his tune faster than Mark Pauly wold under the same circumstances.

And then he seems to have missed the whole concept of the debate on the political left between the Enthovenistas/voucher crowd and the single payers. And most importantly that no one seriously thinks Americans won’t be allowed to trade up to a better class of waiting room with their own money.

The problem is putting in a floor for everyone, not getting rid of the ceiling — that’ll come naturally once everyone’s in the same system.

Nowhere does he mention the one thing that is necessary for fixing health care — the imposition of some type of mandatory universal insurance system. Something that everyone in the voucher v single payer argument realizes is essential. And however it happens that is not “incremental change”.

(Trap, you can use this as a thread to beat up on Kinsely, Krugman me et al)

UPDATE: Meanwhile a (gasp) Republican, although not one in the good graces of the loonies running the country any more, has some ideas that are at least getting at (some of) the problem and mention the "mandatory" word. Here’s what Paul O’Neill said:

Mr. O’Neill has long argued that addressing health care with tax
incentives is an inadequate approach. "When they’re talking about tax credits,
they’re talking about our money, not their money," he said in a phone interview
last night. "When you use tax credits and deductions, unless they are
refundable, … they’re very inequitable, because the value of the credit or
deduction depends on the level of income or wealth accumulation an individual
has."Mr. O’Neill said Congress should pass a law requiring all Americans
who make more than $30,000 a year to purchase catastrophic health care coverage
for themselves and their families, with fewer deductibles and co-insurance
payments. The government would then use general revenue funds to purchase health
insurance coverage for lower-income people, he said.

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John FembupG. Hinson, MDjsh26eric Novackspike Recent comment authors
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John Fembup
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John Fembup

Tom
“I don’t know what I want to see, but what we got ain’t working so well for anybody.”
My conclusion too.

John Fembup
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John Fembup

“I don’t have time to lead an inquiry. I’m too busy trying to get paid” Sorta what I’ve been saying in general, and you seem to agree. Docs have not taken the time to lead on this issue. Docs have taken the time to oppose change whenever they felt it threatened their income (money) or autonomy (power) – there are no angels here. Still, the country needs much more from its physicians on this issue. I really don’t want government policy wonks and academics making the decisions. I really do expect leadership from physicians. But they don’t have time. So… Read more »

Tom Leith
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Tom Leith

Greg, You are in a very tough spot. I understand why that “all cash” approach is so attractive. > she (i.e., her company) would not stay in business if > they had to put up with the crap we do! They have to put up with just about all of it. Their customers take deductions off invoices for reasons they simply invent, or for no reason at all. They pay late. The argue over the bills, everything you describe. Lately the government has added a number of tracking an reporting requirements, and they have added a person just to take… Read more »

G. Hinson, MD
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G. Hinson, MD

John, “Physicians who should be leading the inquiry on this whole subject have largely chosen instead to complain that their charges have not increased and tend to blame the insurance companies for that.” I don’t have time to lead an inquiry. I’m too busy trying to get paid for a physical I began billing 3 months ago. And you have not heard me complain about my charges or contracted allowables. I even said that I thought some were too high. Reimbursement rates, though stagnant, are fine. It’s the increasing overhead necessary to SIMPLY GET THE CHECKS that is killing me.… Read more »

John Fembup
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John Fembup

“Having heard what happens between PCPs and claims processors, maybe you can help do something about it!” Tom, my company has negotiated a range of perfmormance guarantees with our ASO administrators. We receive monthly reports that show 97% of claims are paid within 30 days. Also that the accuracy of payments and compliance with our plan design are above 99%. Also that there is a minimum of claims pended to avoid the 30-day report. A long list of performance criteria. Once a year we engage an outside auditor to determine whether the actual performance matches the reported performance. For the… Read more »

John Fembup
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John Fembup

Dear Dr Hinson, You say that – my charges have not increased in 4.5 years and you say – I see 20-30% more people per day now than I did 4 years ago. Then your income has risen – the amount that you charge to the insurance companies, I mean. Your defensiveness on this point illustrates something that I stated before. Physicians who should be leading the inquiry on this whole subject have largely chosen instead to complain that their charges have not increased and tend to blame the insurance companies for that. In my opinion insurance companies are increasingly… Read more »

Tom Leith
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Tom Leith

So John — Having heard what happens between PCPs and claims processors, maybe you can help do something about it! Suppose you survey the docs you are paying through your ASO contractor about their satisfaction with you as a payer? You can begin to develop performance standards for your ASO contracts to keep the doctors of your employees happy, so your employees stay happy. I had an idea I posted in a comment over here about a way to mitigate the problem of the battling paperwork while still insisting it be done. Could you get your ASOs to do something… Read more »

Tom Leith
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Tom Leith

> Regarding healthcare provider reimbursement, my > charges have not increased in 4.5 years (because > my insurance contracts have still not caught up > with them, so why should I increase just to punish > those without insurance). Can’t you engage in a little first-class price discrimination, and accept less from your self-pays whom you are convinced can’t reasonably pay you $64? You do not “punish” anyone by asking to be fairly paid. In a sense, the patient’s financing mechanism is beside the point — plumbers do not think they “punish” people who don’t have a new home warranty,… Read more »

Tom Leith
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Tom Leith

> They profit by more by obfuscating the whole process. I think I see where you are going — you are saying that in their apparent refusal to have a transparent claims adjudication process, they refuse to standardize or cooperate with you, that all the standardization that has occurred has been one-way, and for their convenience. You say further that through this refusal, the insurance industry profits unjustly. Insurers will counter that a transparent adjudication process is open to gaming, and there is all kinds of evidence that they are being gamed by patients and by providers sometimes cooperating with… Read more »

G. Hinson, MD
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G. Hinson, MD

Regarding healthcare provider reimbursement, my charges have not increased in 4.5 years (because my insurance contracts have still not caught up with them, so why should I increase just to punish those without insurance). I see 20-30% more people per day now than I did 4 years ago. I have the same personnel (though at increasing costs), pay the same rent, buy the same supplies, am dealing with malpractice insurance costs that are 200% higher but should be covered by the added number of people I am seeing, and otherwise have taken home less money each year for these past… Read more »

John Fembup
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John Fembup

“The health insurance industry has NO MOTIVATION to simplify their system. Doing so would mean that many of those charged with the simplification would lose their jobs. Doing so would decrease their profits. They profit by more by obfuscating the whole process.” Doc, you’re probably a nice guy and a good doctor, but you are so busted on this issue. 1. Insurance companies do compete and have invested enormous amounts over the past 20+ years in their infrastructure and operations to deliver benefits at lower cost than their competitors. Their principal investment has been in so-called managed care – which… Read more »

G. Hinson, MD
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G. Hinson, MD

Real examples, right from my practice. If you are a 45 year old male with a family history of heart disease you need to know you lipid levels. I order and submit charges for 80061, Lipid Profile. I give the diagnoses V17.3 (family history of heart disease) as the reason for the test. The charges are denied. When the patient is then billed for the amount, thinking the insurance company must’ve made a mistake, they call their insurer and the rep says, “This was not covered because your doctor used a ‘routine’ code as the reason for the test. He… Read more »

Tom Leith
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Tom Leith

> The profit-driven insurance industry controls > the money and they do not want us to cooperate > and standardize. Nonsense. This is just nonsense. I don’t even know where to start. X12.n. EBM. Pathways. DRG. Any kind of outcome reporting at all. Coding and vocabularies generally. The HMO/PPO experiment (before it was made essentially illegal and became corrupt; yes in that order). Standardized billing. CDSS. Electronic prescribing and now ordering generally. Take your pick. All driven by the profit-driven insurance industry. Invented sometimes by pure-as-the-wind-driven-snow physicians, and thank God for them, but adoption has been DRIVEN by the evil… Read more »

G. Hinson, MD
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G. Hinson, MD

quote: “The healthcare industry will cooperate and standardize when forced to by the people who control the money.”
The profit-driven insurance industry controls the money and they do not want us to cooperate and standardize. They’re profits depend on waste and red-tape and keeping healthcare providers, not good health or cost efficiency.

Tom Leith
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Tom Leith

Trap said that Kinsley meant (or something): > the adversity of adverse selection in health insurance > is tied to wealth transfers. In other words, adverse > selection is a particularly heinous economic problem > in health insurance markets because we are blending > two policy problems and drinking them at once: “how > to pay for medicine” and “who should pay for paying > for medicine”. How in the world to you get this out of Kinsley?!? Adverse selection (not that I think Kinsley understands it) is adverse because it is fraudulent. Wealth is transferred by this fraud, true… Read more »