The Business of Health Care

Monopoly Anyone? The Battle To Control Health Care

Like children gathered around a card table, America’s special interests are engaged in a high stakes game of Monopoly. But the winner of this game gets more than a day or two of bragging rights; this time the spoils are nothing less than control of our health care delivery system for the foreseeable future.

Let’s meet the players: on one side, Big Medicine; across the table, Big Insurance; and between them, Big Government. There’s room at the table for a 4th player…but we’ll get to that later.

Introducing Big Medicine

To compete in this high-stakes game, Big Medicine is reforming itself into large, multi-disciplinary organizations. Independent hospitals are merging into hospital systems. Hospitals and doctors are coming together as self-regulating Accountable Care Organizations (ACOs).

Big Medicine’s path to victory relies on persuasion: “Who knows more about health than the professionals? Then who better to manage healthcare delivery? Government regulation and insurance carrier interference are unnecessary and actually counter-productive, so their argument goes.

But this is the very same thinking that got us into this mess in the first place. Before managed care burst on the scene 40 years ago, 40 percent of American women were undergoing hysterectomies but less than one in ten of those procedures was medically necessary. Medical self-management gave us the spiraling healthcare costs and mediocre quality of care that we are trying to fix today.

Meet Big Insurance

Perhaps Big Insurance would be a more worthy winner. After all, back in the late 80s and early 90s, it was the insurance industry that put the brakes on Medicine’s reckless over-treatment (and over-billing) of patients.

Unlike Big Medicine, the insurance industry is not relying on persuasion to win this game: its weapon of choice is economic clout. The giant, double-digit rate increases of the past two years have put this player in a catbird’s seat.

Insurance carriers are already administering government money through the Medicare Advantage Program and they are likely to dominate the government-sponsored health care exchanges mandated by last year’s health care reform legislation.

But letting insurance carriers manage care is just another old idea in new clothing. As much as medicine failed to self-regulate, regulation by bean counters proved no better. The unconscionable rationing of care by 1990’s HMOs spurred a popular revolt that culminated in the Oscar winning film, As Good as it Gets.

Hello Big Government

Last, but by no means least, comes Big Government. This player may be gobbling up more properties these days than the other two players combined. Not only have we passed health care reform legislation on the federal level, but there are similar reform initiatives percolating in nearly every state. Hawaii already has a single-payer system and Vermont may not be far behind.

Under health care reform, government forces companies to offer benefits, requires individuals to buy benefits, defines how benefit plans are designed and stipulates what benefits they deliver. In the coming years, a steadily increasing percentage of pre-retirement Americans will be dependent on government subsidies for their health benefits; and by 2014, every state will have a government mandated insurance exchange. It’s a good time to be Big Government.

To win this game, Big Government is not content just to use its power to legislate, tax and enforce. Government is also working to choke off the other players’ oxygen supply. Doctors’ fees are to be cut. Insurers’ margins are to be capped. Once cash strapped, these two players may drop out of the game and forfeit their properties…to Big Government.

It is hard to love any of the players at this Monopoly board.

Presenting the Patient

But wait! One side of the table is still empty. There is room for another player. “How about the consumer? After all, it is the plan member who gets sick (or doesn’t) and who gets well again (or doesn’t). Consumers want access, they want quality and they want value. A win by the consumer would be a win for everyone. Surely, this player should have a seat at the table.

But alas, this is still one more idea that has been tried and found wanting. The Consumer Directed Health Care (CDHC) movement of the last decade showed promise, but in the end, consumers were not powerful enough to stand up to the machinations of the other players. Medicine refused to grant consumers the transparency needed for value-based decision making; Insurance turned CDHC into a massive cost-shifting scheme and Government is working feverishly to stifle consumer choice by forcing everyone into cookie-cutter plan designs.

The Player of the Hour

Despite its ultimate failure, Consumer Directed Health Care was a step in the right direction. Unfortunately, the individual plan member was not strong enough to stand up to the behemoths in the room. Consumerism could still work but the consumer needs a more powerful advocate!

Who could represent the plan member at the table? The private sector employer! The employer’s interests are perfectly aligned with the member’s. The employer wants its plan members to be healthy and wants to achieve that in the most efficient way. After all, employers still pick up most of the tab for working Americans’ healthcare and the employer suffers the greatest economic harm when an employee is absent from work or works unproductively due to poor health. Only the employer has incentive to make sure employees have access to the best possible care at the best possible price…and the economic clout to make it happen!

So where is the employer? Why isn’t the employer at the table already? Over the past decade, the employer community has endured a withering assault from Big Government and Big Insurance. And it’s taken its toll. So much so that today’s conventional wisdom holds that the era of employment-based health benefits is coming to an end. The truth is that the percentage of working Americans who enjoy employment-based health benefits has declined slightly in recent years.

But is it any wonder? The policies of Big Medicine, Big Insurance and Big Government have driven the price of conventional health insurance beyond the reach of many small employers. At the same time, these same players have systematically sabotaged the employer community’s efforts to control cost through creative benefit funding strategies.

For example: states continually impose additional expensive benefit mandates and last year the federal government joined the pig pile with Mental Health Parity. Those states with some version of health care reform have limited the range of plan designs available to employers and if federal health care reform takes effect in 2014 as planned, virtually all opportunity for plan design creativity will disappear.

Surprisingly though, Big Government is not the biggest culprit here; it’s Big Insurance. A few years back, many employers began to take control of their benefit budgets by buying high deductible, low premium insurance policies and making up the difference with Gap Plans, Wrap Plans, Health Reimbursement Arrangements (HRA’s) and Health Savings Accounts (HSA’s.) The result was richer benefits for plan members and lower costs for plan sponsors.

But this strategy also resulted in less premium income for the insurance carriers and Big Insurance struck back. Carriers began refusing to issue policies to companies unless they promised to rely exclusively (or at least primarily) on traditional insurance to fund their employees’ health benefits. The use of creative funding strategies has been severely curtailed.

As a result, employers now have just two choices: buy a high cost, cookie cutter plan from an insurance carrier or buy a lower cost plan and shift claims cost onto plan members. Economics has forced many employers to choose the latter option and the resulting redistribution of cost has further fueled cries that the employer-based system is broken.

And broken it is. But broken by design, not necessity.

Big Medicine, Big Insurance and Big Government offer three different paths to the same disastrous destination: uncontrolled inflation followed by severe rationing of care. Big Bang followed by Big Crunch. And in the end, we will be left with nothing that resembles the health care universe we know today.

A Way Forward

The only way to escape this increasingly inevitable fate is to empower the consumer through the agency of the employer. The employer, and only the employer, is in a position to deliver wellness information and services to plan members and to represent those members’ interests in the political and economic arena. Here are a few additional recommendations:
.

  • Insurance carriers must cease their efforts to limit employer- sponsored benefit supplements.  Government needs to eliminate all restrictions on employers’ plan design creativity.
  • Anti-trust laws need to be relaxed to allow companies to share data and cooperate in joint wellness and quality-of-care programs.
  • And hospitals and medical practices need to cooperate with employer-based quality-of-care initiatives and suspend any policies that discriminate against non-traditional claims payers in favor of large insurance carriers.

If we can achieve consensus on just these few policy changes, we will be well on our way to restoring the centrality of the employer in the health benefit process and we may then yet hope to see our game of Monopoly end happily…with no monopoly at all!

David Cowles is a founding Partner and the current Executive Vice-President of Benemax, an innovative benefit management firm in Mefield, MA. He is primarily responsible for new product development.

This post first appeared at Health Affairs Blog on 09/06/2011. Copyright ©2010Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

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137 replies »

  1. You know what Nate, your comment above, “They wouldn’t need PR nor to worry about bad press if people weren’t taking shots at them for political gain. The employer did nothing wring nor anything heartless. They did what they had to do to run their business.”, is about as pure capitalistic and devoid of heart and concern as it comes to prove my point why profit has no place in health care. And I do not expect you to say anything else but more of the same from your replies. I respect you do not want PPACA to succeed, but not for any parallel reasons that I support, but, the enemy of my enemy is my friend.

    I just hope to succeed from your union if the Supreme Court can put this garbage where it belongs in 2012. It is a tenuous union for now.

    And I have no idea how to interpret that last comment: “In doctors defence how do you make a profit off a $12 office visit, no wonder they have no clue what profit is.”

    Me don’t speaka your english.

  2. “California, which already pays Medi-Cal providers less than all but two states, also is pushing to cut payments to doctors, hospitals and others who serve Medi-Cal patients by 10%. That would drop reimbursement for a standard physician visit to less than $12.”

    In doctors defence how do you make a profit off a $12 office visit, no wonder they have no clue what profit is.

  3. “I’m not aware of any companies that have gone out of business as the result of being in compliance with FMLA.”

    Wouldn’t that be becuase small companies that can not afford to comply with it are not required to? Like or dislike the law as written it is workable for business. You can argue could a 45 life company comply, maybe, but does anyone out there think a 3 employee company could comply? In some states you can’t fire the replacement just becuase the person on FMLA came back.

  4. Determined, Let’s be clear on accounting terminology. Assuming you account for your practice on a cash basis, what’s left from revenue, after deducting operating expenses (including rent, salaries, wages, etc. and your draw), is profit.

    What you do with this profit is up to you. You can withdraw it, reinvest it in your practice, pay off loans, or distribute it as dividends. Whatever you do, it NEVER is operating costs.

    What is important to understand, is that without profits, you cannot do any of these things and your practice will rapidly collapse. Many doctors are in this situation today. They haven’t generated profits and, as a result, don’t have the capital to reinvest in their practices and can’t afford the expensive EMR systems Uncle Sam is requiring. So they are selling out to hospitals. The irony, of course, is that most hospitals aren’t any stronger financially than the practices they are buying. They’re just bigger! And unless they generate profits (non-profits call them something else but they amount to the same thing), they will suffer the same fate. They’ll either be acquired or go out of business.

    Does any of this sound familiar? How many of your friends have been forced to sell their practices? How many hospitals you know have been forced to merge, or have closed? That’s what inevitably happens when you don’t make a profit! If you still think profit is a dirty word, you’d better think again!

  5. My conclusion from this thread is that John Ballard is a very smart person.

    There seems to be a genuine misunderstanding of the difference between profit and compensation. I don’t know what else to say…..

  6. “maybe FMLA needs to be redefined, so it wouldn’t put companies at risk for long stays out of work.”

    It doesn’t need redefined its already defined so that companies to small to absorb an employee out on extended leave do not need to comply with the law.

    They wouldn’t need PR nor to worry about bad press if people weren’t taking shots at them for political gain. The employer did nothing wring nor anything heartless. They did what they had to do to run their business.

  7. FMLA was adopted in 1993 during Clinton’s first term. Prior to that no such protection existed. The legislation, as the cited article says, does not apply to small companies. I’m not aware of any companies that have gone out of business as the result of being in compliance with FMLA.

    Then, as now, our two parties were divided along the same lines, with Republicans mostly opposed and Democrats in favor of the new legislation.

    http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=103&session=1&vote=00011

    http://clerk.house.gov/evs/1993/roll022.xml

    The outcome of the case was completely legal. The employer was legally in the right but not necessarily right in the compassionate sense of the word. Just another illustration of how legality and morality are often not congruent.

  8. I expected someone else to reply, but since you ask Nate, and I came back rather foolishly looking for mayhem to be in the thread, I’ll be the hypocrite and answer:

    First of all, maybe FMLA needs to be redefined, so it wouldn’t put companies at risk for long stays out of work. Second of all, how many employees out of work legitimately as compared to the total work force would define the risk of company failure. And third, isn’t PR with handling of employee matters somewhat of a boost to a company when people hear the management, wait for it, has at least a bit of a heart?

    By the way, I’ll risk sounding a bit petty as our antagonist continues to be and ask you, if you write a short reply, can’t you review it and make some spelling corrections to give it some sense of respect and consideration in presenting?

    Good luck with the thread hereon, I have to move on to other fresher posts and other sites with exciting positions on health matters, not just politics and pontificating as usual here!

    End-Jouy!

  9. Are you suggesting the company should just go out of business instead so everyone loses their job? How is a small business suppose to hold a position if they have no one else to do the work?

    Give a praticle answer to how this sitution should have been handled.

  10. Here is your poster child for why there is never a place for profit in health care:

    http://www.myfoxphilly.com/dpp/news/local_news/lawyer-explains-how-donor-was-fired-091311

    And I link the story how a lawyer defends why the company had legitimate rights to fire the woman. For spending time with her terminally ill mother, then donating a kidney to her son. Ok, if it comes out the woman lied and used the most disgusting false excuses to get out of work, then fine, she deserves to be fired. But, not reading that anywhere thus far.

    And I am glad to see a lawyer defend this disgusting mind set of the company’s needs come first irregardless of situations with employees. This is why you all better reconsider letting politicians, who how ironic are mostly lawyers in their day jobs, set up disgusting legislation like PPACA, thus having no business setting policy in health care.

    All I can say to finish my last comment here at this thread is this: anyone who comes on and echoes that the company was completely in the right for firing the woman if her reasons are completely true and accurate, I have two words for such defenders, the first starts with an “F” and the second ends with a “u”. You know what I mean! Yeah, harsh, I get it!!!

    And by the way, Merle Bushkin, your last paragraph about reinvesting the funds into the practice does not make such funds “profit” from a business point of view, it makes them operating costs. Maybe you should reacquaint yourself with this GAAP you spoke of in an earlier comment. Not that you are wrong in the suggestion, but, it seems to take the air out of your premise that profit belongs in health care.

    Tell me how many Fortune 500 companies put more than 50% of their profits back into their systems each year. We’ll understand when you finally get back to us with at least 10 names legitimately. Read about it next week at least!?

    Just remember your math, 10 of 500 is 2%. Not even random chance numbers!!! Profit in health care. Tell that to the woman fired. Or better yet, to her son she hopefully saved.

    As I wrote years ago in a piece about insurance companies destroying health care in their for-profit models, if you want to make money, invest in oil, not blood!!!!

  11. “Rebuttal”? Wasn’t intended a rebuttal, just an inferential observation.

    What, precisely, is YOUR vision for the health care space. Or you simply chronically angry at everything and with everyone?

  12. Determined and Margalit, You are two smart people but, for the life of me I can’t understand your inability to grasp the importance of running medical practices, hospitals and healthcare services, in general, in a business-like manner. I’m not suggesting that business people decide the forms of treatment or care patients receive. But I am saying that healthcare cannot prosper unless its institutions are run in a business-like way. They simply must take in more than they pay out or they will fail!

    We can’t afford to continue our system as is. It will bankrupt our country! And the solution isn’t Medicare-for-all because it will end the same way. Neither the government nor us taxpayers have enough money!

    Like it or not, doctors have to understand the business aspects of their practices and hospitals, and the costs of services they prescribe for their patients. And they have to generate sufficient profits (the funds left after they cover their costs and pay themselves reasonable compensation) to reinvest in their practices/hospitals for new equipment, record systems, etc. — or they will be out of business. Period. And no matter how well intentioned and highly motivated they are, they will be out of business and out of medicine. Is that what you want? I don’t think so.

  13. Determined and Margalit, You are two smart people but, for the life of me I can’t understand your inability to grasp the importance of running medical practices, hospitals and healthcare services, in general, in a business-like manner. I’m not suggesting that business people decide the forms of treatment or care patients receive. But I am saying that healthcare cannot prosper unless its institutions are run in a business-like way. They simply must take in more than they pay out or they will fail!

    We can’t afford to continue our system as is. It will bankrupt our country! And the solution isn’t Medicare-for-all because it will end the same way. Neither the government nor us taxpayers have enough money!

    Like it or not, doctors have to understand the business aspects of their practices and hospitals, and the costs of services they prescribe for their patients. And they have to generate sufficient profits (the funds left after they cover their costs and pay themselves reasonable compensation) to reinvest in their practices/hospitals for new equipment, record systems, etc. — or they will be out of business. Period. And no matter how well intentioned and highly motivated they are, they will not be out of business and out of medicine. Is that what you want? I don’t think so.

  14. Margalit what do you think happens when you remove the profit motive, do you think there are no negative effects. Access to care drops. New innovation drops. Why would a doctor open an extended hour clinic in a rural community if he can’t make a profit. They don’t open the clinic, the community has less access, and care suffers.

    You ignore all the positive drivers of profit.

  15. it’s typical Maggie quality work, what’s not to love. Another shining example of what happens when people that don’t understand healthcare pontificate and legislate healthcare.

    It will be the first of many errors proven that she made but the savings in Appendix A have already been discredited by live data. The OTC change actually increased cost. Instead of people paying for their OTC items post tax like the bill envisioned they have ran to their doctor in hordes to get prescriptions for OTC items. Not only has the tax savings not been realized but now we are wasting money on office visits so employees can avoid a tax.

    http://www.naifa.org/advocacy/govtalk/2011/July1911/govtalk7.html

    Bipartisan bills introduced in the House of Representatives (H.R. 2529) and Senate (S. 1368) would reverse a provision in the health care reform law that now requires people to get prescriptions for over-the-counter medications to qualify for reimbursement from tax-exempt health savings accounts or flexible spending arrangements.
    NAIFA has long argued that this requirement was counterproductive and supports the effort to repeal it. The original measure was supposed to lower costs by discouraging people from buying unneeded medicines. However, NAIFA predicted when the measure was first proposed that it would actually increase costs, because patients would end up consulting their doctors for minor ailments they had previously managed themselves. According to media reports, this has indeed been the case, and doctors have begun to complain that they are seeing patients who schedule appointments solely for the purpose of getting prescriptions for OTC remedies.
    The legislation that would remove the prescription requirement was introduced by Sens. Ben Nelson (D-NE) and Pat Roberts (R-KS) and Reps. Lynn Jenkins (R-KS) and Shelley Berkley (D-NV). The bill is picking up more co-sponsors – check NAIFA’s Legislative Action Center to see if your Senators or Representative have signed on too.

    What a shock Maggie and the Liberals blew another one. So if we already know for a fact CBO scored this 5 billion wrong then we already know for a fact reform won’t save 210 billion like you claimed. Always the same outcome with liberal reform, usually not this quick.

  16. Is that the same CBO required by law to score bills as told by the politician trying to sell it?

    i.e. if ObamaCare claims Leprechauns are going to visit every time there is a rainbow and leave behind $100 billion to be applied to the cost of the bill CBO must score it as such.

    In fact when was the last time CBO got an estimate right, or to be fair to CBO when was the last time a bill scored as legally required was correct? Its not CBOs fault the politicians tying to pass legislation mack a mockery of acturial analysis but they do.

  17. Special link. Hot off the press.
    35 Pages (pdf)
    Just because I love everyone here.

    The Congressional Budget Office has concluded that the Affordable Care Act (ACA), signed into law by President Barack Obama in the spring of 2010, will more than pay for itself, provide coverage for 32 million uninsured Americans, and trim federal budget deficits by some $210 billion over the ten years ending in 2021. In this issue brief, Maggie Mahar synthesizes the relevant numbers and offers in-depth analysis of exactly how the ACA will both strengthen health insurance protections and save money.

    http://tcf.org/publications/2011/9/better-care-for-less-how-the-affordable-care-act-pays-for-itself-and-cuts-the-deficit

  18. You can probably have a decent profit driven agenda that provides most people with mostly good health care, most of the time.
    While this is lovely for selling whole wheat cereal and laptop computers, it is not an acceptable model for health care, because it is neither sound nor responsible, not to mention ethical.

  19. Your rebuttal is Physicians for National Health Program? They would not want a profit oriented system in place either, but, I once was a member and they are not grounded in the realities of the logistics of implementing National Health Care in America. Nice try though.

  20. What, so we can master principles from a sole business point of view?

    I have talked to people with a strong business backround who are grounded and realistic, and they basically say what I have said, business priniciples cannot be applied to the dynamics of health care.

    Face it, you cannot have a profit driven agenda and provide sound, responsible health care. They are eventually incongruent. Again, explain the point of capitated care before it was rejected back in the 1990’s.

    Hmm, maybe it is all those dead bodies who suffered from this heartless agenda the defenders are stumbling over to try to get to the podium!

    Yeah, I am not a nice person about this matter.

  21. 250…sounds like a nice arbitrary number chosen to make a point and not for its accepted standard or commonality.

    How do we have a Small Business Administration that goes up to 500, 1000 or higher depending on industry?

    Wouldn’t a large business in a nation of 1 million be smaller then a large business in a nation of 300 million?

    your other link is to twitter but doesn’t work.

    you link to some academics pushing governemnt healthcare which cherry pic stats. Read the report, there are more ifs and buts in the OCED data then I could count.

    The legal definition of “small” varies by country and by industry, ranging from fewer than 15 employees under the Australian Fair Work Act 2009, 50 employees in the European Union,[2] and fewer than 500 employees to qualify for many U.S. Small Business Administration programs.[2]

  22. Oops, made another typo. It’s the Bordeaux and the fact that I’m watching the Tea Party debate on CNN in an EyeTV window while typing. Must be more careful.

    Lay into me, Nate.

  23. “why do you bother pointing out typing and spelling errors?”
    ___

    Nate, che care you take with your composition is a reflection of the care you take with your views. That’s all.

    Just my opinion, of course.

    DMD:

    “Being sarcastic with the spelling issues is just that, sarcastic.”

    Just your opinion, of course.

  24. Those of you arguing the merits of profits in medicine might be interested in two articles from the NY Times last week, both of which relate to the need for doctors to understand how to run a business:

    http://www.nytimes.com/2011/09/06/business/doctors-discover-the-benefits-of-business-school.html?_r=1&ref=health

    http://www.nytimes.com/2011/09/08/business/smallbusiness/medical-practices-keep-eye-on-the-business-side.html?pagewanted=2&ref=health

    It also would help if you were familiar with Generally Accepted Accounting Principles (GAAP accounting) — not to become accountants but, rather, to be able to intelligently discuss the simple concepts of costs and profits.

  25. Some people just think their twisted interpretations and expectations are the gospel and to be revered. It’s the basis of narcissism and having the world view through a pin whole.

    And they think they are cute and protected from consequences or challenges just because they don’t use names, just those dumbass hyphenated terms like “lol” or “IMHO”. Being sarcastic with the spelling issues is just that, sarcastic. But, enjoy the pin hole view. Notice the view is fairly limited though.

    Just like the opinions!

  26. it ignores the point of why bring them up in the first place? What does typing or spelling errors have to do with an argument? If the constitution was riddled with spelling errors does that make it any less of an important document? If The Odyssey was full of spelling errors does it make it less profound of a piece of work?

    So back to the question, why do you bother pointing out typing and spelling errors? Is that your only argument in support of what you believe? Your ideas are weak and flawed but you spell them better so give them validity?

  27. Once or twice every so often are typos. Everyone makes them. But… your record here speaks for itself.

    “fare enough”?

    😉

  28. Bobbyg

    “Primary colors an(SIC) numbers”

    who doesn’t know and is spelled with a D?

  29. John do you feel wealth disparity is a fare measure of anything?

    In broad terms is wealth not earned/acquired/made, in which case someone who does not work should not expect any increase in wealth, where as those who are working will see their wealth increase. As more and more people, many not Americans, become dependent on the welfare state they are no longer working.

    Why are we surprised at an increasing wealth gap in the same discussion of a declining work force? Minimum Wage for example does not take into account minimum standards of labor offered in return. To be honest a lazy person who is also illiterate is not worth $7.25 per hour. As long as we have laws requiring business to pay people considerably more than they are worth those people will not be hired or ever have steady employment. That will mean those people will never acquire or grow wealth and the wealth disparity will increase. The solution to this is not more taxes or government programs, it is those programs and mandates that create the problem in the first place.

  30. “As to work ethics, there is a huge and increasing percentage of Americans who work for increasingly large employers.”

    Not to pick on you Maraglit but you keep spouting off lie after lie. Which is really ironic in a discussion of Amerian ignorance and lack of education.

    “Small Business is creating 60 to 80 percent of all new jobs in America”

    “Many visitors from abroad are surprised to learn that even today, the U.S. economy is by no means dominated by giant corporations. Fully 99 percent of all independent enterprises in the country employ fewer than 500 people. These small enterprises account for 52 percent of all U.S. workers, according to the U.S. Small Business Administration (SBA). Some 19.6 million Americans work for companies employing fewer than 20 workers, 18.4 million work for firms employing between 20 and 99 workers, and 14.6 million work for firms with 100 to 499 workers. By contrast, 47.7 million Americans work for firms with 500 or more employees.”

    I understand vistors being ignorant to these facts, whats your excuse Margalit? Some day its finally going to hit you that everything you believe is a lie, all your opinions and political beliefs are built on lies. How many of these moments like this will it take?

  31. Dr. D, Ms G-A,

    This thread is drifting into deep water now. (Mind if I order another drink?)

    If I can add my two cents, your mention of a few points made me think of these…

    –DEPENDENCY. I agree with both of you that this is a problem. And efforts to help people too often have dependency as the unintended result. That expression “A hand UP, not a hand-OUT” is how it’s sometimes expressed. My guess is that everyone can cite examples of both from personal experience. I have observed both in my own family in the case of public assistance for housing and/or healthcare.

    But as long as their are successes as well as failures, we cannot cease trying to help people because the social alternatives are just too savage. I’ve listened for decades to a local talk show host who never tires of criticizing anyone receiving public assistance of any kind, referring to them as “moochers” and arguing that those who are poor or unable to support their families are just irresponsible and are only receiving the justice of their own poor judgments.

    In the case of health care, that’s the reason for Medicaid as well as other state and local help. The specter of dependency is no more a reason to stop trying to get it right than the possibility of substance abuse is reason enough to stop using prescription narcotics.

    –EDUCATION This is important but by no means an essential part of crafting good public policy. Policy decisions must be made with the presumption of ignorance, stupidity, deliberate misinformation campaigns and even criminal behavior. As a cafeteria manager I was once tipped off that someone in the kitchen was stealing food. My first instinct was to catch and fire him, but upon further reflection I decided to insure that he couldn’t steal food because he didn’t want to get caught. My instructions were to watch him carefully, inform the subordinate supervisors that he might try to steal, and basically make the work environment an unfriendly place for a thief to work.

    One of my assistants questioned me about my response and I told him that the place had to be a safe place for anyone to work and stay out of trouble. It should be so safe that a criminal could work their safely and still keep a job. (I had an ulterior motive. The person in question was an excellent cook and I really didn’t want to lose him. But after thinking about it I came to the understanding that the same environmental “protections” should apply to everyone, even dishwashers and bussers. It has to do with culture, not legalities.)

    So in the case of education, good policy trumps all, including ignorance.

    –WEALTH DISPARITY Neither of you brought up this issue but it is central to both education and dependency. It also has a lot to do with upward mobility which is a vanishing cultural quality in America, perhaps more than many other parts of the world.

    It strikes me as significant that China, India, the former Soviet Union and other parts of the world — many with large populations for which ignorance and cultural dependency are clear and present dangers — are generating millionaires by the thousands.

    The gap separating the very rich from the destitute is everyday reality in the “developing world” but in America we have historically had great pride in what we call the “middle” class. “Middle” of what, I have no idea, since the bulk or our national wealth is concentrated at the very top. The top three or four percent of the population is sitting on something like ninety-five percent of the wealth. And with every calendar year the amount of new income is sucked into their accounts as well. The rich are getting richer as the poor become more poor.

    A large and growing number of people seem to be against progressive taxation and many are ready to repeal the Sixteenth Amendment. We often hear that half the country pays no income tax, which is true. But no one mentions that that is the half for whom payroll taxes are taken from their first earned dollar and from those taxes there are no deductions. And since those payroll taxes are the revenue stream ifunding both Social Security and Medicare, that’s why those two programs have been scooped up with Medicaid as well as all state and local welfare assistance programs and given the pejorative label “entitlements.”

    These are not easy issues to address or they would have been repaired long ago. But as long as we are discussing how best to deliver good medical care at realistic rates, these are challenges that must be faced. And I’m afraid the blanket name-calling and generalizations I have read here are not helpful and are in fact counterproductive.

    Again, thanks for reading.

  32. Hi Dr. D., I cannot disagree with you about education being less than optimal and engagement being measly, as reflected in voting percentages every two years. Yes, we can do better, but I have to trust that the people can do better, otherwise what would be the point of Democracy?
    We need to be able to govern ourselves, or suffer the consequences.

    I agree with you on the pathology of dependency and I agree that we need to change the way we provide support to people who are in a vulnerable situation. Poverty is the #1 enemy of our society and in my opinion, education is the #1 weapon to combat it. I do recognize though that there may very well be a lost generation here that needs to be supported for the sake of the children, and if we don’t do anything about the kids, they will grow up into another lost generation. If we are to be a society, not just a collection of people that happen to share geography, we need to take some responsibility for each other.

    As to work ethics, there is a huge and increasing percentage of Americans who work for increasingly large employers. It is really difficult to have pride and ownership when you are a tiny cog in a gigantic machine. I am not at all certain that this type of enterprise is very good for us as a species in the long run.
    And the Internet has probably caused quite a bit of collateral damage in the process of creating the global village, and there is probably more to come.

  33. respectfully, Ms G-A, while I would not cite a specific percentage that implies the majority of Americans are poorly educated or not interested in the truth, for me if it is more than 20%, and per my interactions as a doctor and member of my community 1 of 5 reflecting this type of mentality and expectation seems fair, that is not very good as a reflection of our culture.

    Dependency can be very pathological. And if you have government representatives who either innocently or purposely push to increase dependency, does it really matter in the end how the agenda is achieved to make people subservient just because they collect a check or access to services with minimal expenses on their part?

    The work ethic in America is getting worse, and there is less pride and ownership in people’s purpose. And, thanks to the internet, the rest of the world gets to see it up close and personal. What a benefit this medium offers, eh?

  34. true EBITDA is a great way, your right a ton of honest ways to make the comparison then the argument, one that is never honest though is revenue

    Wal Mart
    EBITDA (ttm): 33.81B

    Apple
    EBITDA (ttm): 32.08B

    Google
    EBITDA (ttm): 12.78B

  35. if your going to waste so much time trashing them why don’t you invest the 30 seconds to learn what your talking about

    http://finance.yahoo.com/q/ks?s=WMT

    Profitability
    Profit Margin (ttm): 3.87%
    Operating Margin (ttm): 6.00%

    Compare that to Apple

    Profitability
    Profit Margin (ttm): 23.53%
    Operating Margin (ttm): 30.43%

    or Google

    Profitability
    Profit Margin (ttm): 27.05%
    Operating Margin (ttm): 33.62%

  36. http://detroit.cbslocal.com/2011/05/04/report-nearly-half-of-detroiters-cant-read/

    According to a new report, 47 percent of Detroiters are ”functionally illiterate.” The alarming new statistics were released by the Detroit Regional Workforce Fund on Wednesday.

    Do you need me to post graduation rates for you? On top of that spend a couple years running a business and hiring people then tell me how high your opinion is, and most of the people I interview have college degrees.

    “Yes, like the budget “crisis” we just witnessed,”

    Yes like the budget crisis that was not a crisis at all. The only crisis is Obama had to change his vacation plans. Nothing was going to happen 8/7, 12/7 or even 2012. We had more then enough cash and liquitity to pay dept and essential services., Perfect example of a manufactured crisis that had to be dealt with right away according to those trying to push through more debt.

    ” I do commend Wall-Mart for its 0.08% of revenues contribution”

    Perfect example of liberaql dishonesty and stupidity. Only a dishonest hack would compare charitable giving to revenue then pass judgement. Revenue is meaningless as retail can have single digit margines where as professional services or high end clothing could have 100% margine. If a company with 1% margins gave .8% of revenue to charity they would be giving everything they had. Where as a company with 50% margins that gave 5% of revenue was giving very little. What were you saying about the public being educated?

  37. ‘Most Americans are poorly educated and worst yet not even interested in the truth.”

    I am sorry that you have such a low opinion of American people. I happen to think that American people are a lot smarter than that and as they consistently shown over the years, sooner or later, they will make the right decisions. This is why I want people, ALL people, to come out and vote, and not just blindly vote for the guy with the best hairdo, but vote for their own interests.

    “Liberalism is built on lies. Liberals trick an ignorant public into thinking problems are bigger then they really are…”

    Yes, like the budget “crisis” we just witnessed, where your comrades in arms took a non-existing problem and created the sorriest spectacle for the entire world to see and probably enjoy. But then again, their primary mission is to bar the current President from governing. [And, regardless of your previous banter, there can be only one primary mission, by definition, and it is the one that you pick when push comes to shove. The word primary in this context has a different meaning than when it is used to describe numbers divisible only into themselves, but I’m sure you know that.]
    In my book, this is very close to outright treason.

    There are multiple ways to discuss issues. One of those is to pick some extreme and non-representative example and loudly focus everybody’s attention on that. For example, bringing up pimps and drug dealers, when talking about safety-nets, or an outlier ice-cream company when discussing corporate culture. It usually works well as a diversion, but contributes little to clarity.
    [Not sure what the deal is with the anti-bacterial drug you mention above, but I assume it has something to do with an outlier renewable energy company that failed.]

    Medicare is a good program and it works for millions of people. Perhaps from your sheltered vantage point, it seems like it addresses a small issue, but the vast majority of Americans begs to differ.
    Public housing was done wrong mainly because it was initiated and executed amongst a sea of racism and bigotry which saw no alternatives to segregation. We have a long way to go before a good public housing program can be put in place.
    Welfare is something that the Constitution lists as one of the reasons for its existence, right there in the first sentence. Perhaps one could argue on how best to secure welfare for all people, but we are not at liberty to decide that welfare should be limited to a few chosen ones. Not in this country.

    With all due respect to the impressive philanthropy list you provide, and although I have no idea what is included in those amounts, I do commend Wall-Mart for its 0.08% of revenues contribution and Goldman Sachs for its whopping 0.8% of revenue charitable activities, all tax deductible, of course.
    I don’t think a 100 turkeys was too far off the mark….

    But the main point here is that this country was not founded on the premise that its people will survive by means of begging for charity from a few powerful lords.
    This does not fit the definition of a perfect Union and It does not fit the definition of Justice and it runs contrary to securing the Blessings of Liberty to ourselves and our Posterity.

  38. “And what would be the point of that exercise in futility, Nate?”

    To stop people like you from destroying this country. You might be a lost cause but for every person like you that aggresivly spreads these distortions there is 100 sitting back just reading not quit sure what to think. Most Americans are poorly educated and worst yet not even interested in the truth. They believe in what is handed to them. If all that these people see are your overstated lies the easy path is to believe them. If your confronted with reality and forced to back up and support these statements you make ther worst thing that happens is people are forced to at least give thought to who is correct. Hopefully they will see how you consistently back off your positions, qualify your new answers, then refuse to really get into the meat of arguments and realize what your saying are isolated insistences and no way representative of the whole truth.

    Liberalism is built on lies. Liberals trick an ignorant public into thinking problems are bigger then they really are and liberals have a solution that will sovle those problems. The problems were never as big as liberals claim and the solutions never work.

    Liberals have been on a jihad agaisnt domestic oil production, claiming they are protecting the enviroment. Oil drilling in the US is safer then anywhere else in the world, instead of 1 oil disaster here every 10-20 years we now have daily disasters in niger and other parts of the world far worse then anything that has or would happen here.

    How about Solodyn, we need to move to renewable energy and create jobs so Obama gives his buddies $500 million, 2 years later its all gone.

    Medicare

    Public housing

    Welfare

    time after time people like you have inflated problems to push your politicial agenda and the results are killing this country.

    ” all you will come back with is that Corp W is donating 100 turkeys for Thanksgiving dinner at the local homeless shelter.”

    http://philanthropy.com/article/Interactive-Tracking-Big/128359/

    Exactly Margalit, that is very representative of the scale of business giving. Businesses are running rampant doing all these evils then give away 100 turkeys and think everything is even. Why is it you always overstate the wrongs and trivilize the positives. If people knew some of these companies were giving 20%+ of their profit to charity would it maybe not support your argument that these companies do more bad then good?

    The difference between us and what everyone needs to see is I fight over the truth, if someone does wrong I’ll discuss it and why it is or is not as bad as it looks. You on the other hand lie first, deny second, then if your left no option just move on to another subject. Why don’t you take some of these A to Z corps that are doing so wrong and argue these evils you accuse them of and the good you deny they do instead of dismissing it with 100 turkey remarks?

  39. And what would be the point of that exercise in futility, Nate?

    If I say that Corp A and Corp B are evading taxes, and Corp C and Corp D are gauging prices of life saving items, and Corp E and Corp F are shipping high-paying, high-tech jobs and capital to foreign countries to save a dime, and Corp G and Corp H are destroying small US producers by importing child-produced items from unregulated countries, and Corp I and Corp J are monopolizing markets, and Corp K and Corp L are freely polluting our air, water and soil and don’t give a damn, and so forth, while Corp A through Z are unduly influencing elections and legislation, all you will come back with is that Corp W is donating 100 turkeys for Thanksgiving dinner at the local homeless shelter.

  40. Statement: Summers in St. Louis are very hot.

    Response: How can you say that? On August 28, 1986 it was all of 46 degrees in the evening, and there were plenty other days when the temperature was in the sixties and seventies. It’s 65 degrees outside right now. Do you call this very hot? What is it with Liberals that think the weather is always so hot?

  41. “Instead they are offering some piddly insurance which covers nothing serious, but provides people with the illusion that they are insured. When disaster strikes, of course, it’s time for tax payers to jump in.”

    Can you provide any examples of this? This is an area of business I know very well and can say with 99% certanity your full of it. But if you can tell me which companies are doing this I would be happy to admit I am wrong. I think your way off base in both this even happening and how common it is.

    “could have made a difference”

    All those what ifs are the same thinmgs said about Medicare and Medicaid. And look how poor the results were. What if we had done Medicare for all and all your what ifs didn’t happen, then we would be 300 trillion in debt and totally screwed, your willing to destory the entire nation for your what ifs?

  42. “a Corp’s primary mission is to increase profits,… There can be only one primary mission, by definition.”

    The problem is that the majority of Big Business in not like Ben & Jerry.

    About those more colors, can you see them? I am the one that is arguing some companies are bad some are great and most are in between. Your the one that at first said they are all profit driven then agreed maybe 1 or 2 are ok.

  43. “I am not minimizing Democracy’s effects on the human condition, and I am not minimizing the effects of healthy capitalism either.”

    “all we accomplished in the last 200 years is to exchange local landed aristocracy with global corporate aristocracy,”

    minimizing, you totally dismissed it.

    ” we cannot sit idle while Big Business is undermining everything accomplished so far.”

    Why don’t we cut through the generalizations, what big business are undermining what Margalit, lets hear your specific grievances.

  44. Nate, you have to understand that there are more colors than just black and white and that nothing is ever 100% and that every rule has exceptions.

    Lots of corporations give money to charity and have volunteer programs and community initiatives. It’s usually part of the PR budget.

  45. “the poorest people in the world have living conditions the rich dreamt about in 1776”

    And the poorest people in 1776 had living conditions that the richest people living during the Paleolithic Age couldn’t even dream about. And the industrial revolution may have had something to do with the rate of changes too.

    And Americans were not opposed to taxation in general. They were opposed to taxation without consent or representation.

    I am not minimizing Democracy’s effects on the human condition, and I am not minimizing the effects of healthy capitalism either. Quite the opposite, I would very much like to preserve these systems and this is why we cannot sit idle while Big Business is undermining everything accomplished so far. As I said before, there were several times that government had to intervene before and it is high time it intervened again. Unfortunately, current government does not seem up to the task at hand.

  46. ‘I’m glad I went to bed. When I got up this morning it took a while to clean out the email from Health Care Blog notices.”

    Uncheck the little box.

  47. “Oh and if you get out of line again I will intellectually smack yo ass again.”
    ___

    LOL. Now, THERE’s elevated debate “professionalism” for you.

    Yo’. I feel ya, yo’.

  48. Well, in that case why don’t they just announce that their employees get no benefits? What do you think will happen?
    Instead they are offering some piddly insurance which covers nothing serious, but provides people with the illusion that they are insured. When disaster strikes, of course, it’s time for tax payers to jump in.

    I don’t hate corporations. This statement is meaningless. I do believe that corporations today have way too much power. It’s not a new thing. It happened several times through history and government had to step in and regulate them down to size. The difference today is that we need to deal with a global economy and huge global corporations, which makes things a lot harder.

    It’s hard to speculate, but a Medicare for all program, perhaps structured a bit differently (and no separate Medicaid either), and ability for people to decide how much tax they are willing to bear for what benefits, and a simpler way to administer things, and having a big pool that does not consist only of the old, poor and sick, could have made a difference…

  49. “all we accomplished in the last 200 years is to exchange local landed aristocracy with global corporate aristocracy,”

    Average life expectancy
    1776 35
    2010 78

    Your right Margalit we haven’t accomplished anything

    http://www.cato.org/pubs/briefs/bp-37.html

    Two hundred twenty-two years ago, American colonists declared independence: to be free and to pursue their interests in free markets under a limited government. Americans hated taxes. They listed as a cause for rebellion in the Declaration of Independence “taxing us without our consent.” Their new constitution limited government and banned personal income taxes. The Revolution produced the American Dream, during which the common man became better off more quickly than at any other time in history. For our first 200 years, from 1776 to 1976, America’s per capita income grew at the rate of 458 percent per century, compared with the 3 percent per century growth rate of the pre-American world.

    Your right Margalit nothing at all

  50. “The problem is that the majority of Big Business in not like Ben & Jerry.”

    A minute ago you didn’t allow for even Ben & Jerry’s, your claim was corporations primary and only mission was to increase profit. Now you walk it back and admit ok maybe some corporations don’t have increasing profits as their primary mission BUT they are like super rare.

    BS Margalit you have no clue what you were talking about when you claimed corporations only mission is to increase profit and you have no clue how many corporations are like or are not like Ben & Jerry’s.

    You don’t know anything about business or Big Business or what their missions are or how they conduct themselves. Why do you keep attacking companies you know nothing about. Your exposed to a couple dozen companies you read about and want to take those couple dozen cases to indict all corporations, when you get caught exagerating that then you want to claim majority. For every big business that has done something wrong I can list 10 that have done great things for charity or society as a whole.

    “all we accomplished in the last 200 years is to exchange local landed aristocracy with global corporate aristocracy,”

    This is one of those times the I word needs dropped, Margalit don’t be so ignorant. We have hundreds of millions of people living in democracy, the poorest people in the world have living conditions the rich dreamt about in 1776. Just compare average life expectancy compared to 1776, ya we haven’t accomplished anything.

  51. How is healthcare an expense of business? They have no legal or moral obligation to provide it. How can you argue these are their expenses?

    You give government a free pass for failing to deliver benefits they do promise and passing on 100 trillion in debt but want to hold business accountable for not provideing benefits they never offered nor are obligated to provide.

    Your argument is not acceptable. Its not even an argument, you basically hate corporations and want to blame them for anything you feel like regardless if it is accurate or not.

    “This is why we need to have a system where health care is financed by taxation”

    We have a system where healthcare is financed by taxation, have you forgot about Medicare, its 40 trillion in debt, falling apart and taking the entire nation with it.

    “the mistake we made with Medicare is the same mistake we made with the ARRA stimulus – it was too small and too timid to succeed.”

    I can’t wait to hear how a 40 trillion failure was to small. please do explain.

  52. Regarding Ben & Jerry, I am certain that there are more and perhaps “better” corporations out there. Nothing is ever 100% one way or the other.
    The problem is that the majority of Big Business in not like Ben & Jerry.

    If you think about it, all we accomplished in the last 200 years is to exchange local landed aristocracy with global corporate aristocracy, and if we don’t address the issues, 1776 is bound to repeat itself in a much more gruesome format.
    (there were really nice feudal lords too, here and there)

  53. margalit you could win on semantics, could a primary mission be to live by 3 related missions? It still disproves your corporation’s primary mission is to increase profits but you could never win that argument anyways, at least you can get a small meaningless victory out of it

  54. “There is plenty wrong with profit in health care because a Corp’s primary mission is to increase profits, and a stand alone doctor’s primary mission is to care for people. There can be only one primary mission, by definition.”

    http://www.benjerry.com/activism/mission-statement/

    “Ben & Jerry’s is founded on and dedicated to a sustainable corporate concept of linked prosperity. Our mission consists of 3 interrelated parts shown above.

    Underlying the mission of Ben & Jerry’s is the determination to seek new and creative ways of addressing all three parts, while holding a deep respect for individuals inside and outside the company and for the communities of which they are a part.”

    So Margalit are they lying and the decades they have spent living by these standards where all a charade or are the three parts really code words for profit, I don’t see profits like you describe anywhere. I see someone claiming they want shared prosperity which sounds an awful lot like what you and determined claim you want but insist does not exist.

    And this is but one company and not even the most altruistic.

  55. The current system is not taxing everybody to provide health care for all, and in the current system these corporations are externalizing their expenses, which is not acceptable to me. This is why we need to have a system where health care is financed by taxation and these Corporations should be made to pay their fair share.

    You are the one advocating for States rights to make their own decisions, not me. Don’t travel to NY and NJ if you don’t like their toll system. Drive around, or fly over. That’s the advice you gave me….

    I can accept that we – all of us through history and into the future – sometimes make bad decisions, and I can accept that sometimes these decisions will have dire consequences. We are a continuum, not a singular point in time.
    And, by the way, the mistake we made with Medicare is the same mistake we made with the ARRA stimulus – it was too small and too timid to succeed. We should fix this now.

  56. “Primary colors an(SIC) numbers”

    see what I did there Bobby, I proved I am intellectually superior to you by pointing out a typing error. The great thing is every time I point out a typing error I reinforce my superiority.

    “are irrelevant to this discussion.”

    “There can be only one primary mission, by definition.”

    The is an absurd statement and completely not true. 3 primary colors, infinite primary numbers, and my other examples show the word primary does not by definition mean only one.

    Damn Bobby what just smacked you up side your head, was that a big ole load of relevance. When you pick your self up and dust your self off you can apologize any time.

    Oh and if you get out of line again I will intellectually smack yo ass again.

  57. OMG my finger hit one key to the left I must be the dumbest person in the world. BobbyG is so inteligent he never makes a typing error on a laptop in poor light, that just proves how much smarter he is then everyone else

  58. Yeah, I’m “clueless.” One of your standard epithets. Maybe I misunderstood you. If so, My Bad.

    Primary colors an numbers are irrelevant to this discussion.

  59. “dump the health care and welfare of their workers on the public”

    I thought you were a single payor advocate, didn’t you say you were against employer sponsored insurance? Since when do employers have any healthcare obligation? So when its convienent employers are obligated to offer insurance until you want to argue the other side then they shouldn’t be offering it the government should. Your really owning every side of that argument aren’t you Margalit.

    “drive prices up for everybody through their sheer size”

    So Wal Wart is evil beause it’s low prices drive mom and pop shops out of business and Wal mart is evil becuase they drive up prices through their sheer size. Again Margalit you can’t stake every side of an argument.

    I’m not allowed to vote in NY or NJ yet I am forced to pay tolls to pass through their State. Tolls that are so high becuase of coruption and waste.

    I’m not allowed to vote in CA yet their catering to illegal aliens directly impacts me.

    I wasn’t allowed to vote 40 years ago yet I have to pay for Medicare and SS shortcommings.

    The Medicare and SS liability the Federal government has dumped on future generations is 1000 times more then all the companies combined, why does that not bother you?

  60. “you can’t be exploited by a company you don’t do business with”

    Really? I don’t do business with most corporations that evade taxes, dump the health care and welfare of their workers on the public, drive prices up for everybody through their sheer size, make large fortunes during wars financed by me and carried on by soldiers who don’t do business with these corporations either. Not to mention that I have almost no way of tracking who the corporations I do business with partner with farther down their supply lines.
    The world has drastically changed since free markets were defined in terms of butchers, bakers and candlestick makers. Those theories are no longer applicable in their original form.

  61. at least when I call someone ignorant I have the decency to say why they are ignorant and provide them the correct answer.

    Your just calling names….comes off like you loss the argument and its all you were left with.

  62. Nate. you should have entered the GOP presidential primaries. You would fit right in. (Democrats didn’t have primaries this time — unfortunately.)
    With one or two exceptions they all sport ignorance as though it were the latest in fashion statements.

  63. ? So your ok with government and unions exploiting the vulnerable majority because people can vote?

    Then why can’t we defend the right of a few corporate predators with your ability to not buy their product or use their service?

  64. Bobby you really are clueless. The point of all the examples was the word primary does not mean only one as Margalit said it does….by definition none the less. As you pointed our Primary care physicians are actually 5 different kinds of doctors, not one as Margalit claimed the word primary means.

    Just like there is 3 primary colors.

    I have no idea how many primary numbers there are, would assume infinit, but that is another example of primary not meaning one and only.

    The argument that corporations exist first and foremost and at the cost of everything else to earn profit is liberal. That is why I subscribed it to liberals.

  65. “And without the illusory free-market argument there is no way to defend the right of a few predators to exploit the vulnerable majority unchallenged”

    How do you defend the right of government and organized labor to exploit the vulnerable majority?

    I’ll give you a chance to answer for yourself before I answer for you, allthough we all know the answer to this already.

  66. “So the only group that might be well-informed is a relatively small segment of the population with high-deductible plans, usually coupled with HSAs and MSAs.”

    John which country are you talking about? Here in the United S tates are system is nothing like what ever country your talking about.

    your relativly small segment with HSAs and MSAs is 11.4 million with HSAs alone, Around another 7 million have FSAs which you forgot about.

    Insured people that worry about lifetime and annual max are around 20,000 per year. Talkn about realativly small, is 20,000 even worth discussing in the grand picture of 300 million?

    I was also curious that you don’t see to know about co-insurance, that cost sharing mechanism common in about 120 million health plans. In fact in probably 100 million of those health plans co-insurance is a greater liability then the deductible then those 11.4 million HSA holders have. Why would someone with a $2500 deductible worry about cost more then someone with $5000 in co-insurance liability?

    A bigger question is what do you base any of this on….what you read on the internet…….? Maybe if you actually spoke to some of those insured people with non HSA plans you would have a better understanding

    Your AEI paper is so outdated it wasn’t worth the 5 minutes it took to read it. This would explain your outdated arguments and your not knowing what co-insurance was

  67. A bit off-topic but yes, I agree. Retirement plans are also best coupled with the beneficiary, not the employer. And the distinction between pensions (which are company funded, managed and owned) and other types (401-k, 403-b, ESOP, IRAs, etc.) which are employee/beneficiary funded, owned and managed.

    Group insurance and pensions were both originally aimed at attracting and retaining employees at a time when such perquisites were considered “extras.” Over time, however, both came to be part of the expectation for any self-respecting company. (Compare how designated non-smoking areas were replaced by designated smoking areas, and now entire establishments are usually non-smoking.)

    Old-fashioned pension plans are now an endangered species, being replaced by employee-funded, tax-advantaged plans which also have the advantage of being portable by beneficiaries if and when they leave before retirement (disability, another job, etc.). matching employee contributions to these plans remain tax advantaged as journal entries against taxable profits.

    The AEI paper cited in my longer comment below explains how tax policy influences group insurance and why employee-owned plans are preferable. Most people know that health care is costly, but few know what that really means. Those too poor to pay have no reason to know how much it costs. Insured people are only concerned with co-pays, and annual and lifetime limits. So the only group that might be well-informed is a relatively small segment of the population with high-deductible plans, usually coupled with HSAs and MSAs.

    ACA does little or nothing to help the public grasp the reality of how costly American health care really is. But my hope is that by putting stricter expectations on the private sector and outlining plans for state “exchanges” the private sector will be able to curb costs in the interest of profitability.

  68. Markets properly exist to serve humanity broadly, not the other way around. Anyone arguing for the latter is fundamentally arguing in favor “Might Makes Right.” And the latter is a zero-sum game or worse (and, even in a negative-sum game like the one now ensuing, there are still “winners” — for a time anyway).

    Now, there’s no way to “prove” my assertion. It’s a moral argument (and i can just hear the inevitable “commie” epithets as I type these words).

    Societies simply get to decide — to the extent that individuals deferentially operate within a legal system — how and to what ends their commerce shall be conducted. We get to DECIDE whether — and to what extent — health care should be deemed a “basic right” given its utility as a broad “social good.”

    Oh, crap, I just used the word “social.” I’m about to get hammered.

  69. “This “corporate personhood” idea is at the root of many a political disagreement ”
    ___

    Agreed. And people have a field day mocking it (justifiably so).

    Corporate personhood is what’s known in law as a “legal fiction” stipulated to for a variety of limited ends. “Presumption of of innocence” is another; i.e., the authorities must surmount “probable cause” in order to charge and try you — loosely meaning it’s “more likely than not” that you are guilty — but then, once charged, you are deemed to have a “presumption of innocence, loosely meaning it’s “more likely than not” that you are innocent (and, yeah, it’s considerably more complex than that in the details, but this is not a law blog).

    That your girlfriend has has no legal “free will” the day before her 18th birthday is another, and you could be charged with illegal sex with a minor were the two of you to be intimate on that or any prior day. And, yes, it’s the absurd “line drawing” cases that get all the attention, but the broader point is that a minor (or someone deemed mentally incompetent) cannot give rational adult “consent” to activities and arrangements for which they are necessary.
    ___

    Oh, and Nate:

    “OL, I love how Liberals redefine reality to suite their needs, Only one primary mission, by definition…….by definition I tell you.
    Like how primary care doctors are OB, GYN, Ped, Internest [sic]”

    Primary care providers (PCPs) are most recently defined by HHS as FPs, IMs, Peds, OB/Gyns, and Geriatricians.

    e.g., from CMS:

    “SUBJECT: Primary Care Incentive Payment Program (PCIP), Section 5501(a) of the Affordable Care Act (ACA)

    B: Policy: The ACA defines a primary care practitioner as: (1) a physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or (2) a nurse practitioner, clinical nurse specialist, or physician assistant, and in all cases, for whom primary care services accounted for at least 60 percent of the allowed charges under Part B for the practitioner in a prior period as determined appropriate by the Secretary.”

    Now, OB/Gyn is missing from that, but ONC has included it for purposes of being designated priority “EPs” (priority eligible providers) under the HITECH Act, for what ought be obvious reasons.

    See also http://www.aafp.org/online/en/home/policy/policies/p/primarycare.html

    Has nothing to do with “Liberals” and their scary nefarious schemes. Why can’t you just every leave that part out of your observations?

  70. You are too kind, John. Nate, who is a very intelligent person, does understand the difference between a human being and a corporate entity, and so do all the other libertarian/conservative constituencies. However, admitting that a corporation is not a person, invalidates all those rosy free-market theories which are predicated on commerce between small, local artisans. And without the illusory free-market argument there is no way to defend the right of a few predators to exploit the vulnerable majority unchallenged (i.e. with no interference from elected government, organized labor, collective bargaining, etc.).

  71. “even though corporations, unlike individuals, cannot be incarcerated for lawbreaking,”

    A corporation is incapable of breaking a law absent the illegal actions of people, if the corporations are meerly conduits for the action of people why would you lock them up instead of the people commiting the illegal action?

    What’s next john do you want to start locking up cars for drunk driving? Why don’t we send Carbon to jail for global warming John, I bet a few years in the pokey will teach it to stop warming the planet.

    “have their fingerprints on file for purposes of identification.”

    Are you saying people with dermatopathia pigmentosa reticularis are not people John, thats a pretty cruel and hurtful thing to say, I think you should take a moment to slow down and apologise to them. When you twist and tortue logic to try and support silly ideology you can hurt people, not only facts but real people John.

    I thought we weren’t suppose to subject people to gender difference, see corporations are better then humans they can’t sexually discriminate. Still not sure how you can claim transgender people are people and not see the problem with your argument.

    So your entire argument John is I don’t get it….and it took you 9 paragraphs to make that….you onbiosuly didn’t sleep at a holiday inn express last night.

  72. is employer based retirement pensions and/or 401Ks? This is the same distinction that needs made for health insurance, true health insurance can be more effectivly distributed through employers just like a 401K can be more effecitvly distributed and managed through an employer. That is diufferent then an employer taking on the risk of a pension or low deductible insurance plan

  73. “There can be only one primary mission, by definition.”

    LOL, I love how Liberals redefine reality to suite their needs, Only one primary mission, by definition…….by definition I tell you.

    Like there is one primary color?

    Like how primary care doctors are OB, GYN, Ped, Internest

    Like how primary care doctors provide initial and ongoing care, both of which are primary.

    There is one primary number correct?

    You get the point in regards to that statement/claim so I won’t pile on any more.

    “Profit only accrues to those who employ labor (directly or indirectly) and mark it up.”

    Sorry margalit you have a lot to learn about business and econ. Labor is by far the most common commidity which produces profit but by no means the only. Commodities, intelectual property, just look at the tax code and you can see all sorts of way to make money without labor.

    “pays them less than what their labor is valuated on its own”

    Really Margalit you really want to argue all corporation owned physicians are living somewhere between slavery and indentured servatude? Your just making crap up now. Plenty of doctors go work for big medicine becuase they can make far more then they would ever make on their own.

    Cut your loses, let the dogma go

  74. I think employer-based insurance must go. The consumer and purchaser of coverage should be the patient.

    As the commercial says: “It’s your money…use it when you need it.”

    Employer-based retirement must go as well.

  75. Wow.

    I’m glad I went to bed. When I got up this morning it took a while to clean out the email from Health Care Blog notices. I don’t know what zone the time stamps come from, but this thread lasted well past my bedtime.

    What seems to be happening here is a genuine failure to communicate. I doubt anything I write will help but here goes—

    The nub of disagreement appears to be confusion over the meaning of corporate profit and individual compensation. When Nate argues they are the same he is sincere. He really doesn’t get it. He sees both as the same for the same reason that many (including the Supreme Court, incidentally) regard corporations as individuals from a legal and accounting standpoint. Not only the Citizens United decision but a host of other cases affirms this principle and even poor Governor Romney nearly slid into the quicksand with his “corporations ARE people” quip, which he had to quickly amend to keep from coming across as obtuse.

    http://www.washingtonpost.com/politics/mitt-romney-says-corporations-are-people/2011/08/11/gIQABwZ38I_story.html

    This “corporate personhood” idea is at the root of many a political disagreement and does not seem to be going away, even though corporations, unlike individuals, cannot be incarcerated for lawbreaking, be subject to gender differences or have their fingerprints on file for purposes of identification. Oh, we can split hairs til the cows come home, but in the end we will still be observing a fundamental disagreement about corporate personhood.

    Various “compensation packages” include an array of benefits from use or the company car and travel allowances (ranging from stingy to overly generous) to performance bonuses and sales commissions above base wages. It’s hard to pick through the package, especially for tax purposes, but even medical and insurance billing sometimes refer to “usual and customary charges” to arbitrate differences of opinion,

    When Nate says “take $45 for an office visit and break it down to its components and show me how there is any difference between an individual and a corporation providing the service.” he’s not being obtuse. He really doesn’t get it. If I argue that time and labor are burdened by unlisted expenses (auto, food, shelter, etc.) that is presumed to be a given for everyone, therefore not a valid comparison. But individual compensation is as real to the worker as the $45 office bill is to the practitioner.

    This chicken and egg argument is just one of many differences that have split this debate open. I have spent the last eight years in my post-retirement avocation among seniors and have learned a lot about decision-making, from when to stop driving the car or move from assisted living to long-term care (or worse, stop life support). Since available resources and budgets are finite, in the end we all face two options — we will resolve differences according to mutual agreement or a resolution will be imposed by circumstances and forces over which we have little or no control.

    In the matter of how best to deliver quality medical care to everyone at a realistic cost per person, we still face a multitude of disagreeable options. I think I said before the ACO is not yet clearly defined. It is a work in process, a recapitulation of managed care. And those condemning the idea, along with this most recent attempt on the part of elected representatives to fix a broken system, are doing more harm than good by what is, I’m sure, a sincere effort to defend the status quo.

    (I find it interesting ,at least, that the author of this post has yet to visit the comments thread, which speaks volumes about his swipes at Big This, Big That and the use of the world “Monopoly.” Obviously he’s not one to be caught up in the details of discussions like this.)

  76. My last rebuttal here. I am not a business person, when I was exposed to the basics of business in my travels in college, I found it not appealing nor of value to what I embrace instinctively. Making money is an essential to survive in our culture, but when is an income stream enough? The answer is individual specific, but, argue to the end of time that having a profit motive allows one to provide care without hesitation or restraint. It is not just unrealistic, it is incongruent with the thinking and acting that goes into health care interventions.

    We saw this with capitated care payments back in the 1990s. Good luck defending that basic premise.

  77. If you pay the Corp $44.83 for a 99213, and the Corp pays the doctor in salary (or productivity) an equivalent of $20.00 for a 99213 and spends another $19.83 allocated to each 99213 on staff labor, utilities, etc., then the Corp made a $5 profit.

    If you pay a doc $44.83 and he spends $19.83 on allocated staff and utilities, and then pays himself $25.00, that is a higher valuation for his labor.
    Profit only accrues to those who employ labor (directly or indirectly) and mark it up.

    The difference between Big Medicine and a doctor is that Big Medicine farms many doctors’ labor, pays them less than what their labor is valuated on its own (spare me the economies of scales fantasies), and keeps the difference.

    There is nothing wrong with profit until you add a hefty dash of greed and it turns into profiteering. There is plenty wrong with profit in health care because a Corp’s primary mission is to increase profits, and a stand alone doctor’s primary mission is to care for people. There can be only one primary mission, by definition.

  78. Whatever. My record speaks for itself. Others can decide for themselves.
    ___

    My take on

    “Money-grubbing, egotistical docs”

    “Late one quiet evening on the 4th floor at Brotman, a double-shift weary Dr. Mittleman and I leaned on the counter at the nurses’ station and mused at length upon some of the more absurd alternative therapy allegations. Responding to the notion that his profession was raking it in while suppressing the “competition,” he quietly countered “right; I’m getting rich on the sixteen dollars a day I get from Medi-Cal for seeing your daughter.”

    Here was a man repeatedly to be found perched on the edge of Sissy’s bed at odd hours, talking with her for 30-40 minutes at a time– a temporal generosity he shared time and again with me in the halls as we discussed the more technical aspects of her situation. This is a man who continues to field and return her calls, sees her on a moment’s notice, and jawbones the Medi-Cal bureaucracy on her behalf, even though she is technically no longer his patient.

    I recently emailed Dr. Mittleman to express my gratitude, joking that “should they ever decide to start cloning the best doctors, I’ll be by your office to pick up a DNA/tissue sample.”

    Likewise for Dr. Sherry Wren, the swaggering, 5’3″ supremely confident surgical wizard who saved Sissy’s life in April of 1996, and who continues to stay in touch with us. Likewise also the innumerable doctors, nurses, therapists, and support personnel who have rarely failed to accord my daughter the utmost respect and compassionate, knowledgeable care throughout the past year and a half– many of whom will earn less in a lifetime than Dennis Rodman was debited by the NBA last season for unsportsmanlike buffoonery.

    Every discipline has its share of the “arrogant and narrow-minded,” but I have mostly found mainstream health care professionals to be a dedicated, unpretentious, and self-deprecating lot quite aware of the limits of their knowledge and the risks of presumption. Once, during a series of health care quality improvement seminars I attended at Intermountain Health Care in Salt Lake City during my Peer Review tenure, a speaker– himself a noted pediatric surgeon– wryly observed that “the best place to hide a hundred dollar bill from a doctor is inside a book.” The Director of the seminar series, Dr. Brent James of IHC (and a Fellow of the Harvard School of Public Health), noted in our opening session that physicians would probably admit– off the record, of course– that perhaps only 10% of their clinical decisions made during daily practice could be traced to the peer-reviewed scientific literature. Dr. James also made the droll observation that, were you to walk into the typical medical adminstrator’s office, “you’d be much more likely to see copies of the Wall Street Journal rather than the New England Journal strewn about.”

    What can one take away from such remarks? First, the many physicians I have come to know in the past few years are in the main acutely sensitive to the problems of clinical conceit and “paradigm blinders.” Indeed, the Utah pediatrician’s”$100 bill” wisecrack was offered to an audience of doctors and their allied health personnel during quality improvement training. Second, the body of peer-reviewed medical literature does not constitute a clinical cookbook; even “proven” therapies– particularly those employed against cancers– are generally incremental in effect and sometimes maddeningly transitory in nature. The sheer numbers of often fleeting causal variables to be accounted for in bioscience make the applied Newtonian physics that safely lifts and lands the 747 and the space shuttle seem child’s play by comparison. Astute clinical intuition is a necessary component of a medical art that must, after all, act and act quickly– so often in the face of indeterminate, inapplicable, or contradictory research findings.

    Finally, with respect to Dr. James’ Wall Street Journal quip, the capitalist imperatives within which health care clinicians must operate are, in the aggregate, neither of their making nor under their control. Moreover, blanket indictment of the profit motive as necessarily inimical to optimum medical care and research is a rather simplistic notion. Strategies aimed at maximizing investors’ net returns probably spur at least as many medical advances as they inhibit….
    ___

    circa 1997: http://www.bgladd.com/1in3/

    Also, relatedly, from my 2009 blog post “The U.S. health care policy morass”:

    “It is the soggy and crushingly sad el Nino L.A. winter of 1998. My now- brain-met stroke-addled daughter is painfully traversing the final months of her life. While admitted to acute care facilities (she has been an acute care patient in seven across the two years of her horrific cancer struggle), she gets the best clinical attention available, no strings attached, courtesy of Medi-Cal (the California Medicaid agency for the poor and otherwise medically indigent). But, outpatient care is another matter. Sissy has ongoing need of follow-up physical and occupational therapy, regarding which Medi-Cal will not authorize reimbursement.

    Her therapy team from Brotman Medical Center — at great individual and aggregate personal and professional risk to themselves — arrange to have her routinely come in incognito off the books to an outpatient rehab clinic in Beverly Hills where they work on the side, to continue her therapy — notwithstanding that we all know by that time that she will not likely survive much longer.

    That is an utterly unembellished true story. There are numerous unsung heroes within our health care industry, people whose unrelenting focus is “patients first.”

    Multimillionaire Mergers and Acquisitions Attorney Rick Scott is not among them.”
    ___

    Have a nice weekend.

  79. actually isn’t it you and margalit speaking in absolutes? Individuals have NO profit, for profit corporations have NO place in healthcare, business is NOT applicable to healthcare

    Correctly defining allocation of money is not speaking in absolutes. I’m just correctly identifying the money I mail out

  80. Nate, it is what the individual or corporation does with the money made that defines it as profit versus income. If I make $20,000 more a year than what are my realistic and legitimate expenses to live in our culture and just spend it on excess or wanton lusts, or just pack it away for savings for said intents later, than that seems to be a profit.

    If I give that money to my offspring for their education, or put the money into my practice to improve it’s function, or give it to charities or organizations to help them improve the community I live in, is that still seen as a profit? If you say yes instinctively, then we have different interpretations and expectations with what is money above and beyond our needs. If at the end of the day, you live without discomfort with your choices and goals, then I guess good for you.

    Instinctively, doctors do not gain excess funds to better themselves. Which, whether this comes across as arrogant or insensitive, good for those who think that way. Which is why at least when I went to Med School, the admissions office tried to admit those who embraced said mentality. But, no one is perfect in selecting people to find the need of the profession. I’ll take 80% or more who think the way I think though as success in maximizing the profession doing it’s job right.

    Remember, random chance is 5%. I’ll accept the other 15% as collateral damage that can’t be avoided.

  81. take $45 for an office visit and break it down to its components and show me how there is any difference between an individual and a corporation providing the service.

  82. That comment was directed to Nate, but it did not list in order to what I intended. Ms G-A seems to echo at least some of what I say.

  83. An amount of money is not simply defined as profit or loss. Only a business person thinks in absolutes. Which is why the business model is not applicable to health care as a service.

    But, at least your rebuttal is direct and not insulting or dismissive. Thank you for that respect.

  84. No you are not. What I say is instinctively about protecting our profession. Your attacks and sarcasm are incongruent with what I preach and state as legitimate concerns.

    You fool everyone else who wants to buy your empty concern. At the end of the day, those who read what you preach is not support nor sincere interest in protecting the rights of patients and those who treat them.

    Nice try though.

  85. the converse is it’s impossible you don’t grasp there is no difference.

    Any wages above cost not any wages at all

    If I hire a doctor and pay his SSN to provide me a 99213 its labor?
    If I hire a corp and pay its EIN to provide me a 99213 its profit?

    This makes no sense. The doctor and the Corp are providing the same service. They both have cost to provide me this service and anything over cost is profit, it really is that simple.

    If I pay $44.83 for a 99213 to a SSN or EIN explain the difference to me. How is a doctor making $5.00 off the transaction acceptable but a corp making the same $5.00 evil and the root of our problems in healthcare?

  86. “”Big Government” is not “gobbling up” any properties. It is, however, aiming at more responsible stewardship of our tax dollars by trying to incentivise private sector organizations to replicate the efficiencies and outcomes of already operating segments of the health care world to be more like the Kaisers, Mayos and Geisingers of the world by lowering the cost per patient without compromising outcomes.”
    ___

    Ding, ding, ding, we have a Winner.

    I would add that, last time I checked, there were no top HHS/CMS/ONC execs taking home eight-figure comp packages.

  87. Nate, It’s impossible that you don’t actually grasp the difference….

    According to your definition any wages are profit…. Payment for labor is not profit. It’s valuation of said labor.

  88. Same way you calcualte cost of corporate professional labor. Any labor you receive reimbursement for over your cost to deliver the labor is profit.

    We reimburse for profit hospitals like we reimburse individual providers. Reimbursement is another term for payment it doesn’t address profitability or cost.

    Why do people, besides nuns and monks, provide labor, for personal profit. Nuns and monks market in spirtual profit. Without profit there is no reason to labor, unless your Sisyphus.

    Profit is good both personally and corporate.

  89. How do you calculate “cost” of physician professional labor? Or do you automatically classify that as profit?
    I think the fact that many physicians operate as small business entities is what is throwing you off here. They don’t have profits in the sense of “corporate profits”. They have reimbursement. Even payers call it reimbursement, and calculate it as units of labor.

  90. the distinction is to move past the sound bite or general argument that profit is bad and all profit should be removed.

  91. anything over pure cost reimbursement is profit. Without profit a doctor couldn’t feed his family or pay his personal bills. If an individual doesn’t profit from their labor they can not sustain themselves.

  92. “Someone must always profit or there will be no one to provide the service.”

    Really, Nate? Or, is it about maintaining a positive income stream to support the services that go into health care and putting back the net excess income into improving the system to continue succeeding and providing effective care.

    That is why profit agendas fail in allowing health care to maintain it’s mission statement. But, per your writings over the months I have read and participated in these posts and threads, it is about sheer capitalism for you. You have made some fine and accurate points to some you dissent with, but, I do not see you as the most reliable advocate for the health care system in the end.

    If I am misreading your intent, then I assume you will correct me with appropriate clarifications. I am not interested in a prolonged debate with you though, so I hope you respect my dissent is with the profit agenda you seem to advocate per the above comment. Perhaps we will agree to disagree. In the end though, let’s hope patient care survives the onslaught that PPACA intends.

  93. professional care has its limits. Without corporate assistance we could not distribute professional care to every corner of the country. Take generic cost in the US, our low generic cost is a direct result of corporate profit. Our low generic cost many millions to receive treatment they otherwise could not afford. To take it to an extreme we can’t have a nation served by compounding pharmacist. We need professionaly developed and maximized care delivered at maximum efficency by profit driven corporations.

  94. @Nate
    Forty minutes from comment to reply. That’s impressive. It took me almost that long to understand the AEI link alone. But I’m a slow reader.

    I’m not getting into another pissing contest, btw. Been there. Done that.

    Not articulate enough. I did my best to splain the difference between professional compensation and corporate profits. Big Fail. My bad. Perhaps another time.

  95. “Maximizing profits is good for shareholders but not necessarily good for medicine. But maximizing professional compensation is good for medicine but hard on profits. That’s why some attention is now being paid to “medical loss ratios,” a concept that only saw daylight outside insurance circles during the sausage-grinding exercise that produced ACA. Listen to how that sounds to someone needing medical care: medical LOSS ratio. Medical payouts are regarded as “losses” by the insurance side of care. That strikes me as a contradiction in terms. ”

    Thank you for writing this, as it sounds better from your keyboard than apparantly from mine for some readers. It is absolutely absurd how some people will read this and defend insurance companies for not more agressively maintaining their agenda of profit margins per the arrangement they are in as insurers.

    I will be curious, but in the end doubtful that some readers will reply with respect and understanding of what you have written, even if they legitimately dissent, and not just one person in particular. When medicine allowed the business model to take hold in clinical care affairs, Faustian is an understatement to what played out.

    What is disappointing to me is how few and far between any fellow colleague physicians who are active in clinical care do not speak out about the state of affairs that PPACA is creating. I guess most docs these days just suffer from Stockholm Syndrome, or, more simply, “hear the lie enough and it becomes truth.”

    Nice reply though overall, Mr Ballard. And sorry to be part of that pissing contest you note. Really, I am the only one who is offended by some commenters here? Passion may have some drawbacks, but, if you care about the direction medicine is taking and you do not speak out as a fierce advocate for protecting the process, silence really is death in the end.

    In the end, the antiphysician rhetoric of some is just that, however coy and carefully worded to try to seem sensitive and concerned is not fooling those who pay attention to the overall patterns and themes.

    Have a nice weekend.

  96. ” It is, however, aiming at more responsible stewardship of our tax dollars by trying to incentivise private sector organizations to replicate the efficiencies and outcomes of already operating segments of the health care world”

    John your reading the title and chapter heading and ignoring the actual bill. Just becuase its called affordable care doesn’t mean it makes care affordable.

    Big Government, far from incentivising, private sector to replicate what works outlaws it and when it doesn’t outright make it illegal makes it nearly impossbile to do.

    For example why can’t my self funded plan capitate primary care like Kaiser does…because its illegal. I don’t need an incentive from big government to act more like kaiser, I need the government to repeal the law that makes it illegal to be more like Kaiser.

    “have employer subsidized plans which foster a blank check mentality.”

    You mean plans that pay a laundry list of preventive/wellness services at 100%. Plans that will have minimial deductibles and low out of pocket and no annual or lifetime caps. Ya those plans suck and are/will create a huge problem, so why did Big Government mandate they be the only plans sold?

    “In future part of the solution to getting patients and their families into the reality loop is to uncouple employers from insurance altogether.”

    Totally disagree and think your confusing your objectives. No matter what the policy covers, which is not a condition of employer or non employer sponsored benefits, or how it is taxed, employer provided insurance is a highly efficent delivery mechanism. Selling 300 million policies is far more expensive then selling/distributing 30 million. All the issues you raise are with the insurance being sold not the delivery mechanism.

    “medical LOSS ratio. Medical payouts are regarded as “losses” by the insurance side of care. That strikes me as a contradiction in terms.”

    Insurance is not a side of care and should stop being linked together. Insurance is a funding mechanism, in finance payments are debits, are expenditures, are losses. Any econ term isn’t going to sound rosy from a care perspective, they aren’t terms meant to convey warm fussy thoughts in regards to care. All insureds are liabilities, imagine how that makes them feel.

    “In an ideal world all medical care should be not for profit.”

    That would mean doctors and nurses would provide care at cost of supplies and need second jobs to actually feed their families. Someone must always profit or there will be noone to provide the service.

  97. I see this post is receiving a lot more comments than it did over at Health Affairs.

    http://healthaffairs.org/blog/2011/09/06/monopoly-anyone-the-battle-to-control-health-care/

    I responded there with a too-long comment that got their spam filter all in a twit. Since I’m persona non grata there, I’ll post it here instead.
    (Readers following the pissing contest in progress will please excuse this interruption. I’m sure it’s not finished yet, so scroll past my comment and wait for the next installment.)

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    “The only way to escape this increasingly inevitable fate is to empower the consumer through the agency of the employer. ”

    I wondered where this was headed. And I respectfully disagree. I haven’t time or patience to argue, but would like to make a couple of salient points.

    ►”Big Government” is not “gobbling up” any properties. It is, however, aiming at more responsible stewardship of our tax dollars by trying to incentivise private sector organizations to replicate the efficiencies and outcomes of already operating segments of the health care world to be more like the Kaisers, Mayos and Geisingers of the world by lowering the cost per patient without compromising outcomes.

    You can beat up the ACO’s as much as you like but at this point they are still a work in progress and no one knows what the end result will be. Yes, they are the old HMO’s revisited, but managed care is gonna have to be part of the solution if the economics of health care is ever going to be rational. (Speaking of employers, workers compensation plans are not an altogether bad comparison.)

    ►Regarding that employer-based solution, part of the challenge we face is that most patients have no clue how much medical care really costs. A small number of people with high-deductible insurance policies coupled with MSA’s or HSA’s may be well-informed, but the vast majority of people getting care are either unable to pay (and may or may not be Medicaid beneficiaries) or have employer subsidized plans which foster a blank check mentality. For them the only “cost” is co-pays plus deductible, and even then most never reach annual or lifetime limits.

    In future part of the solution to getting patients and their families into the reality loop is to uncouple employers from insurance altogether. Failing that, having premiums tax-advantaged is a part-way step in the right direction. One policy of the Bush years that never saw the light of day would have been a move in that direction.

    http://www.aei.org/outlook/21921

    Read it and weep

    ►Referring to sick people and their families as “consumers” is one of the most pernicious misuses of the word in the language. I realize that patients represent the only revenue stream for health care professionals. But I also know that until the Sixties all hospitals were not for profit and many group insurance plans were known as “mutual” plans, now an endangered species. The tawdry history of HCA in its mercenary attempt to do for health what McDonald’s did for hamburgers is as much as I need to know about reaching “consumers” with medical care.

    ►I rather like your trifecta of Big Medicine, Big Insurance and Big Government. For descriptive purposes all terms are conceptually accurate. (I presume Big Pharma is a sub-category of Big Medicine, along with Big Device Manufacturers, Big Advertisers, Big Underwriters, and Big Chamber of Commerce Members with their Big Group Insurance plans.) Certainly Big Government must now include Big State-defined Exchanges as well as HHS, CMS, NHI, and all the rest.

    ►Lost in the discussion is the distinction between business profits and professional compensation. My impression is that most discussions of the costs involved tend to overlook the difference between these two costs. Medical professionals are better at healing than business. And sales and business types are better at corporate details than healing. That is as it should be. But there is a tension between the two where the costs of medical care is concerned.

    Maximizing profits is good for shareholders but not necessarily good for medicine. But maximizing professional compensation is good for medicine but hard on profits. That’s why some attention is now being paid to “medical loss ratios,” a concept that only saw daylight outside insurance circles during the sausage-grinding exercise that produced ACA. Listen to how that sounds to someone needing medical care: medical LOSS ratio. Medical payouts are regarded as “losses” by the insurance side of care. That strikes me as a contradiction in terms.

    I’m in favor of the highest possible compensation for medical professionals consistent with market conditions, and the lowest possible profits.

    In an ideal world all medical care should be not for profit. But that’s just the dreamland of an old Fabian Socialist . And by now you already knew that.

    Thanks for reading.

  98. Mr G, you claim to work with physicians, so for some respectful transparency, not to give specific names mind you, are these doctors who practice active clinical care and do so with regularity?
    ___

    ALL of my personal workload is comprised of 1-5 doc shops, daily primary care clinicians (FP, IM, Peds, OB/Gyn, Geriatrics). I do have one GI doc (but we cannot generally do specialists; he got grandfathered in, and we do have some cardiologists — again, grandfathered in). Across our 2-state service area, we work with nearly 1,500, all but about 2 dozen of them small to medium size “primary care” (we only get paid for the first ten at each practice, and we only get paid for performance, incrementally). We also serve rural and critical access hospitals.

    Here’s a “blinded” first cut pt visit workflow diagram I did recently for a 3-doc internal med practice in northern NV:

    http://www.bgladd.com/BlindedPtVisitFlow.jpg

    We will do this for every doc, every sub- process (e.g., scheduling, ins verification/auths, Rx refills, px’s referrals, back office, etc), with a principal aim of eliminating any additional FTE labor burden associated with the Meaningful Use compliance criteria so they don’t negate the incentive money. (And, I’m no reflexive, uncritical cheerleader for the MU/REC thing.)

    BTW- look, doctor, I have no interest in “attacking” you or anyone else (but neither will I — obviously — forego responding to the panoply of names I get called here. And, “outrage” has nothing to do with that.). Quit borrowing trouble. I am on the side of the physician.

  99. Mr G, you claim to work with physicians, so for some respectful transparency, not to give specific names mind you, are these doctors who practice active clinical care and do so with regularity?

    Or, perhaps they are these “Big Medicine” people the author above cites? I guess specifics and details that might reveal your true intent with your involvement in ongoing commentary do interfere with the agenda though, eh?

    Hey, not every doctor works for hospitals or health care organizations who have profit motive agendas in their mission statements. Again, making an income is not equal to making a profit. People like you smear those terms to muddle the conversation that others try to follow. What is fair and reasonable is not black and white in all applications, but, there are inherent expectations of when to say enough is enough.

    Not that I would give you the satisfaction of specifics to my life, but anyone who knows and interacts with me would never call me rich, well off, and profit oriented. But, people like you in your writings seem to imply MD means “Mucho Dollars”. And besides, the real gorilla in the room of health care debate is our culture not accepting boundaries of life. Boomers will stretch this expectation to levels of bankruptcy risk never seen prior.

    And, I am in the boomer group, so don’t try that line of attack.

  100. “You cannot make a profit and responsibly and consistently heal people. They are inconguent in the end.”

    DeterminedMD, reporting from the front lines of Irony-Free-Istan.

    Or, when did you come over to the Dark Side of Single Payer? Y’know, health care as a social good?

    Google “The Moral Hazard Myth”

  101. I never said all doctors, I just said Docs that are the front men for the business puppeteers that really are dragging medicine into the gutter of business principles for health care. I am not a front man, and gee, per my posts here, is that a surprise?!

    You cannot make a profit and responsibly and consistently heal people. They are inconguent in the end.

    Just don’t expect a business minded person to either innocently realize the inconsistency, or, more likely, want the public to realize this truth.

  102. I do not really agree that all Doctors are just “front-men”. There are many corrupt doctors that have their patients do extra exams and therapies just to rake in the cash from Insurance. A large majority of American doctors only care about money nowadays..

  103. Continuing…

    “There is no single strategy that is likely to achieve efficient use of health resources. On the provider side, payments through public insurance programs can be bundled to encourage coordination, and providers can share in the financial gains of improving the efficiency with which they deliver care. On the patient side, more nuanced cost-sharing and leveling the playing field for higher-cost-sharing insurance plans can encourage patient involvement in decision- making and the balancing of resources costs against health benefits, as well as fostering competition. System-wide, better information is needed about which delivery systems – not just which drugs or procedures – are most effective.

    The U.S. has yet to wrestle with the question of public policy priorities in a world of scarce resources: even with perfect productive efficiency, we cannot cover all services for all people. When public resources come at a cost of lower economic growth, there must be some explicit consideration of the value of redistribution, and the public priority placed on covering different levels of service for different parts of the population. By first ensuring that health care resources are used more productively, we will be in a much better position to move towards spending the “right” amount on health.”

  104. “…Designing coordinated insurance plans such as ACOs may help patients choose higher- value coverage and move towards allocative efficiency. ACOs could, for example, aim to attract patients with greater coverage of marginal medical technologies, higher quality, and broader provider networks, with patients responsible for the marginal cost of more generous policies (where the threshold is based on the value of alternative uses of funds). This is much broader than using cost-sharing to affect the choice of generic drugs versus formulary drugs, or a CT-scan in a suburban shopping mall versus one in a hospital outpatient setting. Insights from the behavioral economics literature suggest that patients may be stymied by the cognitive demands of making many price comparisons, but choice may be facilitated by creating larger bundles for patients to choose among..”

    http://www.kc.frb.org/publicat/sympos/2011/2011.BaickerandChandra.paper.pdf

  105. “Big Medicine”, what a crock of stool that title is. Docs that are just front men for the real puppeteers, business people who have suckered physicians into applying a business model to medical care.

    Oh, and how efficient that model has turned out to be. Just more false justification to let PPACA stand. Stand and crush personal choice for patients and autonomy for providers. Blind loyalty, boy, does that term fit here for the usual suspects pining for government takeover of all that was once free and autonomous.

  106. I highly recommend Katherine Baicker and Amitabh Chandra’s “Aspirin, Angioplasty, And Proton Beam Therapy: The Economics Of Smarter Health Care Spending”

    http://www.kc.frb.org/publicat/sympos/2011/2011.BaickerandChandra.paper.pdf

    “…The 2010 U.S. Affordable Care Act (ACA) focused on “accountable care organizations” (ACOs), where shared saving “bonuses” are provided to health care organizations that are able to provide high quality care at lower costs. Examples include the traditional integrated systems such as Intermountain in Utah or the Geisenger Clinic in Pennsylvania, but can also encompass traditional hospital physician networks (Fisher et al., 2009). Such a construct could come closer to the ideal expressed by Weisbrod by providing incentives for cost-saving innovations, and gut the incentives that physicians currently have to engage in “financial entrepreneurship” of the type seen in McAllen, TX, Elyria OH and Redding, California (Gawande 2009)….

    ‘…[W]e do not know how well ACOs will sidestep cost-ineffective technologies, particularly if the latest shiny innovation increases market share. The viability of ACOs will depend on the receptiveness of physicians to capitated payments—some specialists will see their incomes fall and are unlikely to take these cuts quietly. While their concerns may not resonate with patients, they might if providers claim that valuable care is being withheld. Designers of ACOs are therefore keenly interested in measuring ACO performance and patient satisfaction, but current quality measures only capture truly negligent care…”

    “…There is no single strategy that is likely to achieve efficient use of health resources. On the provider side, payments through public insurance programs can be bundled to encourage coordination, and providers can share in the financial gains of improving the efficiency with which they deliver care. On the patient side, more nuanced cost-sharing and leveling the playing field for higher-cost-sharing insurance plans can encourage patient involvement in decisionmaking and the balancing of resources costs against health benefits, as well as fostering competition. System-wide, better information is needed about which delivery systems – not just which drugs or procedures – are most effective.

    The U.S. has yet to wrestle with the question of public policy priorities in a world of scarce resources: even with perfect productive efficiency, we cannot cover all services for all people. When public resources come at a cost of lower economic growth, there must be some explicit consideration of the value of redistribution, and the public priority placed on covering different levels of service for different parts of the population. By first ensuring that health care resources are used more productively, we will be in a much better position to move towards spending the “right” amount on health.”

  107. While it’s not a total solution, our new system can provide some cost effective alternatives and create a more transparent way of purchasing care. We believe there’s a better way of providing care and that patients deserve to have their voices heard!

  108. How has employer provided coverage created an expensive mess? While it might be self serving that doesn’t change the accuracy. Simple logic in regards to the high deductible plans that are outlawed eff 2014 bare this out. Millions of americans are getting low deductible coverage for 20-40% less then if their employer was forced to buy insurance as Obama decalres they should. 2014 when those plans are illegal cost will increase 20-40% and deductibles will shoot up. How can you argue against proven success?

  109. how are the millions of small businesses now magically transformed into big business? The issues David discussed about limiting high deductibles and creativity don’t apply to big business self funded plans those are specifically small employer issues.

    You have to learn to let go of your dogma Margalit.

  110. when was the last time unemployement exceeded uninsured? Historically employement appears to be more stable then insured. Is it a perfect soutlion and will a couple million people slip through the cracks, of course, that is still far better then any government program has achieved.

  111. This is self-serving nonsense.

    Self-serving since it seems to be designed to advance Mr. Cowles’ benefits management business.

    Nonsense because reliance on employer-paid, employer-defined coverage is one of the primary reasons our health care system is such an expensive mess.

    And, by the way, Hawaii does not have a single-payer system.

  112. In this context, “employer” is a pet name for Big Business, which includes Big Medicine and Big Insurance.
    A couple hundred years ago We decided on how to select representatives for this poker game, and over the years even those who used to be represented by their “employer” were allowed to freely select who gets to play with their chips.
    I see no reason to turn back the clock and move the poker game to a new and improved, all inclusive, Dixie.

  113. “The only way to escape this increasingly inevitable fate is to empower the consumer through the agency of the employer.”
    ___

    Given the chronic instability of the U.S. job market (including intractable unemployment, and employment-at-will tenuousness), I have to be concerned about the viability of this approach.

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