House Votes to Repeal Obamacare Provision

[Loki]

Unnecessary preventive treatment? How dare you even suggest that. Minx is now going to shout at you for wasting money.

[Aimless]

I find it amusing that you consider overtreatment to be inexcusable but undertreatment to be a non-issue.

I do consider undertreatment to be an important issue, if you'd read my posts you'd know that (since they're right here in this thread you can actually go read them now) in fact it's an important issue in the US where undertreatment eg. leads to people costing much more money due to preventable emergencies. What, you imagined that undertreatment doesn't occur in the US because you have over-treatment? What you have is unnecessary treatment and unnecessary diagnostic procedures. That doesn't mean you only do too much of the good stuff where the bonus is just good; too often you do the wrong stuff at the wrong time. I find it incredible that you guys still have so many life-threatening emergencies and tragic complications due to eg. people desperately trying to stretch out their asthma medication or their insulin.

I have no doubt these problems also exist in the rest of the western world (although I'm willing to bet that, overall, most of the rest of the western world compares favorably to the US), but the difference is you guys pay far more for this privilege than anyone else does. You seem to have lost track of the original topic for this sub-discussion, which is Lewk's assertion that your healthcare-system is inefficient and wasteful due to government regulation. My counter-claim is that the primary sources of waste in the US healthcare system aren't directly government-related, that the government's greatest fault is not regulation so much as its (forced!) willingness and "ability" to pay through the nose with tax dollars and borrowed money for the unsound medical practices fostered in your country, and its historical unwillingness to address the causes behind those unsound practices.

Do you even understand why it's important (for patients and for society and sometimes even for doctors) to ensure that doctors use appropriate diagnostic measures and appropriate treatment?

Jesus. Suck it up and learn from like Kaiser or something.

[Aimless]

Unnecessary preventive treatment? How dare you even suggest that. Minx is now going to shout at you for wasting money.

Look if I need to be more clear in my posts I'll try to be, but you'll still actually have to try to read what I've actually written in them.

For your benefit, I have emphasised the relevant parts of my posts that address the issue of "undertreatment".

[GGT]

What you have is unnecessary treatment and unnecessary diagnostic procedures. That doesn't mean you only do too much of the good stuff where the bonus is just good; too often you do the wrong stuff at the wrong time. I find it incredible that you guys still have so many life-threatening emergencies and tragic complications due to eg. people desperately trying to stretch out their asthma medication or their insulin.

Yep, because millions don't have primary care access, and wind up using the emergency room for basic care. Sometimes that's just to get a Rx refill for asthma meds or insulin, but often it's when they're in the midst of a full-blown asthma emergency, or have a pre-gangrenous toe.

.... Lewk's assertion that your healthcare-system is inefficient and wasteful due to government regulation. My counter-claim is that the primary sources of waste in the US healthcare system aren't directly government-related, that the government's greatest fault is not regulation so much as its (forced!) willingness and "ability" to pay through the nose with tax dollars and borrowed money for the unsound medical practices fostered in your country, and its historical unwillingness to address the causes behind those unsound practices....

Agreed. But the common US refrain in many political camps is that anything the government touches turns sour and, therefore, gov't shouldn't touch anything. That line of thinking becomes "privatize everything", with an almost romantic revision of history when medical care was totally privatized....but not nearly as complicated or expensive as it is today.

It's easy to theorize that poor people could get care through private "charitable" philanthropies or religious groups, and that's true to a degree. But it would be a low level of care that wouldn't necessarily include chronic dialysis, open heart surgery, joint replacements, premature/neonatal ICU.....or chemotherapy for millions of cancer patients.

[Flixy]

I find it amusing that you consider overtreatment to be inexcusable but undertreatment to be a non-issue.

I find it rather amusing you always only compare to the UK, as if that is the only alternative to what you have. I'd say Obamacare would be closer to, IIRC, Dutch or Swiss systems (could be wrong here). And not all countries have waiting lists like the UK. Show that the US is superior to at least multiple western countries, and you'd have an argument. Compare only to the NHS? Not really.

[GGT]

A system that can get timely access to proper tests for 85% is better than one that grants such access to 1%.

And how does the US system rate that way? Very poorly. The only way millions of people can get timely access to 'proper tests' is by over-charging and over-testing those with private insurance, and shifting the costs around. When public funds don't cover costs, because there are limits or caps on reimbursement, providers will simply raise the charges for private payers.

That might be a way to recoup their costs of doing business, but it doesn't do a damn thing to keep prices from escalating...

or make for better diagnostics and treatment for 85% of a population. Try it with Diabetes type II, and see why it's being called an 'epidemic'.

[CitizenCain]

I find it rather amusing you always only compare to the UK, as if that is the only alternative to what you have. I'd say Obamacare would be closer to, IIRC, Dutch or Swiss systems (could be wrong here). And not all countries have waiting lists like the UK. Show that the US is superior to at least multiple western countries, and you'd have an argument. Compare only to the NHS? Not really.

He could compare it to the Canadian system, which makes the US look really good, but then everyone would bitch about it not being a fair comparison because it's more like the British system with its public and private duality.

[GGT]

The US doesn't compare very well to any of the higher-rated healthcare systems, and they have public/private duality, too.

In fact, the US doesn't compare well within our own country, between places with good working systems (Mayo model) and those that don't. States and intrastate regions have massive differences in access, quality, results and costs. Even though public programs like Medicaid/Medicare have some national standards, what patients get are literally all over the map. Same is true for private insurance with strict regional preferred-provider and out-of-network restrictions.

[Aimless]

You're not going to convince Cain that Canada is better at anything than anyone, even though they have a warship and everything.

[GGT]

I was commenting to Flixy, Loki, and you.

[Lewkowski]

The US doesn't compare very well to any of the higher-rated healthcare systems, and they have public/private duality, too.

In fact, the US doesn't compare well within our own country, between places with good working systems (Mayo model) and those that don't. States and intrastate regions have massive differences in access, quality, results and costs. Even though public programs like Medicaid/Medicare have some national standards, what patients get are literally all over the map. Same is true for private insurance with strict regional preferred-provider and out-of-network restrictions.

That only because they use some pretty damned poor metrics. Life expectancy only works as a standard if the subjects have similar diets, genetics and exercise level. Its no secret that a lot of Americans eat far more crap then the Euro folks do. America is a fat nation and only someone blind wouldn't realize that has a huge health consequence.

[GGT]

That only because they use some pretty damned poor metrics. Life expectancy only works as a standard if the subjects have similar diets, genetics and exercise level. Its no secret that a lot of Americans eat far more crap then the Euro folks do. America is a fat nation and only someone blind wouldn't realize that has a huge health consequence.

You do know that life expectancy is just one variable used in rating healthcare systems, right?

[Lewkowski]

You do know that life expectancy is just one variable used in rating healthcare systems, right?

Sure but its the main one cited in these debates.

[GGT]

Sure but its the main one cited in these debates.

No, it's not. 'These debates' have always included plenty of other variables. Like birth weights and infant mortality, access to preventative care (including vaccinations and cancer screenings), numbers of physicians in specialties, affordability at entry-level participation, numbers and prices of procedures, costs at end-of-life, and costs per patient as well as percentage of GDP. The US isn't at the top in anything except the amount of money we spend.

[CitizenCain]

The US isn't at the top in anything except the amount of money we spend.

I love how this comes up as an argument for untold trillions in more government spending.

[Aimless]

Sure but its the main one cited in these debates.

No it's not, jesus, have you not followed a single one of the discussions we've had on this topic over the past decade?

[earthJoker]

Of course it is. Now how many regulations are on the healthcare system?

The market is distorted as well by government programs, special tax breaks (which is why we have an employer driven health insurance system btw) and other acts of big government.

Yeah but it is also inefficient compared to any healthcare system with the same regulations offering universial healthcare.

"Free market tends towards cost efficency" well in general I agree, but free market tend also torwards a maximum of volume. And that's actually exactly what we don't want in healthcare, we don't want to have a maximum of threadments & medication but a maximum in health.

[CitizenCain]

And that's actually exactly what we don't want in healthcare, we don't want to have a maximum of threadments & medication but a maximum in health.

Why's that?

What's wrong with applying the same concepts to healthcare that we apply to every other market?

[earthJoker]

Why's that?

A maximimum of threadments does not at all lead to the best result, same for medication.

What's wrong with applying the same concepts to healthcare that we apply to every other market?

Because that would mean that patients have the same knowledge about medicine as doctors. Not possible. And the Loki way out (asking another doctor to know what you want or need) will result in a huge overhead.

There is an inherent problem with healthcare, that is to find out what is actually necessary. There is always that other CT, or MRI that you could do, but is it necessary?

[Veldan Rath]

Huh...and here I thought getting a second opinion was a good thing.

[Loki]

European healthcare: the doctors always know best. Don't question them or they'll mock you and/or throw you out of the office.

[Aimless]

Huh...and here I thought getting a second opinion was a good thing.

Getting a second opinion and doing a second test aren't the same. We often request second opinions on eg. CT:s or on treatments (and patients will sometimes--but not very often--request a second opinion) but we generally prefer to not make patients undergo extra unnecessary CT:s.

European healthcare: the doctors always know best. Don't question them or they'll mock you and/or throw you out of the office.

Since I've never once seen a doctor mock a patient or throw one out for questioning his judgement I don't really know what to say to that. The caricature of the greedy American doctor encouraging (wheedling, threatening) patients to undergo unnecessarily expensive diagnostic procedures and treatments comes to mind.

[earthJoker]

Huh...and here I thought getting a second opinion was a good thing.

Two doctors can look at the same CT/MRI. Actually I once could join such a double session on a MRI.

European healthcare: the doctors always know best. Don't question them or they'll mock you and/or throw you out of the office.

Have you ever tried to make a diagnosis opon looking at a MRI? Have you ever watched a doctor making diagnostics? I assisted many doctors in my service and I can assure you, it isn't enough to have watched Grey's Anatomy to be able to make your own judgement.

[Veldan Rath]

Getting a second opinion and doing a second test aren't the same. We often request second opinions on eg. CT:s or on treatments (and patients will sometimes--but not very often--request a second opinion) but we generally prefer to not make patients undergo extra unnecessary CT:s.

Since I've never once seen a doctor mock a patient or throw one out for questioning his judgement I don't really know what to say to that. The caricature of the greedy American doctor encouraging (wheedling, threatening) patients to undergo unnecessarily expensive diagnostic procedures and treatments comes to mind.

Ummm all the extra tests are not to rake in more dough...but to prevent getting sued.

[Aimless]

Ummm all the extra tests are not to rake in more dough...but to prevent getting sued.

It's actually a bit of both. Defensive medicine is one of the major reasons, but there're often financial incentives for eg. referring patients to a friendly radiology clinic for an MRI (eg. a commission, or a direct stake in the radiology clinic).

[Aimless]

I've also seen too many make the "easy diagnosis" (i.e. your wrist hurts, it must be because of carpal tunnel; can't sleep, must be because of stress).

[...]

And no, it's not because I pretend to have any medical expertise. From what I've seen, only really good doctors make a proper diagnosis from the first attempt, and other ones need to see you multiple times and do multiple tests before they can do the same.

Good experienced physicians tend to order fewer and less expensive tests (relying instead on knowledge, experience, a good history and a good clinical exam--unless they're pressured to waste your money), and they can also be better at establishing a good alliance with their patients that lets them get away with such an approach. In the majority of cases you can suss out reasonably likely diagnoses very early based on the history and the clinical exam, with some added help from routine tests. How great you end up looking as a doctor ultimately depends a great deal on how you deal with the uncertainty (and, of course, on lucky you end up being).

If the history and clinical exam strongly suggest carpal tunnel syndrome then carpal tunnel syndrome may in fact be the most likely diagnosis, and it's perhaps also why you're sleeping poorly I'm kidding, I have no idea why your wrist hurts or why you're not sleeping well.

[earthJoker]

I've also seen too many make the "easy diagnosis" (i.e. your wrist hurts, it must be because of carpal tunnel; can't sleep, must be because of stress). As someone who understands something called cause and effect, and who spends more than 2 minutes to look at my own file, I actually am in a better position to diagnose myself than most doctors. In fact, I've done a better job of figuring out my problems (and problems of those around me) than most doctors do at first shot. And no, it's not because I pretend to have any medical expertise. From what I've seen, only really good doctors make a proper diagnosis from the first attempt, and other ones need to see you multiple times and do multiple tests before they can do the same.

Yeah why do we need doctors at all, we should just get more Lokis.

People make errors, of course. It is pefectly reasonable to make several tests. But this tests will cost already, so how do you (as a patient) want to decide how much is needed. In the end you will be influenced by the first answers you get if you decide to spend more money in simply finding what is the best way to solve your heath problems.

I don't think there is a perfect golden solution to this problem, but I don't think free market will solve it either.

[Aimless]

"Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country's best electrician on the job (he trained at Harvard, somebody tells you) isn't going to solve this problem. Nor will changing the person who writes him the check.

This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here's how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some "skin in the game," and then they'll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care."

[Veldan Rath]

It's actually a bit of both. Defensive medicine is one of the major reasons, but there're often financial incentives for eg. referring patients to a friendly radiology clinic for an MRI (eg. a commission, or a direct stake in the radiology clinic).

That smacks of being illegal...so go after the doctors that do this instead for fraud/racketeering?

[Loki]

Good experienced physicians tend to order fewer and less expensive tests (relying instead on knowledge, experience, a good history and a good clinical exam--unless they're pressured to waste your money), and they can also be better at establishing a good alliance with their patients that lets them get away with such an approach. In the majority of cases you can suss out reasonably likely diagnoses very early based on the history and the clinical exam, with some added help from routine tests. How great you end up looking as a doctor ultimately depends a great deal on how you deal with the uncertainty (and, of course, on lucky you end up being).

If the history and clinical exam strongly suggest carpal tunnel syndrome then carpal tunnel syndrome may in fact be the most likely diagnosis, and it's perhaps also why you're sleeping poorly I'm kidding, I have no idea why your wrist hurts or why you're not sleeping well.

It's nice and well that the really good doctors don't need extra tests; unfortunately, most doctors aren't that good. So you either get the British/Canadian system, where you're screwed if the first doctor you see isn't great, or the American variant, where you get extra tests, but eventually get the proper diagnosis.

Except most doctors spend a few minutes looking at your medical history and then a few minutes asking for symptoms. They don't even consider any but the most common ailments. They don't spend enough time to ask the kind of questions that would lead to a better diagnosis, and generally aren't smart/experienced enough to know much about rarer diseases. I know several people in England half of whose doctors refused to believe they had depression, for instance, because they happened to be females at an age where constant worrying is apparently normal. One of them ended up not getting treatment for over a year because no one wants to contradict fellow NHS doctors. Someone else wasn't allowed to see a specialist for a month despite one doctor claiming they might go blind if nothing is done (another doctor disagreed and refused to schedule an immediate test).

The sleeping thing actually was in regard to someone I know. The wrist thing turned out to be a genetic bone issue, a possibility the first two doctors I've seen completely ignored (the third was an NYU professor who automatically came up with the diagnosis).

That smacks of being illegal...so go after the doctors that do this instead for fraud/racketeering?

Not sure whether it's illegal or not, but virtually every doctor either I or my relatives have seen in the US has done this, including a pretty upscale Manhattan specialist.

Yeah why do we need doctors at all, we should just get more Lokis.

People make errors, of course. It is pefectly reasonable to make several tests. But this tests will cost already, so how do you (as a patient) want to decide how much is needed. In the end you will be influenced by the first answers you get if you decide to spend more money in simply finding what is the best way to solve your heath problems.

I don't think there is a perfect golden solution to this problem, but I don't think free market will solve it either.

All but the most common ailments have numerous possible symptoms, and those symptoms overlap with many other illnesses. Unless a doctor is very good, there's no way they'll get the proper diagnosis for anything complex after seeing you for 5 minutes. The doctor also doesn't know you well enough to know whether the symptoms you have could have been caused by another issue, nor the chronology of those symptoms (which often matters). It gets even more complicated when you're taking medication for an area in which the doctor is not an expert (and sometimes even an area where they are an expert), and those medication can reasonably be expected to produce some of the symptoms the doctor believes are part of a common illness. With that in mind, would you prefer a system where you're screwed if the first doctor you see doesn't make the proper diagnosis, or a system where you can get extra tests and second opinions?

From what I've seen, the only European who like their healthcare system are those who've never gotten a serious, but non-life threatening ailment (unless it was one the government was prioritizing at the moment). Luckily for those healthcare systems, most people don't get those kind of problems until they're old and their political views are fully formed.