birdog1960

you do realize that there are very few private medical practices remaining in the us? most docs work for big health systems as employees who in turn work for giant insurance companies. in the end, we all work for giant insurance companies, even the "independent" docs. and the giant insurance companies know all your intimate health details and decide what treatments, tests, physicians and hospitals you can utilize. how is that better than the gov't doing it?

I've actually chaired the ethics committee in my hospital and have been a member for almost 20 years. ethics implies fairness and the effort to identify and do the right thing for everyone concerned. you don't seem familiar with any of those concepts.

nope never heard it used before. my suspicion is that it's a phrase used by policy wonks and industry types. never heard it in a lecture or clinical conversation. seems awkward and counterintuitive..but whatever... excess dollars means the huge number of dollars over and above what single payer countries pay for the same or similar (and equally efficacious drugs). it's billions. I'd rather those billions be directed to drugs based on likely benefit to society as a whole rather than on what will produce a profit. loser drugs are part of the deal, whether the funding is from gov't or private sector. it just hurts less to lose money in this manner when it's being directed at the greater good than when it's being directed at the most profitanble productrs and ultimately, in lining big pharma execs and shareholders pockets. it's a case study for why "for profit" medicine is inefficient. that American patients are funding the lions share of this wasteful r&d while already paying more per capita than any other country in the world for healthcare is especially galling oh, and doctors are still paidf off by big pharma. go to the pro publica site and search pharma doctor payments. then search medicare doctor prescribing. there's an amazing correlation between those taking big pharma payments (most often in the form of "research" payments) and the percentage of brand name drugs prescribed. my personal experience anecdotally shows that big pharma payments and sleaziness are directly correlated among colleagues.. https://www.propublica.org/series/dollars-for-docs

what is an "ethical pharmaceutical"/? what would happen if excess us dollars dried up and the r&d subsidy was taken off the backs of sick americans? I think the solution would be gov't sponsored r&d on a global basis. drugs for development could be targeted for need rather than profit. we then wouldn't end up with 14 drugs for cholesterol in the same class, 4 for erections and 1 for life threatening complication of aids ( that can be used to rip off dying pt's at outrageous prices), as we recently witnessed.

no. but you know what I wrote. if you believe i'm incorrect on that point, prove it. but don't misstate my position and argue against it. good lord, the tired death panel scare again. medicare just recently approved a code to charge (and be paid) for discussion of advance directives. that means I can do a visit just for that purpose and get paid for it. (I don't. I incorporate it in a wellness visit) it's aimed at improving reimbursement to primary care while addressing an important issue: end of life care. it makes perfect sense and is clearly appropriate. those that attempt to demonize it either don't understand the issue or are being disingenuous.

yes, Kaiser permanente. that's not a good thing, believe me. you mean mid levels? even they are going into specialties most often. they make more. but I have a real problem with referring to a neurosurgeon and the first visit being done by a midlevel. we don't currently employ any. over the years, 1 out of 4 passed the mommy test: would I send my mom to him/her. perhaps we had too small a sample or were just unlucky.

umm... you cut the specialist pay while simultaneously increasing the primary care pay and the incentive to do a low paying fellowship for 2-5 years becomes much less. hence, more people choose primary care. if you look at any of the high quality, low cost single payer systems in the world, the discrepancy between specialist and primary care pay is much less. most have 50% or more of their docs practicing primary care. it's a key element. prestige is also directly effected by the pay differential. you are clearly aware of the emphasis put on earnings in determining ones value in this country.

medicare has actually been more proactive than anyone in cutting specialist fees and reimbursing better for nonprocedural work done by primary care. it's not enough by a long shot but they been more responsive to the problem than the private insurers. medicare is the entit6y that can effectively remove us from fee for service which rewards doing more of everything over quality. I like my odds at better pay in a well designed pay for outcomes system.

I saw this recently as well. my partners and I discuss this all the time. Who are we going to find to provide our own care? I guess we'll care for each other as long as we are able. most of the newly minted docs have neither the same work ethic nor the same sense of ownership over their patients' care that the older docs do...and there's even way too few of them coming out. it's really been at crisis stage for years and corporate medicine is just making it worse by forcing us to be clerks and robots for the insurers.

except that doesn't work. many systems charge $50 or so for screening heart CT scans. sounds cheap right? but they do it for the expensive catheterizations, stress tests, echocardiograms, bypass surgeries and cancer work ups fopr incidentally found abnormalities that generate big bucks. where you start is usually not where you finish in healthcare. and you usually finish a whole lot poorer.

not everyone. my Trojan horse take is documented on this site.

a recent true story to illustrate your point: I prescribed insulin for a patient recently to, ya know, keep him alive. one of the big corporate insurers required such a high copay that the patient couldn't afford it (somewhere around $150/month). so he called them and their rep advised him to have me file the papers for compassionate need from the drug company so that he could get his insulin for free. in effect, the big insurer dumped on the drug company by shirking their responsibility to pay for a drug required to maintain life. on the same note, i'm sick and tired of going to fund raisers for cancer patients so they can afford to live. firstly, they often still don't get enough help to afford to survive. second, it's immoral and we should all be profoundly shamed. but you put the power to decide peoples fate in the hands of c level execs that answer to shareholders and this is what you should expect....

yes, I believe some, including me, saw it as a Trojan horse. I think most saw it as the only doable "compromise" (read passable bill) at the time. the only realistic way to achieve near universal coverage, reduced cost and simultaneous improved quality is single payor. was then and is now.

was checking out updates from the acc meeting in Chicago this week and stumbled on this. it was written in 2013. from the comments, it seems a good many cardiologists were having bad days then. it's really not a specialty highly populated by bleeding heart liberals (pun intended). single payor is making sense to more and more non liberals. corporate medicine is not working for anyone but the corporate execs. on a side note, i'd steer clients away from eli lilly right now. a study presented at the meeting caused them to abandon a cholesterol drug they had poured mega bucks into.

proof that opposing parties can agree. from a colleague at the American college of cardiology: http://blog.acc.org/post/i-am-a-republican-can-we-talk-about-a-single-payer-system-2/. right on, brother!

i analyze the question this way: could the team have been made better by another draft approach? was it reasonable for whaley to conclude at the time that another approach would be a better bet at making the team better? I feel the answer to both questions is a solid yes. looked at another way, one could ponder whether the gm of an unnamed perennial playoff team make the same move in the same situation. i think it's highly unlikely that he would.

the move was cavalier and bordering on reckless. it smelled like desperation. and it didn't work. the team was marginally better with Watkins than without. isn't the success of the team the most importanat outcome?

kristof's musings are nonsense. they're explained by misplaced liberal guilt. if it had been kristol writing it, it would have been to serve as a smoke screen for the real issue: the mythical empowerment (mostly by talking head cons) of an emerging underclass that accurately sees it's piece of the American dream disappearing. the saddest part is that trump is the least likely remaining candidate to be their savior and they're too stupid to realize it.

must have been wishful thinking. I read it as kristol, as in William. silly me... will never happen.

yet he refuses to acknowledge the bigger sin: acting as a rabble rouser. stirring hatred and anger together in a toxic brew aimed at poisoning the "establishment" as if that label had any real meaning. these con talking heads have poisoned their own party and potentially, the entire country.

the VA has done a pretty good job in this single regard. so have most state Medicaid programs. the programs are paying small fractions of what other buyers in the US are.

he's correct about THIS: http://www.newyorker.com/news/john-cassidy/pikettys-inequality-story-in-six-charts. the system is designed to concentrate wealth and is doing so very efficiently and quickly. it's unsustainable and will lead to cultural upheaval in the near future if not changed. the ascendency of trump and sanders is the canary in the coal mine for the coming unrest. the difference between the 2 is that trump knows this but blames immigrants and illegals. Bernie honestly blames the system design which predetermines this outcome. the gov't already is the largest buyer of pharm. the difference would be that prices would be negotiated, national formularies implemented, those not bargaining would be left out. I promise you that big pharma in no way wants this.

he was the more electable of the two. people liked him more. I don't know who he's beholden to but he is beholden. he was more establishment than most liberals ever anticipated. Bernie is beholden to no one. it's a major reason he can't win.

it's a rigged game. she works for goldman.

you omit the part where Bernie is actually correct. Bernie is the natural evolution of a party that has been more liberal than generally accepted for the last few decades. his ideas are not revolutionary for most liberal dems. they are reasonable. trump's ideas are not only revolutionary to many repub conservatives but are downright frightening to them. Bernie is not scaring the most conservative dem. he's a gadfly and a damn good one. trump is a demagogue and becoming more powerful in his fractured, dysfunctional party every day.