The Affordable Care Act II - Because Mr. Obama Loves You All

[birdog1960]

But Dog, you of all people should realize you want 10 higher acuity people on your afternoon schedule, rather than 10 low acuity people who really don't need to to see you and access your training and expertise. People will, in theory still visit you for their Annual Exam, where you will order the Scope, Mammograms, and other age based screenings- that doesn't change, and you will be the medical home for these folks. But CVS can offer walk in, high quality treatment of that cough or allergies, and you can see the really sick people.

 

We did a study and of the 60K visits in our Internal Medicine practice, 30% could have been handled either over the phone or by a provider like and NP or PA and have reduction in outcome or quality. 30%. Some of that is poor triage by staff, but if you could cut that in half, in every practice across the Nation... I can't fathom the savings.

in theory,yes. my seeing only very sick patients would be most efficient. and you're certainly aware that there are metrics for a particular provider's patient population severity of illness. i'm happy that mine is relatively high. on the other hand, i'm reimbursed marginally more for a visit managing a patient with 4 or 5 chronic conditions than the walk in clinic is for treating a cold inappropriately with antibiotics or giving antibiotics that have significant interactions with the patients maintenance meds. (how much might that walk in clinc visit actually cost if it results in a bleed due to an interaction with a patients blood thinner?) and that's part of the systemic problem: patients are viewed more as customers and profit centers than sick people requiring care (i.e. patients). reimbursement models are ridiculously slanted towards procedures and against cognitive efforts and spending time with patients. it follows that hitting 2 irons all day is not financially rewarding and currently a barely viable option. you need some pitch shots to even things out. which brings up the question of why you are so certain quality is high in the walk in clinics. do you really want to see someone that either can only hit chip shots or chooses to only hit chip shots? until reimbursement is skewed away from disproportionately rewarding volume and procedures, walk in clinics at cvs make financial sense. the real question is whether they make sense in terms of improving overall care and lowering overall cost. for immunizations, perhaps (especially if ehr's talked to each other). for most other problems, i'm not at all certain. at any rate, i don't believe the ultimate answer lies here. much of it lies in reinventing the reimbursement system and incentives. if you haven't seen it, check out the front page op ed in the nytimes regarding costs and reimbursement with moh's surgery given as an example. i think it speaks directly to these issues.

[DC Tom]

so do you woodwork as juts a hobby? are you a turner of funiture builder?

 

Hobby, and whatever suits my fancy. I've done turning and cabinetry, right now I'm building a guitar (Gibson SG copy) and a new office chair. I'm a surprisingly competent trim carpenter - did an entire bow window in custom red oak, and did our fireplace molding in bubinga.

 

Everybody (ideally) covered now have deductibles. It will nto take people long to realize a visit to my hospital will run them 250+ for a sore throat, a trip to a Little Clinic will be drastically less- they already have the physcial space and are on every corner so no addtioanl overhead cost other than an NP and liability. When you have a 3,000 deductible, all of the sudden people talk to each other and become savvy consumers.. well, maybe savvy is overshooting... lol

 

That's actually something that never occurred to me. Rather than this abortion of a law we have, a lot of reform could probably have been accomplished by saying "Every ER visit requires a $100 deductible. Cash up front." Not practical, I know ("You were in a car accident, and your leg is crushed? $100 cash and we'll help you out.") But the idea of limiting the number of "I have a boo-boo" visits by people knowing they will have to pay out-of-pocket for an ER visit is conceptually an interesting idea.

[birdog1960]

Beat me to it.

 

 

If you were to tell your doctor "all I need/want is a tetanus shot, so if you can't make it snappy, I'm going to CVS instead," I'm sure he/she would "see" you and let you come in and have a nurse administer it. Is this true, birddog?

 

And yes, you are correct about what the majority of people think when it comes to health care, i.e. that it's someone else's job to keep track of it, manage it, and provide it to them at the lowest cost possible, if not free. I have had many patients come in for a colonoscopy who have said "I have to have this done." I tell them "no, you don't have to have this done, you should want to have this done for your own benefit."

yes. we can and do accommodate those requests.many seriously ill patients can't remember what medicines that they're on much less their past history. they walk in to cvs and the midlevel is often flying blind. but that rarely stops them from intervening in some, often worthless or potentially harmful way. after all, intervention is what the customer expects.

Edited February 6, 2014 by birdog1960

[IDBillzFan]

"I said Sprocket.......not Socket"

 

"Were the plumbers supposed to be at this show?"

[Doc]

No one wants to have a camera snaked up their ass. You should pare back your expectations to begrudging acceptance of the fact that it should be done for their own good. More than that, and your dealing with freaky-ass weirdos.

Well, no one wants a needle stuck in his/her arm either. Health care isn't painless, simple, or cheap, and there is no need to get it, unless you want to stay/become healthy. And at worst, that's what propofol is for. I know guys like birddog think it's wasteful, but if it gets more people to get preventative care, it's worth the cost.

yes. we can and do accommodate those requests.many seriously ill patients can't remember what medicines that they're on much less their past history. they walk in to cvs and the midlevel is often flying blind. but that rarely stops them from intervening in some, often worthless or potentially harmful way. after all, intervention is what the customer expects.

Yeah, seriously ill and/or older patients can't keep track of things. I was talking about many not-so-sick and younger ones. And going to your doc, who could have a "minute clinic" of sorts to do shots, would be much more preferable to most people I would think.

[DC Tom]

If you were to tell your doctor "all I need/want is a tetanus shot, so if you can't make it snappy, I'm going to CVS instead," I'm sure he/she would "see" you and let you come in and have a nurse administer it. Is this true, birddog?

 

In my experience, no. They have to make a big production out of it, mostly (I've gotten the sense) to cross the t's and dot the i's on the insurance paperwork, so they can justify charging for the visit.

 

Which reminds me of the one and only time I tried to get a flu shot. At my wife's gynecologist's office. Had to go with her for some post-op consultation or something, and while we were there the nurse said to my wife "We have flu shots available. You want one?" So I said "Hey, I'll take one too, since I'm here."

 

"Okay, sure...uh...wait. Can we do that? Give a man a flu shot? How would we bill that?" Turns out that, no, a man can't get a flu shot at a gynecologist's office.

[B-Man]

 

 

 

 

 

 

 

 

TRAIN WRECK UPDATE: New Cover Oregon allegations: ‘If it’s true, someone’s going to prison.’

 

“Former Republican state Rep. Patrick Sheehan told the KATU Investigators he has gone to the FBI with allegations that Cover Oregon project managers initiated the design of dummy web pages to convince the federal government the project was further along than it actually was.”

 

 

 

 

The Obamacare Jobs Plan: Turn On, Sign Up, Drop Out.

by Ed Morrisey

[Doc]

In my experience, no. They have to make a big production out of it, mostly (I've gotten the sense) to cross the t's and dot the i's on the insurance paperwork, so they can justify charging for the visit.

 

Which reminds me of the one and only time I tried to get a flu shot. At my wife's gynecologist's office. Had to go with her for some post-op consultation or something, and while we were there the nurse said to my wife "We have flu shots available. You want one?" So I said "Hey, I'll take one too, since I'm here."

 

"Okay, sure...uh...wait. Can we do that? Give a man a flu shot? How would we bill that?" Turns out that, no, a man can't get a flu shot at a gynecologist's office.

Yeah, I'm pretty sure it has to do with insurance. But would insurance pay for your tetanus or flu shot at the minute clinic? Because if you were to pay out of pocket at the minute clinic, the doctor would definitely take that cash and wouldn't have to bother with insurance.

[DC Tom]

No one wants to have a camera snaked up their ass.

 

Never been to The Castro, have you?

[keepthefaith]

Walgreens has had a clinic in many locations for years. About 3 years ago I suspected strep throat. Went to the local Walgreen's on a Saturday morning. They said the were backed up a couple of hours. Took my cell phone number and called me when they were within 10 minutes of being able to see me. I drove over. Nurse practitioner swabbed my throat. A couple minutes later told me, yes, you have a strep infection. 10 minutes after that I left the store with antibiotic in hand. Wonderful experience.

 

Now we shouldn't be forced to have insurance to cover piddly crap like this. Let me buy catastrophic and pick and choose what bells and whistles I might want in my coverage.

[B-Large]

Please don't get Tom talking about his woodworking. Not only do his posts start to resemble OCinBuffalo, but I ultimately have to bring in Steve Martin's old plumbers joke to add some levity.

 

"This lawn supervisor was out on a sprinkler maintenance job and he started working on a Findlay sprinkler head with with a Langstrom 7" socket wrench..."

 

Lol, he gets that way, huh? I will have to PM him.

[B-Large]

Hobby, and whatever suits my fancy. I've done turning and cabinetry, right now I'm building a guitar (Gibson SG copy) and a new office chair. I'm a surprisingly competent trim carpenter - did an entire bow window in custom red oak, and did our fireplace molding in bubinga.

 

 

 

That's actually something that never occurred to me. Rather than this abortion of a law we have, a lot of reform could probably have been accomplished by saying "Every ER visit requires a $100 deductible. Cash up front." Not practical, I know ("You were in a car accident, and your leg is crushed? $100 cash and we'll help you out.") But the idea of limiting the number of "I have a boo-boo" visits by people knowing they will have to pay out-of-pocket for an ER visit is conceptually an interesting idea.

 

I saw Norm Abram make a guiter on the Old Yankee a few years ago... he made it looks like childs play... that's a heck of a project, I'd love to see the pics when you are done... working in Bubinga, huh? Changing blades pretty often I suspect? I did some knife and jewerly boxes in Bloodwood and Yellowheart- the BloodWood was about the most dense wood I have ever encountered, blade were dull as **** after a few boxes.

 

Back on topic. People do theorecically have to pay up front for services, they just get billed for thier deductible. My wife and I never had a deducitbel on our managed care plan till a few years ago... its amazing how much even a $1,000 deductible changed our attitudes toward health spending. We now shop arounf for Med refills, and try to jamb services in when we have the dedctible paid for the year- I even e-mailed my Endo MD to see if I would just do labs and he could make changes to my Meds and I could skip the office visit, since all he does is tells me abut his kids and my new TSH... lol... this is one area where OC and I seem to see eye to eye, big deductibes driving price and consumption caution. Where we disgree is where the risk pool sits and who manages it.

 

 

 

 

 

 

 

 

 

TRAIN WRECK UPDATE: New Cover Oregon allegations: ‘If it’s true, someone’s going to prison.’

 

“Former Republican state Rep. Patrick Sheehan told the KATU Investigators he has gone to the FBI with allegations that Cover Oregon project managers initiated the design of dummy web pages to convince the federal government the project was further along than it actually was.”

 

 

 

 

The Obamacare Jobs Plan: Turn On, Sign Up, Drop Out.

by Ed Morrisey

 

Awesome pic- he has a shop in LA and has been featured in Fine Woodworking Magazine. He is the best character on that show, and perhaps all of TV...

[OCinBuffalo]

TRAIN WRECK UPDATE: New Cover Oregon allegations: ‘If it’s true, someone’s going to prison.’

 

“Former Republican state Rep. Patrick Sheehan told the KATU Investigators he has gone to the FBI with allegations that Cover Oregon project managers initiated the design of dummy web pages to convince the federal government the project was further along than it actually was.”

3 things:

 

1. As Tom said somewhere, and he's right: it's not fraud to run a RAD/XP approach, but it is fraud to present a mock up as working, production code. However, Tom didn't say: the reason you run a RAD approach, and not a waterfall, is to prevent the client from holding up your entire project, by being unable/refusing to give you key requirements.

 

The fundamental tenet of iterative is that you don't plan/write future code now, because it's requirements are likely to change between now, and "future". Then, there's the other side: what if you iterate off into the weeds and never get the core design right? ....and now we have yet another pointless, airport bar argument.

 

Knowing how/when to apply the right approach is an art, not a science, and requires talent, not necessarily training or experience. A "certified project manager" is about as relevant and useful as a "certified symphony composer". There's always a time to say "methodology be damned, we need to do X", and that time is usually 2 days into it. For anyone that wants to call that cowboy, hang out in a airport bar, call it cowboy, and prepare for your beating. You'll soon find that running a project for Joe's Accounting Firm and Flower Shop, is not the same as running one for GM. Which...is why Accenture is running things for the Feds now.

 

2. Question: what are the odds on the FBI actually taking this seriously, given their recent propensity to "investigate" the IRS so weakly/get "directed" by the Justice department?

 

3. Oregon being in deep trouble has been around a while. I've heard Maryland is much, much worse, and involves definite fruad and corruption. I know an IT chick who knows an IT guy, etc. I think it's 3 deep, but even if I throw away 50% of it, the remainder is bad.

[JuanGuzman]

How about we have an experiment? I'm going to give you 2 quotes, and any of you tell us which one is more likely to be an election-winning argument today, not 7 years ago.

 

I was explaining the economic theory behind government involvement in health care, not trying to win an election.

 

But if you want my election pitch here it:

 

Obamacare means 30 million Americans will have access to good quality health insurance. The program is fully funded in part by a small tax increase on the wealthiest Americans. Obamacare means that losing your job doesn't mean losing your health insurance. It addresses flaws in the individual insurance market that has made health care prohibitively expensive for many Americans with pre-existing conditions.

Edited February 6, 2014 by JuanGuzman

[IDBillzFan]

But if you want my election pitch here it:

 

Obamacare means 30 million Americans will have access to good quality health insurance. The program is fully funded in part by a small tax increase on the wealthiest Americans. Obamacare means that losing your job doesn't mean losing your health insurance. It addresses flaws in the individual insurance market that has made health care prohibitively expensive for many Americans with pre-existing conditions.

 

That's not an election pitch. An election pitch sounds like this:

 

Obamacare will not add one cent to the deficit. The average family will see their health care plans reduced by $2500 a year. If you like your plan, you can keep your plan. If you like your doctor, you can keep your doctor. Period. Obamacare will add four million jobs...400,000 jobs almost immediately.

 

Okay, actually those are lies repeatedly told by the president and Nancy Pelosi, but they were also election pitches that worked.

 

Follow up...a great article from Mediaite on the left sucking each other's nutsacks in hope one of them makes the CBO report go down more smoothly.

 

Watch the video from MSNBC in the middle. Absolutely hysterical.

 

Link here.

 

She went on to label as “anecdotal” the prediction that “some employers may reduce worker’s hours to avoid paying the employer mandate,” a function of the ACA that has not even taken effect yet. In the following paragraph, however, she said the opportunity provided by not working will allow others to “start the business they’ve always dreamed of,” or allow parents to “spend more time with their children.” Some anecdotes appear are more equal than others.

 

The more thoughtful E.J. Dionne took a stab at spinning the news himself. On Thursday, Dionne offered up his own anecdote, one about a 64-year-old looking to work less to spend more time with the kids. “Many on the right love family values until they are taken seriously enough to involve giving parents/workers more control over their lives,” he wrote. I take back what I said about being thoughtful.

 

[snip]

 

After insisting that 10 million have benefited from the ACA — a figure that is impossible to verifyand leads one to conclude she simply made it up — Moore went on to paraphrase the New York Timeseditorial boardwhich called the federally-funded incentives for people not to work and be supported by those who do “liberating.”

 

“You could say people don’t want a promotion, because if they make more money they’ll have to pay more taxes,” Moore said in false equivalence. This makes sense only to those who do not currently pay income taxes on their wages – which may, in fact, be her intended audience.

[3rdnlng]

That's not an election pitch. An election pitch sounds like this:

 

Obamacare will not add one cent to the deficit. The average family will see their health care plans reduced by $2500 a year. If you like your plan, you can keep your plan. If you like your doctor, you can keep your doctor. Period. Obamacare will add four million jobs...400,000 jobs almost immediately.

 

Okay, actually those are lies repeatedly told by the president and Nancy Pelosi, but they were also election pitches that worked.

 

Do you think instead of the word "period" he meant "comma"?

[GG]

I was explaining the economic theory behind government involvement in health care, not trying to win an election.

 

But if you want my election pitch here it:

 

Obamacare means 30 million Americans will have access to good quality health insurance. The program is fully funded in part by a small tax increase on the wealthiest Americans. Obamacare means that losing your job doesn't mean losing your health insurance. It addresses flaws in the individual insurance market that has made health care prohibitively expensive for many Americans with pre-existing conditions.

 

Thanks for unearthing a 2010 Campaign ad. You would imagine if it was as simple as you say, more than 2 million people would have signed on to the plan.

 

If that was all that the craptastic law did, then it would have a chance. Except it doesn't do that, and worse, it will destroy the health insurance market over time, because it is not fully funded and uses budgetary gimmick to make it seem like it's costing less money. In the meantime, as doctors and hospitals are reducing access, the legislators and courts are springing to action to make sure that the people aren't shut out of this wonderful new law. In effect, a greater price control system will come into effect. And I can count instances where price controls worked to their intended behavior on the fingers of a double amputee.

[Keukasmallies]

Actually, instead of the word "period" he meant asterisk so he could mark the phrase, then go back to it later and change it to whatever fit at the moment.

Edited February 6, 2014 by Keukasmallies

[OCinBuffalo]

I was explaining the economic theory behind government involvement in health care, not trying to win an election.

 

But if you want my election pitch here it:

 

Obamacare means 30 million Americans will have access to good quality health insurance. The program is fully funded in part by a small tax increase on the wealthiest Americans. Obamacare means that losing your job doesn't mean losing your health insurance. It addresses flaws in the individual insurance market that has made health care prohibitively expensive for many Americans with pre-existing conditions.

That's pretty good. But, does it really beat what keepthefaith said? I dunno. Also it's defeated by:

 

"OK, let's talk numbers. We had 30 million uninsured before Obamacare, and we're going to have 31 million uninsured as a result of Obamcare, what are we getting for what we are paying? Speaking of paying, most of the middle class pays more, under Obamacare. How does that help the middle class? And, my soon to be retired father(mother/whoever) is paying for birth control and pre-natal care under Obamacare, yet we are told this "controls costs". Apparently Democrats used the "new math" when they designed this fiasco."

 

Sorry, but what I said above, and what keepthefaith said, probably beats you. See how I play to the "I hate my boss when he talks numbers" crowd here, and I end with distrust of "math" especially when it comes from you? The cost control thing is a bit of a distortion, but not that far off.

 

To illustrate further: It's a tossup between the 30/31 million thing, and this: (http://www.nationalj...ortion-20140205)

CBO estimates that federal debt held by the public will equal 74 percent of GDP at the end of this year and 79 percent in 2024 (the end of the current 10-year projection period). Such large and growing federal debt could have serious negative consequences, including restraining economic growth in the long term, giving policymakers less flexibility to respond to unexpected challenges, and eventually increasing the risk of a fiscal crisis (in which investors would demand high interest rates to buy the government's debt).

 

I'll address this more deeply in a separate column, but CBO estimates that the nation's debt will be 100 percent of GDP (that's correct, 100 percent!) by 2038 unless we change course. That means wrenching entitlement cuts and/or significant tax increases, the former opposed by most Democrats and the latter rejected by most Republicans. Here's where the White House oversimplifies things.

 

Knowingly deceiving the public, Obama and his allies dismiss the debt crisis by noting that the deficit (annual levels of red ink) is lower than it has been. It's a false victory. CBO expects annual deficits to start climbing again in 2016 as the population ages further, and neither party has addressed the causes of durable debt that threaten the nation's fiscal strength and solvency.

 

That is the hard truth. Don't expect to hear much of it.

for most damning, empirically. If you are a thinking person, the above is Raid, it kills Obamacare dead.

 

But, who the hell is going to try to win an election with that? The above is something Mitt Romney would go with, and lose.

 

I'd go with what I wrote above, it's simple, and even a moron understands it.

Edited February 6, 2014 by OCinBuffalo

[IDBillzFan]

Do you think instead of the word "period" he meant "comma"?

 

No. It's pretty clear...his intent was to lie straight up to get this law passed. In typical progressive thinking, once everyone enjoys the lush sweetness of free health care, his lies would be quickly forgotten. Pelosi and Wasserman-Shutlz and Reid are more Baghdad Bob in their lies, but Obama told the biggest and his legacy of being the first black president will forever take a deep backseat to his legacyh of being the single most blatantly dishonest and incompetent of presidents in the history of forever.

 

Following Obama's interview with O'Reilly, when he compared himself to Nixon, someone somewhere commented that you know things are bad when the president who started out comparing himself to Lincoln is hoping people will at least compare him to Nixon.