Medicare optouts

58 thoughts on “Medicare optouts”

1. “Massachusetts has a bill under consideration to make participation a condition of licensure.”

   Glad you mentioned that. In the end whatever actions the doctors decide to take are irrelevant. Once the State is yielded control, absolute control in the case of ObamaCare, the allocation of resources is purely a logistic exercise and a dream for the army of HHS bureaucrats. Imagine the thousands of coercive ways to ensure doctors see those patients? The possibilities are endless.

2. Canada actually arrested some physicians who resisted the health plan so the rest fled unless they were going to bow their heads. That was in the 80s and many came to southern California. I know, perhaps, 15. Multiply that by the number of counties in the west.

   Private clinics are now opening in Canada but it has been 25 years. I used to go to a laparoscopy meeting in Saskatoon. Then, one year, it wasn’t scheduled. I asked about it and was told the surgeons who had put on the program, one of the best and I used to go to France for such programs, had emigrated. They were full time academics. Not everyone realizes that the salaries of academics, in fields like medicine and engineering, are set by private incomes. The professor can always hint that he could go out and get a spot in a private clinic. When that option is gone, the salaries sag.

3. OK, I understand doctor’s side.
   Now, from a patient’ side (not me, but I have parents…): at the age when visits to doctors increase dramatically and several very expensive operations and procedures are necessity (cardio, oncology, gallbladder removal, etc) – while at the same time income sharply fell – what are these patients to do when there are no doctors accepting Medicare?
   My father just returned home from a hospital where he underwent a coronary angioplasty; I can’t even imagine what would that cost him and how many years he’d have to pay that bill if not for Medicare.

4. I can’t even imagine what would that cost him and how many years he’d have to pay that bill if not for Medicare.

   the old are the proxies in the fight with the statists

5. “what are these patients to do when there are no doctors accepting Medicare?”

   Stop depending on the government.

   I’m sure that sounds cruel to you, but, by the way, my Mother is 86 and I’m a scant 6 years from Medicare heaven myself. We are not wealthy. I have no idea how I would survive if there were no Medicare, but neither do I expect doctors to sacrifice their careers for me.
   The problem is Medicare; not the doctors who wish not to participate in it.

6. That’s all fine and dandy, Craig, and your sentiment is noble. Still, I’d prefer an answer to my question.

7. Tatyana,

   One solution would be to give seniors and other people who have not been given the chance to save for later life health expenses a voucher that can be used on open market Health Insurance and/or an HSA. What Medicare is doing here is placing a price on services that are at or below cost, meaning those services are unavailable to people dependent on the current Medicare system. Giving people say over how money is spent on their healthcare would reduce the cost. Cost reductions would occur due to many factors including steep reduction of compliance cost, higher specialize and higher productivity due to unlimited access to the doctors (now you can have access to any doctor that accepts money, instead of any doctor accepting Medicare) and the ability to bargain.

8. “That’s all fine and dandy, Craig, and your sentiment is noble. Still, I’d prefer an answer to my question.”

   But why is that a question to ask others? My kid needs braces, so let me ask you and the other taxpayers…what are YOU doing about it?
   Craig’s sentiments might or might not be noble, but they describe reality. No one works for free.

   Imagine, just imagine, if in 1963, the majority of senators and representatives would have voted against medicare? Imagine if doctors were just allowed to practice medicine without mandates from government? I would dare say that the insurance market for the elderly (one that covers only catastrophic conditions only) and even hospitals like the Mayo Clinic, which recently dropped medicare patients in Az, would welcome seniors with open arms.

9. Kevin -oh, they have been given chance to save for healthcare: they were making involuntary deductions from their paychecks for several decades into Medicare! And they still pay for supplemental Medicare programs even now, 7 years into retirement.
   For some reason people talk about Medicare in a context as if it’s a handout, something government gives “for free”. It’s not a grant, it’s an insurance being funded by seniors.

   Prices are supposed to go down, Kevin? Not sufficiently they wouldn’t. I know that through my sister’s example: she broke her leg 2 years ago and the operation and post-surgical care cost her about $200 because she had insurance then. This year she has no insurance – and she happen to strain her ankle really bad; she decided against CAT scan and visit to the Dr, even though this case is relatively simple compared to what she had before – because that Dr. now only accepts cash and the visits plus tests will cost her over $1000 – and that’s her mortgage money.

   What difference will it make for my father if the cost of angioplasty plus a day in the hospital’s post-op ward will be priced not $155,000 (I’m guessing here), but $122,000? That’s still out of his reach. Besides, when at an annual checkup your doctor tells you you have a 90% artery blockage, you don’t have time to shop around for bargains. You can literally die any minute from a heart attack.

   Medicare management screwed up their finances and screwed up relationship with doctors – so who’s now left to suffer? Not the doctors, of course – they have a choice. Patients are – they have no choices.

10. JB: nobody have to work for free – as I said, I understand doctors’ side.
    But why is it patients’ fault? They paid to Medicare – involuntarily, as we all still do – but they did pay. It was a contract. Through no fault of their own they are now made to pay for government’ screwup.

11. It’s not a grant, it’s an insurance being funded by seniors.

    it is a tax like social security that fdr argued before the scotus.
    you bought into snake oil and blame us for your stupidity. besides rahm “‘dead fish” emmanual’s brother thinks you old age folks should just die for the collective.

12. indeed obama is going to argue that the individual mandate is a tax.
    these proggs are frauds

13. Tatyana,
    Well, yes, you are right. Seniors will get the half screw as an “efficiency panel” determines whether the individual’s “potential benefits to society” outweighs the cost of treatment, while future generations get the full screw. I believe Robert Rector has estimated the liability of this program alone, over the next 50 years, at over 34 trillions. Consider that the US economy (all goods and services ), prior to Barack’s assault, produced about 14 trillions.

    That’s not mere guessing either. Recall that lady in Oregon, who while on their universal health care system, was not only denied lifesaving medicine by the state as it was too expensive, but was recommended, in an unsigned letter, to avail herself of the free assisted suicide services. She was eventually saved by a pharmaceutical company which provided the medicine for free.

    But understand that it was not a screw up. This was intentional. The social security “lockbox” never existed and does not now. The retirement age of 65 was instituted at time where most people died around their early 60s. Roosevelt sold the program to the nation as an insurance program, while his lawyers argued before the Supreme Court that it was a tax. No screw ups, just left wing politics as the means to attain full control.

14. newrouter: so that’s your solution – to call me names?

    I didn’t buy into any snake oil (that makes no sense anyway – but when one drinks then types…it happens) and I have no love for government. I ask about specific situation – and that’s a situation all current Medicare users will be faced with when all doctors stop accepting Medicare. How many of them have savings sufficient to pay for inevitably increased out-of-pocket medical expenses if they are forced to pay cash?
    So far you are the one who advocates “old age folks should just die for the collective” – collective you belong to.
    Because that’s what will happen.

15. JB: I am aware of history of both Medicare and Social Security. Knowing history still doesn’t solve Craig’s 86yo mother’ problem. Or his own, in a decade or two. Or my father’s, at 73. And millions of people’s who don’t have money to pay medical bills in cash-only operations. There’ll just not going to be enough Samaritans in pharmaceutical companies to pay for all…

16. I didn’t buy into any snake oil (that makes no sense anyway – but when one drinks then types…it happens) and I have no love for government. I ask about specific situation – and that’s a situation all current Medicare users will be faced with when all doctors stop accepting Medicare.

    yes you did in thinking gov’t would provide for the service it said it would. well with these proggs in control your elderly relatives might be told to grab any health they can get. it ain’t going to go any easier now that the gov’t wants to have control over 1/6 of the economy.

    as far as docs leaving: they are making an economic decision based on the actions of the gov’t.

17. And millions of people’s who don’t have money to pay medical bills in cash-only operations.

    yea well guess who made everything expensive: might be the all of gov’t. just like they want to make your energy costs more expensive. jeez you’re not that dumb.

18. Tatyana – but your question seems to imply that it is the doctors’ responsibility, and not the responsibility of the government which is knowingly paying them far less than the cost of treatment. It is not a question of making money, but how much money the doctor has to spend to treat the patient. In the next five years, a giant wave of boomers are going to move on to Medicare, which makes it increasingly hard for doctors to subsidize their Medicare patients

    This is your fault. It’s my fault. It’s Pelosi’s fault. The doctors are not at fault. Do you expect your grocery to provide food below cost and stay in business? Do you think that that doctors don’t have to pay for their employees, computers, offices and utilities?

    The hapless question “What are seniors supposed to do” is just a redirection of the fact that US taxpayers have been avoiding paying the bill for their care. This shows up in many ways – in higher rates for privately insured and uninsured persons, and in a shortage of doctors who can still afford to provide care.

    The obvious solution is that we could raise Medicare taxes and pay something close to what it costs, which would then cut private insurance rates.

    Questions like yours are evasions of reality.

19. I’m not sure why the answer evades you. YOU will help your father cover the cost of the medication and care, if not pay for the whole thing. Craig must do the same. And when your parents can no longer live independently, they’ll move in with you. And yes, you will have to sacrifice for those who brought you up. Believe it or not, this is a reality in 90% of the world.

    Your mistake is in assuming that the standard medical care he is receiving now will be there a few years into Obamacare. It won’t. Re-read the OP. As Mark Steyn has stated, once medicine ceases to be an upper middle class profession, once it becomes the subject of the State, the quality of service as you know it, will not be there. So what use is it to worry about paying the bills, when the service will not be there? Why would service be offered to an old man — no offense to your father– when the waiting area in the ER awaits care from an ever smaller pool of doctors? Even more basic, what makes you think that YOU or HIM have any choice as to your medical needs? That “choice” was given away by the Britons in 1946, the Canadians in the 50’s and by the Americans in 2008. From this point forward, the care of your body, and your body itself, belongs to the State.

20. I’m quite worried about how all of this will affect the quality of care. What else can it do but go on overall?

    And I’m sure that the types that sit on efficiency and efficacy boards will find a way to “opt out” – there will be systems within systems, and the connected will somehow magically move to the head of the line.

    It’s very depressing.

    – Madhu

21. Sorry, I meant “go down.”

    – Madhu

22. Obama will denounce you as wreckers and capitalist roaders. You will engage in self-criticism and be rehabilitated by labor in in a re-education camp.

23. Of course, this was the plan all along. Once enough caregivers refuse Medicare patients and enough seniors complain, government will solve the crisis with their single payer solution. Obama has made no secret that he favors the single payer. A crisis needs to be created to make the public accept.

24. Tatyana: As I understand it, Medicare requires that a doctor/practice/hospital/etc give no other patient a better price than they give Medicare, this causes a significant increase in the minimum cost of care, by preventing discounting (I know some cash-only dentists, for example, who will significantly discount the cost of their labor to those who have difficulty paying their standard rates) and also encourages additional expenditures for procedures and test with lower cost-benefit ratios (get additional money from Medicare and also cover your ass against less likely scenarios and risks).

    A lot of these Medicare complaints apply to some extent to insurance companies.

25. seems to me that it is easier to get cheap auto and pet care than human care these days. why is that?

26. the oil change is $29.95! the dental check up is what or even a health check up? this sys sucks and getting worse

27. Obama will denounce you as wreckers and capitalist roaders. You will engage in self-criticism and be rehabilitated by labor in in a re-education camp.

    Maybe we’ll get free health care in the re-education camp.

28. Interesting thread. I am 41 and have no illusions that I will ever receive a penny of ss or medicare or anything else that I have paid into – so I have to save and invest with that in mind. Also I have taken to exercising and eating right so I don’t get sick later in life.

    The whole huge Ponzi schemes will collapse under the weight of the boomers and I will end up being the sucker at the bottom of the pyramid, even though I was not a participant of choice. At least a lot of you got something out of all those paycheck deductions. I fully expect zero.

    Of all the things Bush did wrong, at least he made a run at privatizing just a sliver of ss, and BOY did you hear everyone howl? You would think they were just rounding up the old people and blasting them to the moon.

29. So, apart from unnecessary explanations why doctors want out and why Medicare will be broke soon, you guys thought of three practical solutions.

    1st, Dan’s: exercise, eat healthy, save what you have for your rainy day.

    Good advice – when you’re 41. Because when you’re 70, getting seriously ill is not a possibility that you can eliminate by eating green salad: it’s a certainty. The kind of deceases you get when you'[re older are not cured by running 5 miles every morning: my father did exactly that, for 50 years of his life, and it didn’t save him from cancer and heart condition due to blocked arteries, and host of other health problems. You get old=>you get sick.
    Now, cost: how much money you have to save to be a be able to pay your medical bills in full by yourself? From what I hear about medical costs – anything you save will not be nearly enough.
    Maybe traders and investor bankers will have enough after 30 years of $200,000 bonuses – good for them, they deserve it – but how many savvy investors are here to be able to accumulate the kind of money that serious care cost? One operation – out of maybe 5 necessary – will wipe out majority of people’s life savings.

    2nd, Sam’s: Beg. Ask dentists to “significantly lower the cost of their services”. And I assume, do the same with cardiologists, anesthesiologists, lab technicians that read your biopsy, and hundred of other medical specialties that more likely than not you will have to come into contact. Depending on charity of strangers is not a very sound policy.

    3rd, JB’s: Impose yourself on your children. Make them spend their savings on you -your medical bills, your life expenses. To hell with their own prospects of being broke and ill in their 70’s because of that.
    I’d like to know how many people on this thread pay medical bills of their elderly relatives?
    I mean – full bills: cost of operation, post-op care, tests, procedures, medications, home attendants etc. JB -do you pay your parents’ medical bills? Do you even know how much is their full medical bill?

    I thought the invention of medical insurance, or similar “mutual benefit” societies/hospital expense credit societies (I don’t know English term), sometime in 19th cent. was aiming to eliminate or ease these issues. It seems nobody has a better solution than getting an insurance – but it doesn’t seem to work either.

30. Tatyana – don’t get me wrong, these weren’t my solutions to anything. I will be frank and say I don’t have solutions. Just stating a few facts and noting that I am doing some preventative things so I have a smaller chance of getting things like heart disease, and other obesity related illnesses. At least I can control that.

31. Sorry, Dan, but you don’t control that. Statistically – yes, but statistics of vast groups of people and your personal chances are not the same things. Genetics, family history, pure chance – they all come crashing on you no matter what you do. Linda McCartney was a strict vegetarian – and died of cancer.

    I am, like you, do what I can to stay healthy as long as possible – but I know futility of my efforts.

32. Tatyana,

    Like many things involving BAD government we in Chicago are far ahead of the curve.

    In the end state, which we are stumbling towards, we will have 2 systems. We will have a public health care system. This will look like Cook County Hospital. Pray that you never have to go there for any reason, although they do have an excellent trauma ward. Prior to the start of our wars in the mideast the military used to send doctors to train there because of the many shooting wounds that they could work on.

    There will then be a private system. In this private system, you will get what you pay for.

    Not all of the public systems will be bad. It is likely that if you go to a place like North Dakota, relatively free of urban ills, and you will get good care from locals.

    This is similar to the vast private security systems that have sprung up around the US. Someday only the poor will rely on publicly paid officials for school, security, health and electricity. And they will get shoddy, unreliable, government service.

    Everyone else who can, over time, will opt out, the same way people moved out of the inner city into the suburbs to get away from the public school monopoly.

    This “middle” state is confusing but the end state is clear. Unreliable, post-office level service for those who have to depend on the government and their own tax dollars, and better service for those who can afford to pay up.

33. Carl,
    I didn’t see Cook County hospital, but I grew up in USSR.
    I was on the phone with mom yesterday and we talked about how lucky they are to be here – moving to US literally extended their life. My father would not live till 73 if he stayed in Russia – and his position and status afforded him better medical care than 50% of population there.
    I don’t want this country turn to the one I left – where only people with money and connections live, and others – die.

34. Remember that the doctors are giving up the certainty of being paid “something” to the perils of the free market. The insurance system really began in earnest after the War. Blue Cross was founded in the 1930s. During the War, there was a great shortage of doctors as many were in the military. The “golden age” of medicine, in the sense that doctors had all sorts of new treatments and everybody got paid pretty well, lasted from about 1960 to 1980.

    When I was a child, doctors were definitely middle class. A family friend was a GP in the 1930s when a grateful patient offered to finance his return to do a residency in orthopedics. Once he finished the residency, the War had started and he was gone for four years. He came back from the War and became very successful as an orthopedic surgeon in Chicago. Eventually, he was the White Sox team doctor for some years. My family and his used to rent a house in Grand Beach together for the month of August. When he died I was in medical school. He left his wife with a big accounts receivable and many friends who owed him money. She had to go back to work as a nurse. That was just before the period of doctor affluence through insurance.

    These doctors are stepping into a void as they assume the risk of every other businessman (or woman) who opens the doors and hopes for clients. That’s the way it used to be. Now, most young physicians coming out of training, are going into group practices and expect to live on salary. They have huge student loans to repay and few will be able to make this choice. The people who are dropping out are the physicians with 10 to 20 years experience. Their loans are paid and they are successful enough to think that patients will follow them into a market system.

    It is quite an experiment.

35. Tatyana wrote I don’t want this country turn to the one I left – where only people with money and connections live, and others – die.

    Amen to that. This is what the failure to truly pay for medicine will produce. In the end, health care for everyone will suffer. Yes, if you dealing with private insurance or paying cash you can afford a good doctor, but if catastrophe happens (as it generally does at some time or another in most lives) you will wind up in whatever hospital’s closest at the time, and if the standard of medical care is poor, you will suffer. You may die. You may suffer lasting disability.

    Insurance OUGHT to be the answer – because although the diseases of old age, such as cancer, are unpredictable, they are not universal, so we can each afford enough to pay as a pool for the treatments the pool will incur – but the problem with our current government insurance scheme is that we are underpaying for many services. This is shifting costs to uninsured and private insurance, and is blowing up the system.

    The solution is to raise Medicare and Medicaid reimbursements to a level that pays for the services, even if we all have to pay more. Still the net benefit is there.

    What we have now is the worst of all possible worlds.

36. The end game is Russia’s system if nothing is done. Its not a bug its a feature. The current laws are trying to go in that direction. There will be no solution until enough docs drop out that seniors scream. Solutions are actually easy if you rethink the system.
    1)end the balance billing prohibition. Admit that mcare is a crappy insurance. Allow waivers of deductables if the patient can’t pay. (right now a discount is fraud and abuse)
    2)end medicare audits. They are pissing off docs, not saving money, and costing the government a large fortune. Docs respond by ordering marginal expensive procedures. why spend time and take risk to save the government money. They won’t thank you and don’t care.
    3)Tort reform. If you take mcare and something happens no one can sue. After all the government is still paying for your care. This can eliminate marginal CYA testing.
    4) eliminate JCAOH regulations. estimates are that they add 25-30% to hospital bills.
    5)stop threating docs w/antitrust if they have any clue as to what each one charges. How can you run a business/compete if you are not allowed to know competitors pricing.
    hayek pointed out that free prices act to help efficiently direct capital flow and investment. that can’t be done by using command and control. Mcare right now is the equivalent of rent controlled housing.

37. Doctors tend to forget that they’re ALL beholdin’ to the government (and therefore to taxpayers, too), since the gov’t maintains the doctors’ monopoly through force of law – the monopoly which is responsible for their unnaturally high incomes. As part of licensing, I think doctors should be *required* to work for low-or-no pay some of the time return for their gov’t-protected status. IOW, if a doctor wanted to “opt out” of Medicare completely, he could only do so by giving up his license to practice.

38. Tatiana:

    I have had open heart surgery and various other repairs. My bill from the hospital has always been monster big – $7000-$10,000 per day. My bill from the surgeon has always been very small. Open heart surgery was $6000. Other stuff much less.

    XRAYs, MRIs, CATSCANs are enormously costly in hospital but dirt cheap at the mall.

    A world without Medicare will be a better place. If we close down all the hospitals we will stamp of MRSA. Frankly I’d rather recover in a hotel room on the mall and hire my own nurse. Without Medicare prices would be affordable. Medicare is nothing more than a system of price controls and the effect of price controls ALWAYS is to inflate prices. Besides I am sure that some surgeons would start their own facilities for low cost post-op care. Dr Kennedy has described some solutions.

    Remember the US survived without Medicare before 1960. And if you watch old movies from the thirties you can see scenes where a 2 week hospital stay costs $50.00!

39. “As part of licensing, I think doctors should be *required* to work for low-or-no pay some of the time return for their gov’t-protected status.”

    Involuntary servitude will encourage more people to go into medicine, for sure.

40. As part of licensing, I think doctors should be *required* to work for low-or-no pay some of the time return for their gov’t-protected status. IOW, if a doctor wanted to “opt out” of Medicare completely, he could only do so by giving up his license to practice.

    This is certainly one opinion. Why do I “owe” the government for my education ? The “monopoly” you allege is pretty porous. A friend of mine, a GP, told me about a friend of his who was a podiatrist. He decided after about 10 years in practice, to go to medical school. Another friend of mine, an oral surgeon, did the same thing. Both wanted the certificate so they wouldn’t be bothered by rules about having to have an MD check your patient if you are going to do something in a hospital instead of your office.

    Both finished their training as MDs and went right back to podiatry and oral surgery. Why ? They made more money.

    There is a lot of nonsense around about how powerful the AMA is. That was probably true in 1965 but not since. I was a delegate to the AMA from California. I quit. Waste of time.

    The solution for Medicare and most insurance is to change the model. Get rid of the prepaid care model we have now and go back to insuring insurable events like cancer and heart attacks. It is a ridiculous system to pay in advance for routine care. Those huge hospital bills, by the way, are fiction. I have previously explained this here and at my own blog so I won’t waste time. You are seeing the retail bill and it has very little to do with the real bill which is a contracted rate. The doctors who are dropping Medicare are lowering their fees by 75 to 80% because Medicare pays 20% of the usual bill. The fee is a fiction but you are committing a crime to lower it for cash patients. If you lower it for everybody, Medicare will pay you 20% of the lower fee.

41. Lawyers/dentists/hairdressers/Appraisers/Architects/Auctioneers/Bail bonds/Camping resorts/Collection agencies/Cosmetologists/Court reporters/Engineers/Funeral and cemeteries/Geologists/Home inspectors/Land surveyors/Landscape architects/Limousines/Notaries public/On-site designers/Private investigators/Real estate agents/Security guards/Sellers of travel/Tattoos, body piercing, and body art/Timeshares/Vehicle and vessel dealers/taxi drivers tend to forget that they’re ALL beholdin’ to the government (and therefore to taxpayers, too), since the gov’t maintains the (see above) monopoly through force of law – the monopoly which is responsible for their unnaturally high incomes. As part of licensing, I think (see above) should be *required* to work for low-or-no pay some of the time return for their gov’t-protected status.

    This is a partial list of professions and workers licensed by my home state of Washington.

    Now how do you feel about forcing people to work for nothing, “LeMur?”

    Personally, I think you should come over to my house and take care of my lawn for less than it costs to do the work.

42. “JB -do you pay your parents’ medical bills? Do you even know how much is their full medical bill?”

    No. They work and they have insurance. But unlike you, I’m not expecting anyone to pay for them.

    Matter of fact, after reading your responses, I’m not sure why you are even in the US. The USSR’s perfect society should have fit your socialism just fine. Go ahead and add your father’s medical bill to the trillions of dollars that is the US debt, but do us a favor- catch the next ticket to Venezuela or Cuba or North Korea, and take your father with you. I rather have a million illegal immigrants from Mexico seeking to make a buck in this country than a 20 something whining that society is not taking care of her father’s medical bills, WHILE she saves her own earnings. Cubana Airline’s flight to Habana leaves from Mexico City on a weekly basis. And get off this blog, you big dope

43. “You are seeing the retail bill and it has very little to do with the real bill which is a contracted rate.”

    Michael, in your opinion, how much of an effect does the utter lack of transparency in medical services pricing have on the overall healthcare affordability issue? My b-school training leads me to thinking that an opaque price structure is in itself a major contributor to the problem.

44. Agree with Percy Dovetonsils.
    The billing (either from a hospital or from a private practitioner) appear to be arbitrary and not known in advance. Any other business that provides service to customers would lose clientele pretty quickly if they use this model. I read about some cash-only doctors who provide their price list before treatment, and it’s firm and clear – but it’s a rarity and rather an exception than a rule.

    Sol:
    but that’s the thing: if you prepped for surgery, you can’t go to a mall for your CATSCAN or other tests, it has be all in one place. Besides, I know my experience is limited by 19 years in NYC, but I can’t imagine MRI at the mall. When you had your operation, did you pay full sum out of pocket or pay the balance remained after Medicare or other health insurance payment?
    I have no emotional attachment to Medicare, believe me – and I know all about its gross failures. What I wanted to know – and I thought other people already figured it out – what other ways to get quality medical care for an average senior on a limited income? I understand that if my parents (again: or any other average senior)dropped Medicare, no other insurance will take them on the same relatively inexpensive premium schedule, if they take them at all, as they have a host of illnesses and “preexisting conditions”.

    JB: now try to breath, in-out, in-out. Or you’ll get a premature heart attack. Would you have enough money to pay the bill IN FULL? Very much doubt it.
    Besides, you’re inconsistent: you want me (a fellow tax-paying US citizen) to pay my and my parents’ bills in cash, but your parents rely on insurance. Why don’t you pay for them? You’re a bad son, JB! – apart from being a total ignoramus and sanctimonious hypocrite.

45. Tatyana,

    It’s not the patients’ fault, it’s the voters’ fault. And as far as your basic question, the real answer is that quote from Animal House: “You f****d up… you trusted us!”

46. Michael, in your opinion, how much of an effect does the utter lack of transparency in medical services pricing have on the overall healthcare affordability issue? My b-school training leads me to thinking that an opaque price structure is in itself a major contributor to the problem.

    I think it is a huge part of the problem. No one knows what their care costs.

    One example. Many of us with high deductible insurance have a provision that we will pay 20% of the bill after the $5,000 (or less) deductible. So, we get a bill for $16,000, for example. We pay $5,000 plus $2200 for the 20%. What do you think the insurance company pays ? $8800 ? Not on your life. They pay less than you paid for the “20%” copay plus deductible. In some cases, they pay nothing. The contract rate may be less than the $7200 you paid.

    Here is another tidbit from the Physician list that I had not thought of:

    The irony is that if you are a physician employed by a hospital, Medicare reimburses the hospital for your work at a cost plus basis. So if the hospital says the cost of your services (including all overhead) is $100 they will get paid the hundred bucks and then some.

    This is why more and more physicians and groups are selling their practices to hospitals and becoming employees. Hospitals can make money from your labor, you can’t. This is going to be the stake in the heart of private practice.

    This is interesting. The Byzantine ways of physician reimbursement grow more and more mysterious.

47. Kirk,

    it’s not so much a issue of broken of trust as a case of default on obligations. Deductions to Medicare and SS are automatic and involuntary and have been such for a long time.
    I think the downsizing Medicare and SS is inevitable and absolutely necessary, but it has to be done in stages/phases. And the money should not be coming from current 20+yo, as they are not be getting benefits they pay for now.

48. Tatiana:

    I own my own business and I always paid the full amount for health insurance for my self and my employees. We always had the best plan BCBS offered and never paid nothing for medical care. In the 80s the plan cost $100/month for each of us. In 2008 it cost $700/month. When I was forced onto Medicare I discovered that my doctors got screwed out of money they should have been paid and medicare required me to make copayments even though I had the best Medicare Advantage plan available. Further, I discovered that I could go to jail if I tried to pay the doctors extra money on top of what they were paid Medicare. In other word Medicare forces me to cheat the people whom I hope will save my life.

    I have died 3 times. All under my pre-medicare BCBS plan. So I have no desire to punish or cheat the man who brings me back to life. Not so the government. Their attitude is “how come he’s still alive? We cut your fee by 80%.” I’m afraid the next time I die it will be permanent. And I will go to jail if I try to make up the 80% that medicare cheats them out of.

    Now about Doctor’s pay. They make $250,000 per year. They work 80 hour weeks. If they were members of the UAW they would be paid $28/hour plus $12 in health and retirement or $40/hr. If a UAW member worked 40 hours overtime at double time, he would make $40 * 2080 hrs + $80 * 2080 hrs = $249,600. The average doctor makes $400 more than the average UAW autoworker. Of course, Doctors get unlimited overtime.

    Why do doctors work long hours? Because people need them. Because they like to cure people. Money is not all that important. It has a way of showing up. Patients are grateful and usually pay what they can. Doctors end up with nice cars and nice houses and their patients are glad for them and their neighbors are happy to live next door to a doctor. Doctors have job satisfaction. There is nothing quite so enjoyable as working a miracle cure or saving a child’s life, or leg or hand.

    What would happen if there was no medicare, no health insurance, and no malpractice law. Further, assume that the FDA would allow technicians to own the machines they operate. Doctors would charge their patients based on what they can afford. It was done that way before 1960. No point in being a doctor if nobody can afford you.

    Before Medicare, Hospitals were charitable institutions. Medicare made charity illegal. Now hospitals are dangerous places where you can catch MRSA. The charitable hospital model has worked for 3,000 years (since Hippocrates) and it can work again. All we need to do is eliminate Medicare and the lawyers.

    My first computer needed 2000 square feet, 10 operators, and cost over $1,000,000. It had almost 20,000 bytes of memory and almost 5 mb of disk storage. Today you can buy a netbook for $300 that is totally better. The price of computing has dropped enormously.

    For some reason the prices of MRIs and CATSCANs (which are nothing more than hi tech computer based systems) have risen since they were invented. I think the prices will drop if price controls are removed and bad laws, Medicare and insurance plans are abolished. I do know that a few years ago a few entrepreneurs had purchased CATSCANs and were selling “full body” scans at the mall for $500 each. The FDA closed them down.

    When price controls exist, no one dares to lower a price because they fear they will never be able to raise it back up. Back in the 70s when the Feds had price controls for oil, the government constantly pushed for lower prices and suppliers continually searched for reasons to raise prices. Price controls cause prices to rise.

    Reagan campaigned on the promise to end price controls. Carter argued, as did every Democrat, that oil prices would skyrocket when price controls were removed. When Reagan was elected he eliminated price controls all at once. Suddenly gasoline shortages disappeared. Gas prices, home heating oil prices, and oil by the barrel prices fell 50% in less than a year. Sadly some of the people sent to jail in the 70s because they violated the price control laws died in prison. I expect prices will tumble when Medicare and insurance based price controls are removed.

    Here is an old joke. “The British have decided to join the rest of Europe and drive on the right. However, they plan to switch over gradually. Starting in September trucks and buses will drive on the right. In December everyone else will switch over to driving on the right.” Eliminating Medicare, health insurance and malpractice law cannot be done gradually. It must be done all at once — otherwise there will be accidents.

49. No one I know well is in medicine – except on this blog. No one in our family has had a long-term or chronic illness. We’ve been covered for decades by state insurance and my employees were young or had spouses covered by the state. So I’ve ignored how bizarre the system has become. But I looked up a couple of week’s ago to see the shock on my daughter’s face when I said her birth hadn’t been covered by insurance. We were pretty much average young people (professionals in fact) with pretty average insurance; we wanted to have a baby, well, we saved up a bit, but it was under a thousand. If she’d arrived with major problems, the insurance would have kicked in. Those weren’t the dark ages and the infant mortality rate had already seen major improvements. She couldn’t imagine that world & that time.

    When did we start thinking that we shouldn’t pay for anything. But that isn’t even true, of course; -the co-pays have kicked in and aren’t all that small. The staff (many of whom have minimal service skills) and the people in accounting at our doctors, dentists, hmo outnumber doctors and RNs by a
    good-sized ratio. Do we really need all those people filling out all those papers? Do they really improve our health? And how much more money is going into those services when Obama’s plan kicks in. Why can’t our government if it must and our insurance companies if they can insure us for catastrophes? We couldn’t afford a heart transplant if one of us needed it next year. But we would be more likely to afford our regular bills if we just paid them and the middle men were cut out.

50. Sol,
    even if your prognosis will prove true, and prices will fall 50% within a year, for lots of people that transitional year of high prices will be fatal: they wouldn’t be able to afford the bills.
    Also: charity model failed, not proved itself successful. To see that just look at descriptions of hospitals and state of medicine and medics for the last 3000 years – doctors were considered not better than barbers, and rightly so, with their leeches and blood-letting, and the hospitals – organized death wards.
    If you give something out of charity, you expect people to be grateful for what they get, and shut up about the quality of care they received. This is not a model that stimulates innovation and progress. I rather prefer healthcare institutions run as service business. I don’t see why normal people, who honestly worked all their lives and made contributions into their healthcare should rely on goodwill of some charity.

51. ‘To see that just look at descriptions of hospitals and state of medicine and medics for the last 3000 years – doctors were considered not better than barbers, and rightly so, with their leeches and blood-letting, and the hospitals – organized death wards.’

    1. Thats more a matter of technology than payment system, and also, hospitals are still organized death wards just less than they used to be. Look at statistics for morbidity from thoracic surgery for example. Another great example is risk of infection from hospital visits.

    2. Your answer is raising taxes. That doesn’t work. Raising taxes to pay for medical care isn’t enough, you also have to start denying or delaying care for it to become fully fundable via taxes.

52. ‘The staff (many of whom have minimal service skills) and the people in accounting at our doctors, dentists, hmo outnumber doctors and RNs by a good-sized ratio. Do we really need all those people filling out all those papers? Do they really improve our health? And how much more money is going into those services when Obama’s plan kicks in. ‘

    The overhead is a result of attempts at cost cutting measures. One of the reasons that the per unit costs for doctors that don’t accept medicare is so low, is that they don’t have to hire people to deal with medicare reimbursements. I don’t have medical insurance, so I shop around for my medical needs, and the price varies a lot. I got a doctor to look at my symptoms and prescribe me antibiotics for about 30 dollars because I shopped around. When looking at prices some doctors were charging as much as 120 dollars for an office visit.

53. ‘For some reason people talk about Medicare in a context as if it’s a handout, something government gives “for free”. It’s not a grant, it’s an insurance being funded by seniors’

    Not actually true.

    1. It has negative cash flow, so it is a grant in party.
    2. The expectation value for medicare reimbursements is significantly less than long term market return on investment. In other words, they would be far better off investing that money into the bond market and paying their medical bills out of that that they would be paying that money into medicare.

54. Once again, the doctors who are dropping out of Medicare are lowering their fees by 80%. What they are doing is charging, in cash, what they were previously being paid by Medicare. The difference is that they are paid promptly and they do not need all the staff for collecting from the insurance companies.

    The busiest hip replacement surgeon in Newport Beach has dropped out of Medicare. He charges $1250 for a total hip. A physician friend fractures his wrist playing tennis. He went to another well known orthopedist in the county. He has also gone to cash practice. When they do this, they drop the fiction that a total hip costs $5,000. They not being paid that so they drop the fee to what they are being paid. They also post fees, similar to the French system. Transparency returns.

    Hospitals have a more difficult problem but there are now specialty hospitals appearing. There is a very modern hospital in Irvine that opened 20 years ago and failed. It has been closed for several years and Hoag Memorial, the big hospital in Newport Beach has bought it. Soon, it will reopen as an orthopedic only hospital. There are cardiac only hospitals opening. They can operate more cheaply and are considered a threat by most general hospitals. Now, we see Hoag, a general hospital, opening its own specialty hospital. I don’t think they are counting on Medicare.

    It will be interesting to see how this evolves.

55. Doc Merlin: pray, point to where I said that “my answer is raising taxes”.

56. Doc Merlin:
    of course Medicare is bankrupt now, and of course the seniors WOULD BE better off if they invested their payments to it over lifetime into alternative schemes.
    But it is all from “if” category.
    The reality is that they (and so far, us, and our children) are involuntary participants in state-enforced Ponzi scheme. It is not seniors’s fault that the money they were forced to contribute were mismanaged by the State. State has a legal obligation to deliver on their promises.
    Is that so difficult to understand? I have been saying the same thing from the beginning of this thread – and I have been accused of god knows what.
    Don’t put words into my mouth, OK?

57. Tatiana:

    People don’t need insurance and medicare to get health care. The doctors and nurse are not going to keep prices so high that patients end up dying of disease and the doctors and nurse die of starvation because they have no income. In a free market supply and demand come together at a price where patients get healed and doctors and nurse get fed. I predict this will happen at current Medicare reimbursement rates. However, there are many good arguments that equilibrium prices will be much lower.

    Prices will fall quickly. As Dr Kennedy points out, doctors are paid only 20 cents on the dollar. So if they continue to bill what they are currently paid, prices will “fall” 80%.

    “Why would Doctors and hospitals be happy with Medicare payment when they complain the payments are too low?” you ask. No Medicare means no paperwork. No insurance means no paperwork.

    For example. Doctor walks into exam room, looks at patient, guesses what’s wrong. Taps patients knee with a hammer, asks a couple questions, prescribes some pills. Patient pays $30 at the desk and leaves. Total time 15 minutes. A week later patient’s totally healthy and another disease bites the dust!

    With Medicare doctor does the same thing. THEN he has to fill out forms describing the tests he made, what he diagnosed, how he got there, what he prescribed. 7 minutes for paperwork. He charges $150. Medicare sends $30 unless it disagrees with diagnosis and wants more facts.

    Summing up — without Medicare and insurance, doctor sees 30 patients, 15 minutes each = 7 ½ hours. With medicare and/or insurance, 7 ½ hours for treatment plus 7 minutes each (3 ½ hours) for paperwork. No increase in pay, 50% increase in work.

    So the doctor hires a registered nurse at $20/hour to fill out insurance forms, write letters if insurance company or medicare disagree. Doctors often hire billing specialists who speak the language of Medicare and insurers and know which secret medical codes pay the best.

    Most people can afford to pay out of pocket what Medicare or insurance companied pay to providers. However, the Medicare 80% discounts are available only to Medicare and insurance companies. If you or I try to pay them and the doctor accepts, this transaction would be called Medicare fraud and both the doc and patient go to jail. Medicare does this to us for our own good.

    All we have to do is take our Medicare premiums and insurance premiums and save them in a cookie jar and spend that money for medical costs. Warning: Don’t save at banks where government will tax savings. Also doctors prefer cash over checks and credit cards because it saves them a trip to the banks.

    So if Medicare and insurance are eliminated we patients will pay what Medicare used to pay, the doctors and hospitals will save enormously on paper work and regulatory costs and a whole bunch of lawyers and government workers will be out of work – and they all vote Democrat.

    Yes, Tatiana, prices will come down 50-80% and perhaps even more because Medicare is really a price control system that forces prices up. Now for those people who currently don’t have insurance. The system is currently taking care of them for free and it will continue to do so after Medicare and Insurances are gone.

    People without insurance are required by law to pay the super high prices no one can afford. Doctors usually treat them by pretending they never saw them and never record them on their books. Hospitals cannot treat people off the books but they can make deals on payments. For example suppose a girl decides to have a baby rather than a $500 abortion. The delivery costs $20,000. I know several girls who have agreed to pay $5/month until principal and interest are paid (ie – every month until God comes to judge the living and the dead).

    A good question to ask is “Why should insurance companies and Medicare get a discount?” Is it because the doctor gets to fill out extra paper work? NO. Is it because the doctor gets hassled? NO. Is it some sort of “volume discount”? NO. Then, why does this discount exist? Is it to scare people into buying insurance or accept Medicare?

58. “Why would Doctors and hospitals be happy with Medicare payment when they complain the payments are too low?” you ask.

    No I didn’t. I know about Medicare payment scheme, no need to chew on it for me.

    Sol, I’m not a 5yo. Don’t tell me fairy tales. People without insurance are required by law to pay the super high prices no one can afford. Doctors usually treat them by pretending they never saw them and never record them on their books. No they don’t. They charge them almost the same price they would fill in on insurance claims. My sister was charged ~$1000 for an CATSCAN + consultation+ samples of medication (that doctor received for free from pharma reps) for a twisted ankle at orthopedic surgeon’s office. And that doctor does not accept insurance anymore!
    First you tell me it’s immoral to ask the doctors to work for free (I agree), then you say they do just that, for patients w/o insurance…They must be suicidal – or altruistic to they point of self-distract!

    I don’t believe the prices will fall sharp even if the doctors will save on disappeared paperwork. And there is no doctor worth the piece of paper he writes the proscription on who’ll charge $30 for a visit.

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