U.S. Politics: Confirming The Trumpocalypse

[TrackerNeil]

51 minutes ago, Ser Scot A Ellison said:

Commodore,

Sure, but if you are saying such choice is just like the choice to buy or not buy a washer and dryer you are kiding yourself.  This is choice on a different emotional plain and as such should be looked at differently from other economic decisions.

I think that "kidding yourself" pretty much sums up most of the impetus to repeal the Affordable Care Act. That, or thinly disguised indifference to human suffering.

[Week]

20 minutes ago, Rippounet said:

So what I gather from my quick search is that there is a small gap in spending between the US and Europe, but that this does not translate into a significant difference in innovation. Of course, this was only a quick search and I'm not  an expert... But I think if the US was far ahead we'd know it (Europeans would flock to the US to get treatment for instance, just as Eastern Europeans sometimes move to Western Europe for that purpose).

What do the folks on the other side of the pond have for penis pills? I bet your penis pills are nowhere near as good as our penis pills.

[A Horse Named Stranger]

Chinese pills made of Tiger spare parts are best.

Having said a sentence I never believed I would say. Now to something completely different.

 

I hope that Russian stuff all leaks out within weeks after the inaugaration. And I hope it's so upsetting that Hannity throws himself from the top of the Trump Tower. Nah, don't worry. The second part will not happen, as Hannity has no shame. So he is safe.

[Ice Queen]

50 minutes ago, Ser Scot A Ellison said:

But to be clear, I favor this system despite its draw backs for the very utilitarian reasons for which I criticize it.  I think Single Payer provides the best coverage to the most people.  I'm simply pointing out that it cannot be perfect, nothing can.

We're at least in agreement that no system is perfect, but even ACA is an improvement. Don't repeal it--no need to take an axe to it when all you need is a scalpel. 

It's either single payer or total universal. Personally, I like universal because I think the insurance companies are evil--making a profit on people's suffering is just immoral IMO. Take them out of the equation altogether. 

[Ser Scot A Ellison]

1 minute ago, Crazy Cat Lady in Training said:

We're at least in agreement that no system is perfect, but even ACA is an improvement. Don't repeal it--no need to take an axe to it when all you need is a scalpel. 

It's either single payer or total universal. Personally, I like universal because I think the insurance companies are evil--making a profit on people's suffering is just immoral IMO. Take them out of the equation altogether. 

How many people would be put out of work if you just made private health insurance illegal?  

[Ice Queen]

Trump's non-news conference. When they trotted out Pence I didn't think Trump would show up. LOL

[Rippounet]

11 minutes ago, Week said:

What do the folks on the other side of the pond have for penis pills? I bet your penis pills are nowhere near as good as our penis pills.

You guys need pills for your penises? I don't think we have that kind of problem here...

[Ice Queen]

2 minutes ago, Ser Scot A Ellison said:

How many people would be put out of work if you just made private health insurance illegal?  

Where did I say illegal? 

Let me ask you something. Why should someone who makes $8 an hour at an insurance company have more decision-making power over life or death than a physician? 

[MerenthaClone]

Oh boy healthcarechat! I should mention that I work in the same medical system that Crazy Cat Lady in Training's mother was treated at.  

So, first, in the hospital, Medicare works in a block system.  That is, if you're diagnosed with, say, pneumonia, they'll pay a set amount of money to the hospital for the treatment of pneumonia, (usually) regardless of what was done to the patient.  The reimbursement rate is set based on the average cost that hospitals incur treating pneumonia across the country, so if you can get as good outcomes with fewer resources, you get increased profit.  They are explicitly not fee-for-service at this time, so hospitals do not get reimbursed for a battery of unnecessary tests.  This is heavily modified by many things, including patient satisfaction surveys, value-based metrics, and readmission rates.  The middle one is the interest here, in that hospitals who regularly have good outcomes with lower costs get reimbursed at a higher rate for whichever diagnosis-related-group we're talking about, specifically to prevent bombarding people with tests/treatments that aren't going to alter outcomes.  Reimbursement is also modified by some factors for specific DRGs.  If you don't meet certain benchmarks, the hospital reimbursement is either reduced or eliminated altogether.  In most cases, these are reasonable (if you don't hit an acceptable door-to-drug time for acute strokes, you don't get paid) and in some, they're utterly not (hospitals are basically resigned to eat the cost of sepsis every time).  

So, on to CCLIT's mother.  Unless there was an initial test showing or leading the doctor to suspect that there was early DM2, none of those tests would have been reimbursed.  Conversely, it is possible that if those tests did meet certain CMS criteria, and certain follow-up tests were not ordered, that they wouldn't meet the benchmarks for adequate care laid out by CMS.  As an example, I'm going to talk about sepsis for a second since its what I know.  CMS requires that every patient that meets sepsis criteria receive a crystalloid fluid bolus equal to 30mL/kg, at a rate of ~2L/hr within an hour of those criteria being charted.  If that patient does not receive that bolus, the hospital will receive no reimbursement for anything specifically sepsis-related for the rest of the admission.  This is, for anyone know knows anything about, say heart failure, potentially a fucking terrible idea, (and why I expect that this specific benchmark will be changed soon)  but if you come in with vitals that meet sepsis criteria, you're going to get a specific battery of tests and treatments.  Almost every time.  And yes, my hospital policy is to eat the cost and not give a large, rapid fluid bolus to anyone that it isn't appropriate for, relying on the MD and RN to document why while the finance whoevers appeal (so far unsuccessfully) to CMS.  Their sepsis protocol is very much a work in progress.  So, if CCLIT's mother met certain criteria, I can absolutely see CMS's DRG system essentially forcing her doctor to order tests just so that UPMC doesn't eat all or some of the cost at a later date. In theory, that does mean that now you've ruled out DM2 for awhile, and you've ensured that doctors aren't under-treating or ignoring potential warning signs for DM2.

Now, on to triage!  No matter what, in a healthcare system, people will suffer.  At a certain point, higher levels of care start being detrimental to the patient, but with those detriments balanced by the benefits.  We shouldn't put everyone in an ICU even though a lot of in-hospital harm is related to people not being in a high enough care environment, because then we'd be placing people at risk for ICU delirium, increased infection, and more.  Its not worth it completely from a medical side, even ignoring the ludicrous costs that ICU care for everyone would bring.  See: complaints about unnecessary tests, but ramped up several times.  So there's that.  And yes, adding in a single-payer system will probably result in slightly increased triaging of care, but we're actually really good at triaging things.  This is something the system would be able to easily flex to.  The framework is already there, you'd just need to expand services to outpatient treatment areas which is not only better for the healthcare system, its better for the patient.  

Yes, occasionally CMS has frustrating guidelines (ask me sometime how I feel about perverse incentives caused by patient satisfaction surveys) but in general, they give hospitals leeway to treat effectively.  Even the sepsis guidelines, which are frustrating, serve a purpose.  Sepsis is still the hot new thing.  Plenty of hospitals were and still are utterly failing to treat and diagnose it effectively and these guidelines help.  Several years ago, similar methods were put in place to improve stroke and MI outcomes, and they worked very well.  I have faith that sepsis protocols will likewise get there.  

[Mexal]

This press conference is bad. He took 3 questions. Also, Trump isn't divesting any of his interest in Trump Organization so conflict of interests won't change.

[Week]

26 minutes ago, Mexal said:

This press conference is bad. He took 3 questions. Also, Trump isn't divesting any of his interest in Trump Organization so conflict of interests won't change.

Reince Priebus went out to the hacking defense market and said "buy me the best hacking defense I can buy!" Way to go buddy!

[Mr. Chatywin et al.]

This is bizarre, and frankly, rather scary.

We're so screwed....

[Gertrude]

This press conference is a shit show. He's really showcasing his ability to completely divorce himself from fact, reason, grace or anything resembling personal qualities you want in a president. Go America!

[Mexal]

1 minute ago, Tywin et al. said:

This is bizarre, and frankly, rather scary.

We're so screwed....

Beyond screwed. This is insane.

[Ice Queen]

34 minutes ago, MerenthaClone said:

Oh boy healthcarechat! I should mention that I work in the same medical system that Crazy Cat Lady in Training's mother was treated at.  

So, first, in the hospital, Medicare works in a block system.  That is, if you're diagnosed with, say, pneumonia, they'll pay a set amount of money to the hospital for the treatment of pneumonia, (usually) regardless of what was done to the patient.  The reimbursement rate is set based on the average cost that hospitals incur treating pneumonia across the country, so if you can get as good outcomes with fewer resources, you get increased profit.  They are explicitly not fee-for-service at this time, so hospitals do not get reimbursed for a battery of unnecessary tests.  This is heavily modified by many things, including patient satisfaction surveys, value-based metrics, and readmission rates.  The middle one is the interest here, in that hospitals who regularly have good outcomes with lower costs get reimbursed at a higher rate for whichever diagnosis-related-group we're talking about, specifically to prevent bombarding people with tests/treatments that aren't going to alter outcomes.  Reimbursement is also modified by some factors for specific DRGs.  If you don't meet certain benchmarks, the hospital reimbursement is either reduced or eliminated altogether.  In most cases, these are reasonable (if you don't hit an acceptable door-to-drug time for acute strokes, you don't get paid) and in some, they're utterly not (hospitals are basically resigned to eat the cost of sepsis every time).  

So, on to CCLIT's mother.  Unless there was an initial test showing or leading the doctor to suspect that there was early DM2, none of those tests would have been reimbursed.  Conversely, it is possible that if those tests did meet certain CMS criteria, and certain follow-up tests were not ordered, that they wouldn't meet the benchmarks for adequate care laid out by CMS.  As an example, I'm going to talk about sepsis for a second since its what I know.  CMS requires that every patient that meets sepsis criteria receive a crystalloid fluid bolus equal to 30mL/kg, at a rate of ~2L/hr within an hour of those criteria being charted.  If that patient does not receive that bolus, the hospital will receive no reimbursement for anything specifically sepsis-related for the rest of the admission.  This is, for anyone know knows anything about, say heart failure, potentially a fucking terrible idea, (and why I expect that this specific benchmark will be changed soon)  but if you come in with vitals that meet sepsis criteria, you're going to get a specific battery of tests and treatments.  Almost every time.  And yes, my hospital policy is to eat the cost and not give a large, rapid fluid bolus to anyone that it isn't appropriate for, relying on the MD and RN to document why while the finance whoevers appeal (so far unsuccessfully) to CMS.  Their sepsis protocol is very much a work in progress.  So, if CCLIT's mother met certain criteria, I can absolutely see CMS's DRG system essentially forcing her doctor to order tests just so that UPMC doesn't eat all or some of the cost at a later date. In theory, that does mean that now you've ruled out DM2 for awhile, and you've ensured that doctors aren't under-treating or ignoring potential warning signs for DM2.

Now, on to triage!  No matter what, in a healthcare system, people will suffer.  At a certain point, higher levels of care start being detrimental to the patient, but with those detriments balanced by the benefits.  We shouldn't put everyone in an ICU even though a lot of in-hospital harm is related to people not being in a high enough care environment, because then we'd be placing people at risk for ICU delirium, increased infection, and more.  Its not worth it completely from a medical side, even ignoring the ludicrous costs that ICU care for everyone would bring.  See: complaints about unnecessary tests, but ramped up several times.  So there's that.  And yes, adding in a single-payer system will probably result in slightly increased triaging of care, but we're actually really good at triaging things.  This is something the system would be able to easily flex to.  The framework is already there, you'd just need to expand services to outpatient treatment areas which is not only better for the healthcare system, its better for the patient.  

Yes, occasionally CMS has frustrating guidelines (ask me sometime how I feel about perverse incentives caused by patient satisfaction surveys) but in general, they give hospitals leeway to treat effectively.  Even the sepsis guidelines, which are frustrating, serve a purpose.  Sepsis is still the hot new thing.  Plenty of hospitals were and still are utterly failing to treat and diagnose it effectively and these guidelines help.  Several years ago, similar methods were put in place to improve stroke and MI outcomes, and they worked very well.  I have faith that sepsis protocols will likewise get there.  

Thanks very much for that explanation. So you work for UPMC, eh? I won't bombard you with questions--I have Highmark.  

I understand that Medicare works differently than other insurance, which is why I was so angry that she was diagnosed by her doctor as pre-diabetic with an A1C of 5.1 and FBG of 90, which is well below the threshold by any standard. My impression was that the doctor was attempting to get reimbursed through Medicare for unnecessary tests--effectively committing Medicare fraud and potentially harming my mother's health in the process. She'd been his patient for years, yet he didn't seem to care about ordering that battery of tests until she turned 65 and got Medicare; then it was a whole new ballgame. The nurse on call at UPMC agreed with me and if I remember right the doctor was warned. 

You mention the hospital not being reimbursed for anything sepsis related if that bolus isn't given within the stated time frame. What's to stop a doctor or nurse from charting that it was given even if it wasn't, or would that show up in a pharmacy audit?

One of my neighbors died last year from urosepsis--an undiagnosed UTI while she was in an in-patient skilled nursing facility. I'm sure you see that kind of thing a lot. 

Edit: As I understand it, the rates of HAI are decreasing for a lot of states, except in ICU which really is understandable. So the situation is improving, though still not fabulous. 

[Manhole Eunuchsbane]

 Can anyone remember such a circus sideshow of a press conference from a President in your lifetime? Holy shit, this is surreal. He's at war with his own Intelligence Apparatus and he hasn't even taken office yet.

[Ser Scot A Ellison]

22 minutes ago, Crazy Cat Lady in Training said:

Where did I say illegal? 

Let me ask you something. Why should someone who makes $8 an hour at an insurance company have more decision-making power over life or death than a physician? 

I don't think they should.  I've never said they should.  I'm saying that there are consequences for every "positive" action that are not necessarily positive.  The job loses in the Health insurance industry if it ceased to be would be a negative consequence.

[Lordsteve666]

Holy crap this press conference is utterly bizarre.

Its like watching a child having a tantrum crossed with a compulsive liar crossed with someone who doesn't have good use of their native language and clearly does not even have a clue about what they are talking about. 

Plus the way trump is acting is about as un-presidential as you could possibly get. Seriously, he make Rodrigo Duterte look statesmanlike .

Insult security services -check, insult press -check, get into arguments with press -check, refuse to answer questions -check, present vague nebulous ideas as well planned policy solutions -check, accuse someone of acting like Nazis -check. 

What kind of insane hell is the US about to tip into?!?!

[A Horse Named Stranger]

Looks like I need to watch this.

While the world is going to hell, it at least sounds like somewhat entertaining. But I also enjoyed the Saw movies. But that's probably not the best standard to judge a press conference by the PEOTUS. 

[Jo498]

If now many people have almost no access to healthcare is it so obvious that there would be net job losses? Demand should rise, so it does not seem to be clear if the pruning of inefficiencies or redundancies will result in overall losses or gains. And if the current system is highly inefficient should we not welcome more efficiency even if it implies that some jobs are lost?