The (medical) cost conundrum: McAllen, TX

The Cost Conundrum

What a Texas town can teach us about health care.

by Atul Gawande June 1, 2009



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Costlier care is often worse care. Photograph by Phillip Toledano.

Related LinksAudio: An interview with Atul Gawande.




It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.


McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.


The explosive trend in American medical costs seems to have occurred here in an especially intense form. Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government. “The greatest threat to America’s fiscal health is not Social Security,” President Barack Obama said in a March speech at the White House. “It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”
The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.


From the moment I arrived, I asked almost everyone I encountered about McAllen’s health costs—a businessman I met at the five-gate McAllen-Miller International Airport, the desk clerks at the Embassy Suites Hotel, a police-academy cadet at McDonald’s. Most weren’t surprised to hear that McAllen was an outlier. “Just look around,” the cadet said. “People are not healthy here.” McAllen, with its high poverty rate, has an incidence of heavy drinking sixty per cent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate.


One day, I went on rounds with Lester Dyke, a weather-beaten, ranch-owning fifty-three-year-old cardiac surgeon who grew up in Austin, did his surgical training with the Army all over the country, and settled into practice in Hidalgo County. He has not lacked for business: in the past twenty years, he has done some eight thousand heart operations, which exhausts me just thinking about it. I walked around with him as he checked in on ten or so of his patients who were recuperating at the three hospitals where he operates. It was easy to see what had landed them under his knife. They were nearly all obese or diabetic or both. Many had a family history of heart disease. Few were taking preventive measures, such as cholesterol-lowering drugs, which, studies indicate, would have obviated surgery for up to half of them.



Yet public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too. El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high. (Or the reason that America’s are. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)


Was the explanation, then, that McAllen was providing unusually good health care? I took a walk through Doctors Hospital at Renaissance, in Edinburg, one of the towns in the McAllen metropolitan area, with Robert Alleyn, a Houston-trained general surgeon who had grown up here and returned home to practice. The hospital campus sprawled across two city blocks, with a series of three- and four-story stucco buildings separated by golfing-green lawns and black asphalt parking lots. He pointed out the sights—the cancer center is over here, the heart center is over there, now we’re coming to the imaging center. We went inside the surgery building. It was sleek and modern, with recessed lighting, classical music piped into the waiting areas, and nurses moving from patient to patient behind rolling black computer pods. We changed into scrubs and Alleyn took me through the sixteen operating rooms to show me the laparoscopy suite, with its flat-screen video monitors, the hybrid operating room with built-in imaging equipment, the surgical robot for minimally invasive robotic surgery.


I was impressed. The place had virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers. Poor towns don’t. But that rule doesn’t hold for health care.


At McAllen Medical Center, I saw an orthopedic surgeon work under an operating microscope to remove a tumor that had wrapped around the spinal cord of a fourteen-year-old. At a home-health agency, I spoke to a nurse who could provide intravenous-drug therapy for patients with congestive heart failure. At McAllen Heart Hospital, I watched Dyke and a team of six do a coronary-artery bypass using technologies that didn’t exist a few years ago. At Renaissance, I talked with a neonatologist who trained at my hospital, in Boston, and brought McAllen new skills and technologies for premature babies. “I’ve had nurses come up to me and say, ‘I never knew these babies could survive,’ ” he said.


And yet there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.



Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.


One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.


Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.


“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.



Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.


“It’s malpractice,” a family physician who had practiced here for thirty-three years said.



“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.


That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?


“Practically to zero,” the cardiologist admitted.


“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”
Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.


The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.


Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.


I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?


Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.


And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.


“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.


To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice, which has three decades of expertise in examining regional patterns in Medicare payment data. I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.


The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.


This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.


In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.


That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.


To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.


In an odd way, this news is reassuring. Universal coverage won’t be feasible unless we can control costs. Policymakers have worried that doing so would require rationing, which the public would never go along with. So the idea that there’s plenty of fat in the system is proving deeply attractive. “Nearly thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” Peter Orszag, the President’s budget director, has stated.


Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.


I had what I considered to be a reasonable plan for finding out what was going on in McAllen. I would call on the heads of its hospitals, in their swanky, decorator-designed, churrigueresco offices, and I’d ask them.
The first hospital I visited, McAllen Heart Hospital, is owned by Universal Health Services, a for-profit hospital chain with headquarters in King of Prussia, Pennsylvania, and revenues of five billion dollars last year. I went to see the hospital’s chief operating officer, Gilda Romero. Truth be told, her office seemed less churrigueresco than Office Depot. She had straight brown hair, sympathetic eyes, and looked more like a young school teacher than like a corporate officer with nineteen years of experience. And when I inquired, “What is going on in this place?” she looked surprised.
Is McAllen really that expensive? she asked.


I described the data, including the numbers indicating that heart operations and catheter procedures and pacemakers were being performed in McAllen at double the usual rate.



“That is interesting,” she said, by which she did not mean, “Uh-oh, you’ve caught us” but, rather, “That is actually interesting.” The problem of McAllen’s outlandish costs was new to her. She puzzled over the numbers. She was certain that her doctors performed surgery only when it was necessary. It had to be one of the other hospitals. And she had one in mind—Doctors Hospital at Renaissance, the hospital in Edinburg that I had toured.


She wasn’t the only person to mention Renaissance. It is the newest hospital in the area. It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given. (In 2007, its profits totalled thirty-four million dollars.) Romero and others argued that this gives physicians an unholy temptation to overorder.
Such an arrangement can make physician investors rich. But it can’t be the whole explanation. The hospital gets barely a sixth of the patients in the region; its margins are no bigger than the other hospitals’—whether for profit or not for profit—and it didn’t have much of a presence until 2004 at the earliest, a full decade after the cost explosion in McAllen began.


“Those are good points,” Romero said. She couldn’t explain what was going on.


The following afternoon, I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined “Opinions from an Unrelenting Conservative Spirit.” He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let’s-get-this-over-with.


So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”


Then why do hospitals in McAllen order so much more surgery and scans and tests than hospitals in El Paso and elsewhere?


In the end, the only explanation he and his colleagues could offer was this: The other doctors and hospitals in McAllen may be overspending, but, to the extent that his hospital provides costlier treatment than other places in the country, it is making people better in ways that data on quality and outcomes do not measure.



“Do we provide better health care than El Paso?” Gelman asked. “I would bet you two to one that we do.”


It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.



And, I realized, few people in their position do. Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How is Lawrence Gelman or Gilda Romero to know whether all that is essential, let alone the best possible treatment for the patient? It isn’t what they are responsible or accountable for.


Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.


If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.


Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things.


Why? Some of it could reflect differences in training. I remember when my wife brought our infant son Walker to visit his grandparents in Virginia, and he took a terrifying fall down a set of stairs. They drove him to the local community hospital in Alexandria. A CT scan showed that he had a tiny subdural hematoma—a small area of bleeding in the brain. During ten hours of observation, though, he was fine—eating, drinking, completely alert. I was a surgery resident then and had seen many cases like his. We observed each child in intensive care for at least twenty-four hours and got a repeat CT scan. That was how I’d been trained. But the doctor in Alexandria was going to send Walker home. That was how he’d been trained. Suppose things change for the worse? I asked him. It’s extremely unlikely, he said, and if anything changed Walker could always be brought back. I bullied the doctor into admitting him anyway. The next day, the scan and the patient were fine. And, looking in the textbooks, I learned that the doctor was right. Walker could have been managed safely either way.


There was no sign, however, that McAllen’s doctors as a group were trained any differently from El Paso’s. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.


“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.


He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing.

“It’s a machine, my friend,” one surgeon explained.


No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.


Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.


Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.



Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.


In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.


In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”



“How much?” I asked.


“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.


He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.


Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.


Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream.


Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.


“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.


About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.


The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.


I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.


“I’ll be there,” the cardiologist said.


Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.


The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.


The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.
“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.



“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.
Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.



The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.


Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.
This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.


When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.



There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.


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


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


One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.



“Medicine has become a pig trough here,” he muttered.



Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.


We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.


“I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.


How about doing the opposite and increasing the role of big insurance companies?


“What good would that do?” Dyke asked.


The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”


He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”


Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.


This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.


Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.


Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.


In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”


As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future. ♦

June 14, 2009
EDITORIAL

Doctors and the Cost of Care

As the debate over health care reform unfolds, policy makers and the public need to focus more attention
on doctors and the huge role they play in determining the cost of medical care — costs that are rising
relentlessly.

Doctors largely decide what medical or surgical treatments are needed, whether it will be delivered in a
hospital, what tests will be performed, and what drugs will be prescribed or medical devices implanted.

There is disturbing evidence that many do a lot more than is medically useful — and often reap financial
benefits from over-treating their patients. No doubt a vast majority of doctors strive to do the best for their
patients. But many are influenced by fee-for-service financial incentives and some are unabashed
profiteers.

All Americans are affected. Those with insurance are struggling to pay ever higher premiums, as are their
employers. If the government is going to help subsidize coverage for the millions of uninsured, it will need
to find significant savings in Medicare spending, at least some of which should come from reducing
over-treatment. In the long run, if doctors can’t be induced to rein themselves in, there is little hope of
lasting reform.

A glaring example of profligate physician behavior was described by Atul Gawande in the June 1 issue of
The New Yorker. (His article has become must reading at the White House.) Dr. Gawande, a Harvardaffiliated
surgeon and author, traveled to McAllen, Texas, to find out why Medicare spends more per
beneficiary there than in any other city except Miami.

None of the usual rationalizations put forth by doctors held up. The population, though poor, is not sicker
than average; the quality of care people get is not superior.

Malpractice suits have practically disappeared
due to a tough state malpractice law, leaving no rationale for defensive medicine. The reason for McAllen’s
soaring costs, some doctors finally admitted, is over-treatment. Doctors perform extra tests, surgeries and
other procedures to increase their incomes.

Dr. Gawande’s reporting tracks pioneering studies by researchers at Dartmouth into the reasons for large
regional and institutional variations in Medicare costs. Why should medical care in Miami or McAllen be far
more expensive than in San Francisco? Why should care provided at the U.C.L.A. medical center be far
more costly than care at the renowned Mayo Clinic?
After adjusting for differences in health, income, medical price and other factors, the Dartmouth
researchers’ overall conclusion is that the more costly areas and institutions provide a lot more tests,
services and intensive hospital-based care than the lower cost centers. Yet their patients fare no better and often fare worse because they suffer from the over-treatment.

Editorial - Doctors and the Cost of Care - NYTimes.com

The Dartmouth group estimates that up to 30 percent of Medicare spending is wasted on needless care.

Although most experts think the Dartmouth research is essentially right, a few believe that other factors,
including the health of individual patients, play a bigger role. Even if the over-treatment is less than the
Dartmouth researchers believe, their findings point to areas and institutions where Medicare should be able
to coax or push physicians to behave more prudently, for all their patients.

When President Obama speaks at the annual meeting of the American Medical Association on Monday he
will need all of his persuasive powers to bring doctors into the campaign for health care reform. Doctors
have been complicit in driving up health care costs. They need to become part of the solution.

Copyright 2009 The New York Times Company

============

For-profit health care is huge milk cow being sucked dry by doctors, hospitals, insurance companies, for 100s of $Bs annually.

For spending only few $100M, the for-profit-health care will easily, undoubtedly buy enough votes to kill cost reductions, single-payer, and a public insurance plan.

Bottom line, it doesn't matter who writes the checks if nobody's keeping track of waste and quality of care. The Mayo Clinic system seems to work: take away the financial incentives to overtreat patients, and let the doctors figure out how to treat people better for less.

June 14, 2009

POLICY AND PROFIT

Following the Money in the Health Care Debate

By REED ABELSON

Congress appears ready to confront one of the nation’s most contentious issues — health care reform — and
arguments will fill the air in the coming months.
Much of the discussion so far has focused on President Obama’s proposal for a government-sponsored
health plan that he says will reduce costs. Insurers and doctors argue it will limit patient choice. Drug
companies warn that the quality of care could be compromised.

But Mr. Obama’s proposal is only one of many that await Congress as it wrestles with how to rein in
exploding health care costs while taking care of the country’s nearly 50 million uninsured. The size and
complexity of the issue are daunting. To help understand what’s going on, you need to follow the money.
Roughly $2.5 trillion is at stake, the amount the nation spends each year on health care, nearly a fifth of the
American economy. How that money is divided up — or prevented from rising at its current pace — is at
the center of the debate. Many doctors, insurance companies and drug companies say they fear that their
revenues could shrink significantly and patient care could be threatened.

( what they really fear is cost reduction, since cost = their revenue )

Their arguments may prove to have merit. But “people are voting with their own economic interests,” said
Les Funtleyder, a Wall Street analyst who is following the debate closely for Miller Tabak & Co. in New
York.

When you hear nothing from one of the interest groups on an issue that is part of the larger debate, you can
assume the silence means it has no financial stake in the outcome, he said. “You wouldn’t probably weigh in
if you don’t have any skin in the game because if you weigh in, it makes you more of a target,” Mr.
Funtleyder said.

What all of the interest groups reliably support is any new program that would expand coverage to the
uninsured. Such a program would translate into tens of millions of new, paying customers for hospitals,
doctors, insurers and drug makers.

But what worries those groups is the accompanying talk in Washington about how to address the
skyrocketing cost of health care, since any decline in spending would correspond to a reduction in
revenues. The discussion has become particularly heated over exactly how the government will find the
savings necessary to help generate the $1 trillion or so that the government will need over the next decade
to pay for universal coverage. The nation’s doctors, for example, say they wholeheartedly support health
care reform. But the American Medical Association has a long history of being opposed to legislation that
Policy and Profit - Following the Money in the Health Care Debate - NY... http://www.nytimes.com/2009/06/14/we...lson.html?part...

threatens the status quo. It opposed the creation of Medicare more than 30 years ago.

What concerns doctors about a government-run insurance program that looks like Medicare is the
possibility that it will pay like Medicare, said Robert Laszewski, a health policy consultant in Alexandria, Va.
“Medicare pays doctors 80 percent of what an insurance company pays,” he said. “If you get a public plan, the doctors are going to get a 20 percent pay cut.”

But doctors are also likely to disagree among themselves over how different types of physicians should be
compensated. Congress is thinking about raising the pay of primary-care doctors — general practitioners,
family physicians and the like — as a way to encourage them to more actively oversee the care of patients
and reduce expensive visits to specialists and hospitals.

The specialists — the cardiologists, neurologists, surgeons and others — may have a different take on the
discussion, Mr. Laszewski noted, especially if Congress cannot raise salaries of primary-care doctors
without taking money from the highly paid specialists. “The question is, how are you going to help the
primary-care doctors without cutting the cardiologist and the other specialists?” he asked.

But even the family physicians, who stand to benefit the most, say they are opposed to a government-run
plan if it reimburses them at the Medicare rate.
Another group with a lot to win or lose is the nation’s private health insurers. With the number of people
who are privately insured through their employer or their own policy not increasing, insurers are eager to
find a new source of business. Health reform promises them at least some new customers who cannot
afford insurance now but who might receive government help to pay for coverage.

But the trade association, America’s Health Insurance Plans, has clearly staked out its opposition to any
kind of government-run health plan, which it says would have an unfair advantage. The trade group fears
its members would be driven out of business as the government uses its purchasing power to demand much
lower prices from doctors and hospitals.

( driven out of business? why not? they're fucking everybody now. A public insurance plan would kill them. Good riddance)

Karen Ignagni, the chief executive of the association, has criticized the government’s track record in
running Medicare as a good reason not to expand government health insurance beyond the elderly and
disabled. She says the program has done a poor job in taking care of people when they are very sick.

“Medicare has not effectively coordinated care, addressed chronic illness, or encouraged high
performance,” she recently told Congress.

( and the private non-Medicaare has addressed all those issues better? McAllen?)

As one way of finding savings to pay for health reform, Congress is also discussing lowering payments to
private insurers who are now being compensated to cover some Medicare patients. The A.M.A., perhaps
mindful that such savings would not come from doctors if it comes from insurers, says it supports such cuts.
The hospitals have also voiced concerns about a government-run plan. They, too, are paid much less by
Medicare than they are by private insurers.
The nation’s drug makers are also lining up against a public plan, predicting that it would ultimately lead to
a government takeover of the entire system. “I don’t think that American patients would — or should —
accommodate themselves to the long waits for care, limited options and other forms of rationing that
Policy and Profit - Following the Money in the Health Care Debate - NY... http://www.nytimes.com/2009/06/14/we...lson.html?part...

inevitably accompany government health care monopolies,” John C. Lechleiter, the chief executive of the
drug maker Eli Lilly & Co., recently told a meeting of business leaders. “American doctors and patients need
to retain the ability to make choices based on the real value of treatment options.”

( doctors make treatment decisions to maximize their take )

But drug companies are also wary of the government’s pull in demanding lower prices for their products
than the insurers they deal with today. “The more government intervention you have, the less payment you
have,” said Mr. Funtleyder, the analyst.

These companies are also concerned that the government will play a greater role in determining the
effectiveness of different drugs and medical devices and use that information to decide which should be
covered and how much the government will pay for those products. Insurers, not surprisingly, support the
government’s taking a harder line against drug and medical device makers so they don’t have to.

As Congress gets closer to finalizing any legislation, the opinions of the many stakeholders are likely to
become more strident and self-interested, Mr. Laszewski predicted. As in watching the last lap of the
Daytona 500, he said, there will be attempts by some of these groups to break out of the pack. “When you
get the last lap, there are no friends — it’s me, me, me,” he said.

===========

A $2.5T industry is amazingly complex and extremely powerful. It will kill any attempt to kill or injure their cash cow.

you know how to fix this problem?

Get rid of the patents on the drugs and devices.

watch a million more BETTER drugs and devices go on the market at a fraction of the price.

problem solved.

Much better than creating a government monopoly in health care in order to combat government created private monopolies in health care.

intellectual monopoly is bullshit.

There is no simple solution because people will not listen to what is needed for a step 1. I find it so ironic that there is a push for socialized medicine that will take away the extra cost burdens that people refuse to do for a free market approach. Shouldn't free market fixes first?

I had the idea for drug and device companies to do drug/device devlopment ONLY. The govt would pay for REAL testing to get REAL results, all publicly on display. The drug development companies would have to compete for govt testing funds.

If a drug or device actually delivered demonstrable results in long-term, double-bind testing, the govt would buy the patent from the developer.

Drug manufacturing would be done by companies that compete for the contracts.

There would be no drug marketing of prescription drugs. No more Ask Your Doctor bullshit, no more Drug Babes/Cheerleaders seducing docs into trying their drugs or devices.

Totally theoretical, will never happen, too much corruption and $$$ in the current system.

Typically, the anti-comsumer/pro-business Repugs will obstruct anything, with the current justification that a public insurance option would be "unfair" and hurt the for-profit insurance companies. They much rather than the for-profit insurance companies continue to hurt the consumers, sucking $Ts out of their pockets.

Quote:

---

Originally Posted by boutons_deux

If a drug or device actually delivered demonstrable results in long-term, double-bind testing, the govt would buy the patent from the developer.

---

So, the tax payers foot the bill then huh? Redistribution of wealth?

We once has a society of very few or now prescription drugs. It is not a right to have them. Sorry, but the hard facts in life are that the more money you have the more you can buy of something. We need to get past this false notion of rights that don't exist. Doing so takes away from the rights of others.

"tax payers foot the bill"

sure, citizens foot a much bigger bill already as the drug companies pay for the testing, then hide negative results, hype the positive results, add on enough profit to cover $60B in annual marketing costs, stuff the execs pockets with huge salaries, bonuses, life-time retirement luxury.

citizens also pay with their health and their lives as well as with their $$ as many drugs and devices maim and kill, and very often offer very little benefit to those who survive. The drug/device companies' goal is to make money, 1st, last, always, not to help the consumers with their health problems, which are always secondary.

ideological bitch, meet concrete slap.

Quote:

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Originally Posted by Winehole23

Bottom line, it doesn't matter who writes the checks if nobody's keeping track of waste and quality of care. The Mayo Clinic system seems to work: take away the financial incentives to overtreat patients, and let the doctors figure out how to treat people better for less.

---

I read this article when that issue came a couple weeks ago. Very interesting and very telling of an industry in which the government is a large purchaser and consumers rely on insurance to pay virtually all of their health care purchases. You do hit on a central issue, which as I think of it is a breakdown in the professional duty of physicians to not game the system and instead, actually (*gasp*) focus on providing the best care for the patient. In part because physicians are unable to check themselves and their colleagues, they will likely face a much more undesirable government scheme which will exacerbate the problem instead of dealing with it. The Mayo and Grand Junction schemes were interesting. The problem is, unless the 3rd party payers are willing to reward such arrangements, we'll see more of the same.

Quote:

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Originally Posted by boutons_deux

There would be no drug marketing of prescription drugs. No more Ask Your Doctor bullshit, no more Drug Babes/Cheerleaders seducing docs into trying their drugs or devices.

---

I'm not sure what to think of your idea boutons but I agreed with that point. They need reinstate the ban on direct to consumer marketing of drugs as well as place restrictions how pharmaceutical companies can market to physicians. A few years ago my wife's practice banned drugs reps from bringing food to their practice because everyone was getting fat and the drug reps were just interfering with the daily work. They were bringing breakfast and lunch every single day for the entire practice (probably 25-30 people), not just the physicians. And I'm not talking about just pizza from Little Ceasers but places like Ruth Criss, The Palm, Paesano's. That's just ridiculous, although I do miss her bringing my dinner home.

I showed this article to my wife and was suprised that she pretty much agreed with most of the author's points. Especially in regards to physician owned hospitals. Too much conflict of interest.

Although she did say that even with tort reform there is still alot of defensive testing that goes on. She's been in practice 15 years, never been sued, and we pay around $15k/year for malpractice insurance. The insurance company will jack the rate if she ever gets sued, which I think she said statistically is around 50% probability.

Proof that docs are after the money more than they are after caring is that the objective to provide health care to 50M uninsured is doomed because there is already a huge shortage, critical in some regions, of primary care docs, most of whom have fled to the specialties where they can make a lot more for less time.

They become docs perhaps with some very admirable, naive desire to care for the sick, but the medical system cures them of that fantasy by brutally grinding them down in med school and residency, and a couple $100K in education debt to start their career. They don't "avoid making people healthy". But that's secondary to stuffing their pockets. That's the way the failed medical system works. The Business of America is Business.

Quote:

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Originally Posted by boutons_deux

Proof that docs are after the money more than they are after caring is that the objective to provide health care to 50M uninsured is doomed because there is already a huge shortage, critical in some regions, of primary care docs, most of whom have fled to the specialties where they can make a lot more for less time.

---

If you had to take out a 6-figure student loan, work years in residency, and then pay a large part of your salary to malpractice insurance, you'd want to be compensated too.


If and when socialized medicine goes through, expect to be cared for by someone who probably didn't go to med school in the US.

Read more: http://www.time.com/time/magazine/ar...#ixzz2NQOlye3V

Thanks for resurrecting this thread. I didn't mark it, and lost this study. It remains a very good read.:toast
Now if I can find the (New Yorker?) article about a Dr. losing his father and writing about the experience.....

*adding thread subscription*

Quote:

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Dr. Ryan Neuhofel, 31, offers a rare glimpse at what it would be like to go to the doctor without massive government interference in health care. Dr. Neuhofel, based in the college town of Lawrence, Kansas, charges for his services according to an online price list that's as straightforward as a restaurant menu. A drained abscess runs $30, a pap smear, $40, a 30-minute house call, $100. Strep cultures, glucose tolerance tests, and pregnancy tests are on the house. Neuhofel doesn't accept insurance. He even barters on occasion with cash-strapped locals. One patient pays with fresh eggs and another with homemade cheese and goat's milk.


"Direct primary care," which is the industry term for Neuhofel's business model, does away with the bureaucratic hassle of insurance, which translates into much lower prices. "What people don't realize is that most doctors employ an army of people for coding, billing, and gathering payment," says Neuhofel. "That means you have to charge $200 to remove an ingrown toenail." Neuhofel charges $50.


He consults with his patients over email and Skype in exchange for a monthly membership fee of $20-30. "I realized people would come in for visits with the simplest questions and I'd wonder, why can't they just email me?" says Neuhofel. Traditional doctors have no way to get paid when they consult with patients over the phone or by email because insurance companies only pay for office visits.


Why did he choose this course? Neuhofel’s answer: “I didn’t want to waste my career being frustrated.”


This model is growing in popularity. Leading practitioners of direct primary care include Seattle, Washington-based Qliance, which has raised venture capital funding from Jeff Bezos, Michael Dell, and comedian (and Reason Foundation Trustee) Drew Carey; MedLion, which is about to expand its business to five states; and AMG Medical Group, which operates several offices in New York City. Popular health care blogger Dr. Rob Lamberts has written at length about his decision to dump his traditional practice in favor of this model.

---

http://reason.com/archives/2013/03/1...cian-fight-bac

Quote:

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Originally Posted by TeyshaBlue

Thanks for resurrecting this thread. I didn't mark it, and lost this study. It remains a very good read.:toast
Now if I can find the (New Yorker?) article about a Dr. losing his father and writing about the experience.....

---

I think Marcus Bryant may have posted that one . . . will check ...

voila: http://www.spurstalk.com/forums/showthread.php?t=134292

Holy Crap! Thanks WH!:toast:toast:toast

http://www.washingtonpost.com/blogs/...280-in-france/

for-profit health care is an obvious failure, too expensive "care" delivered to 10Ms too few citizens, with worse results in overall longevity and health, compared to industrial countries with heavily regulated/non-profit health care.

Breaking! : there is no solution to USA's fucked up health care system.

:lol

How do these multi-country surveys actually find out what medical care costs in the USA? patients can't find out until the mysterious bills hit, and doctors don't know nor GAF.

Ostensibly, the people being surveyed have the ability to read. Seems like an easy bit of data to uncover.

The bill from my recent hospitalization is pretty easy to read. I damn sure didn't get an MRI as cheap as the US figure in the article tho.

REPORT: Over Half Of U.S. States Get An ‘F’ On Health Care Price Transparency

http://thinkprogress.org/wp-content/...eport-card.png

http://thinkprogress.org/health/2013...-transparency/

smh...

“We’ve been trying to help patients get good value, but it is really hard to get price commitments from hospitals — we see this all the time,” said Jeff Rice, the chief executive of Healthcare Blue Book, a company that collects data on medical procedures, doctors visits and tests. “And even if they say $20,000, it often turns out $40,000 or 60,000.”

http://well.blogs.nytimes.com/2013/0...s-are-stumped/

Quote:

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Originally Posted by boutons_deux

REPORT: Over Half Of U.S. States Get An ‘F’ On Health Care Price Transparency

http://thinkprogress.org/wp-content/...eport-card.png

http://thinkprogress.org/health/2013...-transparency/

---

Go Massachusetts and New Hampshire, my two childhood locales! Woohoo!

They scored higher after getting your sick ass out of there.

Quote:

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Originally Posted by TeyshaBlue

The bill from my recent hospitalization is pretty easy to read. I damn sure didn't get an MRI as cheap as the US figure in the article tho.

---

Lots of factors change the price quite a bit unfortunately.

Quote:

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Originally Posted by Agloco

Lots of factors change the price quite a bit unfortunately.

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I protested the "Agloco Cheeseburger Fee".:flipoff

Quote:

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Originally Posted by TeyshaBlue

They scored higher after getting your sick ass out of there.

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:(
















:lol

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Originally Posted by TeyshaBlue

I protested the "Agloco Cheeseburger Fee".:flipoff

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:lol

After all, Agloco and his ilk must eat. Thank you for your generous contribution.

Also funny since getting scanned in a "big boy" MRI is likely to run you extra as well since most places will have to outsource the scan. Quite shameful really.

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It used to be that if you were running a fever you had three options. You could stay home, wait for a doctor’s appointment, or take your chances with a local hospital’s emergency department. About a decade ago, three Minnesota entrepreneurs came up with a fourth option: a walk-in clinic that would provide fast, inexpensive care for simple ailments. CVS Caremark bought them in 2006, and these days there is probably a MinuteClinic not far from you.


Retail clinics like MinuteClinic offer patients convenience and clearly-posted prices. They treat only basic conditions and primarily serve customers who have health insurances. But the clinics are a practical way to address the big question that continues to bedevil the American health-care system: How can we provide more care at a lower cost?



The rapid expansion of walk-in clinics—there are now approximately 1,400 retail clinics around the United States—could have consequences for the larger health-care industry. “These fairly low-cost services are forcing responsiveness by the entire provider community around patient convenience,” says Tom Charland, CEO of the research and consulting firm Merchant Medicine.

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Care at a retail clinic “is about 30 to 40 percent cheaper on a per-visit basis than care at a doctor’s office, and 80 percent lower, on average, than the care at an emergency department visit,” says Ateev Mehrota, policy analyst at the RAND Corporation. A flu shot given by a nurse is cheaper than one given by a doctor, even though it’s the same injection.

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http://www.nationaljournal.com/next-...ritos-20130321

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In recent years, a growing number of doctors have begun holding group appointments -- seeing up to a dozen patients with similar medical concerns all at once. Advocates of the approach say such visits allow doctors to treat more patients, spend more time with them (even if not one-on-one), increase appointment availability and improve health outcomes.

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http://vitals.nbcnews.com/_news/2013...e-isnt-a-crowd

both articles via The Dish

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Originally Posted by Winehole23

www.newyorker.com

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never see anything like that at "fox news".

Just sayin'.

The OP was freaking awesome.

I have a meeting with an HMO CEO coming up, this makes for good background material to ask about. Thank you.

There are some awesome links in this article.

An End to Medical-Billing Secrecy?

http://swampland.time.com/2013/05/08...lling-secrecy/

Here's the gov link: http://www.cms.gov/Research-Statisti...ata/index.html


And here's a couple of searchable databases built off of the above:

http://ovrcharge.com/

http://www.hospitalowl.com/

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Originally Posted by TeyshaBlue

There are some awesome links in this article.

An End to Medical-Billing Secrecy?

http://swampland.time.com/2013/05/08...lling-secrecy/

Here's the gov link: http://www.cms.gov/Research-Statisti...ata/index.html


And here's a couple of searchable databases built off of the above:

http://ovrcharge.com/

http://www.hospitalowl.com/

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Bam, more background material.

http://www.washingtonpost.com/blogs/...are-ludicrous/

http://www.theguardian.com/news/data...-world-country

BigPharma has hired US govt as policeman/confiscator of BigPharma's drugs imported from cheaper countries.

As Drug Costs Rise, Bending the Law Is One Remedy

Lee Higman, a 71-year-old artist from Bellevue, Idaho, who considers herself a law-abiding citizen, was shocked last month when she got a notice from the Food and Drug Administration telling her: “A mail shipment addressed to you from a foreign country is being held.”

The 90 tablets of Vagifem, prescribed by her physician, that she had ordered from a Canadian pharmacy had been impounded as an illegal drug at Los Angeles International Airport.

First marketed in 1988, Vagifem estrogen tablets are used by millions of women to relieve symptoms of menopause. There is no generic version available in the United States, and brand-name drugs are expensive here. So about five years ago, Mrs. Higman started ordering the tablets from Canada, where a year’s supply that would cost about $1,000 in the United States sells for under $100.
...
http://mobile.nytimes.com/2013/10/23...ne-remedy.html

And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.



After all the care the author takes to get an answer to a straightforward question he then uses an oversimplified, possibly disingenuous question like the above...

I found this very strange.
The read is quite good though.

"oversimplified, possibly disingenuous question"

it's the KEY question, and the answer is NO, which has caused a huge percentage of doctors to arrive at burn-out. Too much time on chasing money to pay off $100K in college loans, flipping patients quickly, and not enough time on their student-days goal of practicing medicine.

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Originally Posted by boutons_deux

"oversimplified, possibly disingenuous question"

it's the KEY question, and the answer is NO, which has caused a huge percentage of doctors to arrive at burn-out. Too much time on chasing money to pay off $100K in college loans, flipping patients quickly, and not enough time on their student-days goal of practicing medicine.

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What are the appropriate needs of each patient Dr. Buffoon? With more tests arising every week from medical technology which tests should and should not be run? Which are too expensive and way overdoing it and which are not?

Oh so you did NOT run this test, and now the patient needs a more expensive surgery... And you did not run the test because you thought it was excessive and expensive, so, you missed the diagnosis Dr. Buffoon.

But its easy for Dr. Boutons err.. Buffoon. Obviously there are clear cut cases, but there are many that are not. But it's all so black and white for the ideologue.

Boutons will write the protocol for each patient based on information from the patient and the past medical history from each patient. Because it's all so easy to get and so easy to decide exactly which tests to run. We await your AMA manual Dr. Boutons.

And this is only one problem...

Buffoon, you assume every new test available is useful AND better than existing tests. Not the case, and is well known not to be the case with patented drugs (eg, generic metformin vs new patented replacements)

defensive medicine is part of the problem

but cost and revenue pressures dominate in FOR-PROFIT health care

some doctors have quit private practice to join clinics and hospitals, only to find mgmt considers them not to be doctors, but revenue centers will all the revenue pressure of private practice.

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Originally Posted by pgardn

What are the appropriate needs of each patient Dr. Buffoon? With more tests arising every week from medical technology which tests should and should not be run? Which are too expensive and way overdoing it and which are not?

Oh so you did NOT run this test, and now the patient needs a more expensive surgery... And you did not run the test because you thought it was excessive and expensive, so, you missed the diagnosis Dr. Buffoon.

But its easy for Dr. Boutons err.. Buffoon. Obviously there are clear cut cases, but there are many that are not. But it's all so black and white for the ideologue.

Boutons will write the protocol for each patient based on information from the patient and the past medical history from each patient. Because it's all so easy to get and so easy to decide exactly which tests to run. We await your AMA manual Dr. Boutons.

And this is only one problem...

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If you give patients an itemized list including cost of procedures and include them in the decision making process ot that extent it would transfer a great deal more responsibility to the patient. That is the thing that annoys me, the manner that they charge creates an environment where they should be responsible yet they try and legislate away their liability.

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Originally Posted by FuzzyLumpkins

If you give patients an itemized list including cost of procedures and include them in the decision making process ot that extent it would transfer a great deal more responsibility to the patient. That is the thing that annoys me, the manner that they charge creates an environment where they should be responsible yet they try and legislate away their liability.

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Totally agree.

But we again run up against the patient, especially in Medicare and Medicaid, who does not have any idea what they need. And then we find ourselves back to the age old problem of individual responsibility. It has always been assumed that the patient will not understand what tests they need. And requiring a doctor to explain it... Then they can't see massive number of patients they need for the million dollar mortgage and country club dues (Boutons rendition)

The government actually has made some cuts to tests some doctors think are necessary therefore they will not take patients in those programs, especially Medicaid, as they will not have any supplemental insurance.

This is a real mess. The boomers are old. The problem gets bigger.

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Originally Posted by boutons_deux

Buffoon, you assume every new test available is useful AND better than existing tests. Not the case, and is well known not to be the case with patented drugs (eg, generic metformin vs new patented replacements)

defensive medicine is part of the problem

but cost and revenue pressures dominate in FOR-PROFIT health care

some doctors have quit private practice to join clinics and hospitals, only to find mgmt considers them not to be doctors, but revenue centers will all the revenue pressure of private practice.

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I don't assume anything. I am telling you new tests come up that are better (give fewer false +) AND are more expensive.

Defensive medicine starts with the individual taking care of him or herself and taking care of their children. You read the number of Hispanics that are prone to diabetes and heart disease in the OP's article yet continue to consume processed sugar and saturated fats. I live in San Antonio, it's rampant here as well.

And the poor old folks that are constantly told by their physicians to stop a certain practice and they totally forget as no child is present to hear the instructions. I don't doubt some doctors are greedy and don't care, but others are continually frustrated by their patients.

When your average doctor's visit (note this has nothing to do with any testing or drugs, a mere office visit) costs 5x-17x what costs anywhere else in the world, and the standard of living difference is nowhere near as much, then something just doesn't add up.

One other thing I noticed when I moved to the US is how little time a doctor actually spends with a patient during such a visit. Most of the work is actually done by a PA or RN (if one is even available). Pretty similar situation with dentists.

That's not to say there are no exceptions to that, but that's my observation in general.

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Originally Posted by pgardn

What are the appropriate needs of each patient Dr. Buffoon? With more tests arising every week from medical technology which tests should and should not be run? Which are too expensive and way overdoing it and which are not?

Oh so you did NOT run this test, and now the patient needs a more expensive surgery... And you did not run the test because you thought it was excessive and expensive, so, you missed the diagnosis Dr. Buffoon.

But its easy for Dr. Boutons err.. Buffoon. Obviously there are clear cut cases, but there are many that are not. But it's all so black and white for the ideologue.

Boutons will write the protocol for each patient based on information from the patient and the past medical history from each patient. Because it's all so easy to get and so easy to decide exactly which tests to run. We await your AMA manual Dr. Boutons.

And this is only one problem...

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I'm with you on this one, mostly.

Doctors are caught in a pinch, but I can tell you first hand from experience that doctor practices seem to me at least to be set up to milk the maximum revenue out of a patient for the least effort on the part of the doctor.

I love my doctor, who is a wonderful, kind, and smart woman, but the business model of the practice she is stuck in... sucks monkey balls.

We need to heavily subsidize med school, and pay doctors a fairly generous salary. Fee for service seems too likely to distort things, regardless of whether it does in reality. Even if you only reduce the appearance of impropriety, that is reason enough to change the system, IMO.

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Originally Posted by RandomGuy

I'm with you on this one, mostly.

Doctors are caught in a pinch, but I can tell you first hand from experience that doctor practices seem to me at least to be set up to milk the maximum revenue out of a patient for the least effort on the part of the doctor.

I love my doctor, who is a wonderful, kind, and smart woman, but the business model of the practice she is stuck in... sucks monkey balls.

We need to heavily subsidize med school, and pay doctors a fairly generous salary. Fee for service seems too likely to distort things, regardless of whether it does in reality. Even if you only reduce the appearance of impropriety, that is reason enough to change the system, IMO.

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Perfectly reasonable.

I personally think its a good thing we are seeing more women doctors. My doctor is male and very good at explaining why he is doing certain tests and very good with the studies as well. But I ask questions that indicate I know the stuff. He gets a chance to show off his knowledge. He sees way too many patients imo.

What happens to the people who are not proactive with their yearly checkup? What happens to the poor folks with a chronic problem that are not proactive because they just don't understand enough to ask good questions? They, and or their insurance, keeps getting milked. And I am sure my own doctor is good at rationalizing the large number of patients he sees everyday, just like in the OP's article.

I think a huge step forward would be requiring a health class everyday in elementary school. A health class in middle school. And a much more rigorous health class in high school where all the major body systems are studied for a full year. And we require a biology teacher, not a coach, to teach it.

People must know more about their own body. Some people treat their body like a car, let the mechanic handle it. On the other hand there are quite a few males who know how a car works better than how they work.

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Originally Posted by ElNono

When your average doctor's visit (note this has nothing to do with any testing or drugs, a mere office visit) costs 5x-17x what costs anywhere else in the world, and the standard of living difference is nowhere near as much, then something just doesn't add up.

One other thing I noticed when I moved to the US is how little time a doctor actually spends with a patient during such a visit. Most of the work is actually done by a PA or RN (if one is even available). Pretty similar situation with dentists.

That's not to say there are no exceptions to that, but that's my observation in general.

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Well, if you want lowered costs, we need serious tort reform.

Let's take the example in post #44. I'll bet that the only reason Canada can sell them for less if that the agreement to sell at the lower price included that no lawsuits can come to haunt them. We are a sue crazy society. Drug manufacturers calculate a given percentage of the profits as going to pay for such litigation, hence the wholesale cost is higher here as well. I would be OK with people buying their drugs from Canada if at the same time, they sign away any right to sue the drug manufacturer.

:lol tort reform

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Originally Posted by Trainwreck2100

:lol tort reform

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"that no lawsuits can come to haunt them."

Canadians get killed and maimed and compensated for the same untested toxic drugs that kill and maim Americans.

US drug mfrs spend twice as much marketing as they do on research and testing. New drugs, FDA accepting the drug mfrs own testing (negative results suppressed), are basically beta or alpha tested on unknowing, trusting patients.

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Originally Posted by Wild Cobra

Well, if you want lowered costs, we need serious tort reform.

Let's take the example in post #44. I'll bet that the only reason Canada can sell them for less if that the agreement to sell at the lower price included that no lawsuits can come to haunt them. We are a sue crazy society. Drug manufacturers calculate a given percentage of the profits as going to pay for such litigation, hence the wholesale cost is higher here as well. I would be OK with people buying their drugs from Canada if at the same time, they sign away any right to sue the drug manufacturer.

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LOL tort reform.

Small part of a very large, complicated machine.

http://heartland.org/sites/all/modul...pdfs/20309.pdf

If you really want to get a better sense, start parusing the white papers on what drives the costs. it takes some sifting and everybody has their pet interests, but you are vastly oversimplifying the issue.

http://www.spurstalk.com/forums/show...ht=tort+reform

the OP was based on Medicare stats, a new study reveals what's happening with thye privately insured:

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Differences in the number of tests and treatments given from place to place are still huge for the privately insured. But the cost of health care is like the cost of groceries—the total depends on the price of every item and on how many items you get. Both Medicare and private insurers have adopted policies and reforms that are reducing unnecessary tests and treatments and improving preventive care. In McAllen, as I wrote in May, such changes have saved Medicare an estimated half-billion dollars for that one community alone. But cutting costs for privately insured patients also requires addressing prices. And that’s a different matter entirely.


When your grocery store is the only one in town, it can jack up prices without losing customers. The same goes for hospitals. The study found that hospital prices in monopoly markets are fifteen per cent higher than in those with four or more hospitals.


It’s the Cost Conundrum Squared. The bigger the hospital, the more it can adopt systems that deliver better-organized, higher-quality, less-wasteful care. But the bigger the hospital, the more power it has to raise prices.

We have a few ways out of the conundrum. We can regulate the prices hospitals charge insurers—this is what Maryland does. We can break up big hospitals. We can encourage hospitals to become the insurers. (That’s what Kaiser Permanente in California has done. It provides members with prepaid care at its hospitals and clinics.) Or we can expand Medicare to more and more people until we’re single payer.

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http://www.newyorker.com/news/news-d...undrum-squared

"We can regulate the prices hospitals charge insurers"

no, can't do that. the (mythical) unfettered free market and competition always deliver the optimal solution (for BigCorp)

"We can break up big hospitals"

the opposite is happening. Hospitals are buying up hospitals, clinics, hiring independent doctors who are pressured by financial managers to deliver revenue, not care.

Kaiser is a historical artefact, a non-profit that is extremely profitable.

expand medicare? Repugs block expanding medicaid.

single payer? ain't NEVER gonna happen, has been and will be blocked by the unstoppably powerful BigInsurer, BigMedicine, BigPharma.

if people who believe otherwise take their marbles and go home, they cede the political field to those trying to screw them.

is that what you want?

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Originally Posted by Winehole23

if people who believe otherwise take their marbles and go home, they cede the political field to those trying to screw them.

is that what you want?

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Whine Hole, it's already marbles GAMEOVER. Human-Americans, patients, customers, employees LOST BIG.

I'd love to hear your path from where we are fucked up now to the airy-fairyland at the end of that article.

I have family in the area (10 miles away from McAllen, TX actually), and the amount of piss poor service and corruption in the health services segment is repugnant. Places like Retama Manor in Weslaco (at least up until a couple years ago) were only interested in the govt checks, treated patients extremely poorly, had illegals with little to no medical training looking after patients and an amazing turnover rate for employees (not to mention having things stolen from patients' rooms all the time, or when two employees were busted for having sex in one of the rooms).

Another fairly common occurrence around here is 'agencies' that 'hire' somebody in your family to do home care for you, paying them dimes while billing Medicare/Medicaid for the 'service' and pocketing most of it. My father in law (disabled) actually did not want to be part of that and couldn't get the 'agency' to stop calling him.

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Originally Posted by ElNono

I have family in the area (10 miles away from McAllen, TX actually)

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But what does Reynosa have to do with health care in the US tbh?

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Originally Posted by baseline bum

But what does Reynosa have to do with health care in the US tbh?

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:lol I was actually in Las Flores (Mejico) for the first time ever two days ago... chock full of winter Texans

Reminded me a lot of Argentina

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Originally Posted by boutons_deux

Whine Hole, it's already marbles GAMEOVER. Human-Americans, patients, customers, employees LOST BIG.

I'd love to hear your path from where we are fucked up now to the airy-fairyland at the end of that article.

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you think we should all give up, go home and suck our thumbs?

you're the fucking apologist. you think the game is over. you'd cede the field to the motherfuckers without a fight.

you're wrong.

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Originally Posted by Winehole23

you're the fucking apologist. you think the game is over. you'd cede the field to the motherfuckers without a fight.

you're wrong.

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it's (has been) GAMEOVER, Whine Hole.

fight?

I'm still waiting for your PRACTICAL path to (winning) the battle with the BigCorp and 1%.

What steps do we take to stop the looting of Human-Americans by the 1%, by BigCorp, BigFinance, BigHealthcare?

and of course the "steps" must include electing an unblockable "socialist" majority (aka For The People) in Congress.

Gerrymandering, voter suppression, the VRWC/1%/Repug SCOTUS' "C-U $Bs in politics" have DISENFRANCHISED Human-Americans.

Even the duped tea baggers and duped cosplay patriot "marans" are pissed that THEIR (1%-financed) Repugs can't, won't do shit for them, other than protect/enrich the 1% and BigCorp.

Where do we assemble for the fight, Oh Great Fighter?

Aren't you worried about the militarized, police/surveillance state, which already snoops on anti-war dissenters, like nuns.

Those NSA/FBI/CIA/der-heimat-security Madame Defarges have knitted your name and "thoughts" into their wooly databases, ready to pounce.

We can't even raise the minimum wage to $15 or $20 to lift 10Ms of We The People out of poverty in The Greatest, Wealthiest, God-preferred Country Ever In The Universe.

America, after the anomaly of 1945 - 1975, has regressed to the historical mean of an oligarchy, the country owned, operated, ruled by a few wealthy people who will NEVER, have NEVER yielded power without your "fight".

Where do we assemble?

<a href="https://www.facebook.com/RepresentUs/videos/1175706399109896/" target="_blank" rel="nofollow">

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We can't even raise the minimum wage to $15 or $20

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many cities have done it already, without the permission of the oligarchs. how could that possibly have happened in a wholly owned subsidiary like the USA?

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Originally Posted by Winehole23

many cities have done it already, without the permission of the oligarchs. how could that possibly have happened in a wholly owned subsidiary like the USA?

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nope, only a couple.

Most as of 1 Jan don't go above $10, or $20K/year for 2000 hours, still deeply in poverty,needing taxpayer subsidy to poverty-wage businesses.

$15 or $20 has be a FEDERAL minimum so cities, regions that pay more don't get screwed by slave, red states that pay $7.25. And Federal minimum has to be adjusted for cost-of-living by metro region.

Does it really make a difference on poverty if the minimum wage increases? I say, never has and never will. What difference does it make if a hamburger flipper now make $15 / hr. as his rent and food prices clime in the process? Then at the same time, our exports are moe expensive to sell, and imprts are relatively cheaper, causing more US job losses yet.

Let those of us who do full circle thinking know when you plan to deal with the root problems of our society, instead of addressing things that your solutions will cause greater harm.

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Some workers across the city are left telling bosses to give them fewer hours at the higher wage because a full week’s earnings now puts them past the threshold for some welfare payments such as food stamps and assistance with rent.

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This is from a blog that didn't source it well, but it is a reality. There is no good bandage solution. The root problems need to be addressed, then supply and demand for wages will prevail.