Author Topic: Munger Says We Will Have Single Payer  (Read 8472 times)

Spekulatius

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Re: Munger Says We Will Have Single Payer
« Reply #50 on: October 07, 2018, 06:24:26 PM »

Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that. 

This is an area of significant current research.  Here, for example, are recent thoughts from someone researching this question:  http://www.latimes.com/opinion/op-ed/la-oe-singh-food-deserts-nutritional-disparities-20180207-story.html

Lazy and stupid don't appear to be the reasons.  Instead, the reasons appear to be deeper and, in my view, profoundly sad.  At the end of the day, I think the poor are essentially the same as everyone else -- same hopes, same dreams, same love for their children, same fallibilities -- they just have a lot less money.  If I was working two minimum wage jobs while taking care of a few kids, and the only respite I could find was a bit of nicotine, maybe I'd smoke too.

A lot of the poorer people have very little time to prepare meals, because they work several jobs. I got aware of this because my wife worked and heard what the techs were doing at her facility. Most of them were working two jobs, some of them 3 jobs. There are other reasons and they were undoubtedly wasting money too, but they was one factor that was evident.
To be a realist, one has to believe in miracles.


Cigarbutt

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Re: Munger Says We Will Have Single Payer
« Reply #51 on: October 07, 2018, 08:28:02 PM »
https://www.propublica.org/article/in-montana-a-tough-negotiator-proved-employers-do-not-have-to-pay-so-much-for-health-care

"The discounts, however, are meaningless if the underlying charges arenít capped. When Bartlett looked at a common knee replacement, with no complications and a one-night hospital stay, she saw that one hospital had charged the plan $25,000, then applied a 7 percent discount. So, the plan paid $23,250.
A different hospital gave a better discount, 10 percent, but on a sticker price of $115,000. So, the plan got billed $103,500 ó more than four times the amount it paid the other hospital for the same operation. Bartlett recalled wondering why anyone would think this was okay."

Hospitalsí negotiated transaction prices for the privately insured typically vary by a factor of +/- 8 or more across the nation and by a factor of about 3 within a region (for equivalent services). Hospital market structure (degree of competition) appears to be a major factor but the relative absence of determined negotiators also plays a role.

Marilyn Bartlett "was a potent combination of irreverent and nerdy, a certified public accountant whose Smart carís license plate reads DR CR, the Latin abbreviations for debit and credit."
Never underestimate an irreverent nerd.

rukawa

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Re: Munger Says We Will Have Single Payer
« Reply #52 on: October 11, 2018, 09:14:05 PM »
Whatever dissatisfaction with the NHS exists comes from the fact that the NHS rations out care to keep costs low which creates wait times. But you want to spend some more money, the system get better in a hurry. 

This is the problem with US single payer solutions. They don't really understand what makes single payer work. Rationing is key. Without this the costs of single payer will spiral out of control. All good single payer systems include lots of rationing or they use deductibles (a much much much better method) to control costs.

Interestingly Singapore avoids this problem completely. It has much much lower costs that even the NHS and it has much much much much much MUCH MUCH lower wait times. Singapore wait times are measured in hours...British wait times are measure in weeks. This means that Singapore's wait times are more than 100 times shorter than Britains. Its costs are half of Britains. Singaporeans also live longer.

The interesting question is given the incredible wait times in Britain...why aren't their healthcare outcomes much much much worse?! My explanation is simple...its because healthcare mostly does nothing. It doesn't really improve health. Thus single payer works because it rations something that was a useless expenditure to begin with.

A rational system would focus much much more on determining what actually is useful in healthcare and focusing all subsidies on that. Its also important to avoid killing people...something the US healthcare system does very often:
https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/

Its also really shocking to me how little connection there is in the healthcare system between scientific evidence and actual healthcare practice...or even how little concern there appears to about this issue. Given the way healthcare is practiced and the complete lack of incentives for evidence based care I don't see how healthcare could possibly be very effective. The proper way to view modern healthcare is mostly as witchdoctors, voodoo and shamans. That is what healthcare mostly is.
https://retractionwatch.com/2016/03/16/evidence-based-medicine-has-been-hijacked-a-confession-from-john-ioannidis/

Honestly this whole debate is mostly arguing about how to do insane and stupid things in a slightly less ridiculous way but no one questions the fundamental ways the whole system is setup. Single payer is just lipstick on a pig.
« Last Edit: October 11, 2018, 09:17:04 PM by rukawa »

meiroy

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Re: Munger Says We Will Have Single Payer
« Reply #53 on: October 11, 2018, 09:31:38 PM »
Whatever dissatisfaction with the NHS exists comes from the fact that the NHS rations out care to keep costs low which creates wait times. But you want to spend some more money, the system get better in a hurry. 

This is the problem with US single payer solutions. They don't really understand what makes single payer work. Rationing is key. Without this the costs of single payer will spiral out of control. All good single payer systems include lots of rationing or they use deductibles (a much much much better method) to control costs.

Interestingly Singapore avoids this problem completely. It has much much lower costs that even the NHS and it has much much much much much MUCH MUCH lower wait times. Singapore wait times are measured in hours...British wait times are measure in weeks. This means that Singapore's wait times are more than 100 times shorter than Britains. Its costs are half of Britains. Singaporeans also live longer.

The interesting question is given the incredible wait times in Britain...why aren't their healthcare outcomes much much much worse?! My explanation is simple...its because healthcare mostly does nothing. It doesn't really improve health. Thus single payer works because it rations something that was a useless expenditure to begin with.

A rational system would focus much much more on determining what actually is useful in healthcare and focusing all subsidies on that. Its also important to avoid killing people...something the US healthcare system does very often:
https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/

Its also really shocking to me how little connection there is in the healthcare system between scientific evidence and actual healthcare practice...or even how little concern there appears to about this issue. Given the way healthcare is practiced and the complete lack of incentives for evidence based care I don't see how healthcare could possibly be very effective. The proper way to view modern healthcare is mostly as witchdoctors, voodoo and shamans. That is what healthcare mostly is.
https://retractionwatch.com/2016/03/16/evidence-based-medicine-has-been-hijacked-a-confession-from-john-ioannidis/

Honestly this whole debate is mostly arguing about how to do insane and stupid things in a slightly less ridiculous way but no one questions the fundamental ways the whole system is setup. Single payer is just lipstick on a pig.

The U.K. health service is absolutely fantastic if you have something serious and you literally would not have to pay a pound for it. This is its main purpose.  If, on the other hand, you have a sore throat then you'd do better to just research it on the internet and resolve it yourself.

Of course, it has a lot of crap built into the system but it is still far better than what the US got.

The fact is that the pig with the lipstick which you mentioned is us.  The single payer system is the best we can come up with, just like how capitalism is the best system we can come up with considering all of our faults and biases and whatnot.  It's stinky, it has a lot of issues but damn do we look good with that lipstick on.
« Last Edit: October 11, 2018, 09:33:22 PM by meiroy »

rb

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Re: Munger Says We Will Have Single Payer
« Reply #54 on: October 11, 2018, 10:11:33 PM »
Whatever dissatisfaction with the NHS exists comes from the fact that the NHS rations out care to keep costs low which creates wait times. But you want to spend some more money, the system get better in a hurry. 

This is the problem with US single payer solutions. They don't really understand what makes single payer work. Rationing is key. Without this the costs of single payer will spiral out of control. All good single payer systems include lots of rationing or they use deductibles (a much much much better method) to control costs.

Interestingly Singapore avoids this problem completely. It has much much lower costs that even the NHS and it has much much much much much MUCH MUCH lower wait times. Singapore wait times are measured in hours...British wait times are measure in weeks. This means that Singapore's wait times are more than 100 times shorter than Britains. Its costs are half of Britains. Singaporeans also live longer.

The interesting question is given the incredible wait times in Britain...why aren't their healthcare outcomes much much much worse?! My explanation is simple...its because healthcare mostly does nothing. It doesn't really improve health. Thus single payer works because it rations something that was a useless expenditure to begin with.

A rational system would focus much much more on determining what actually is useful in healthcare and focusing all subsidies on that. Its also important to avoid killing people...something the US healthcare system does very often:
https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/

Its also really shocking to me how little connection there is in the healthcare system between scientific evidence and actual healthcare practice...or even how little concern there appears to about this issue. Given the way healthcare is practiced and the complete lack of incentives for evidence based care I don't see how healthcare could possibly be very effective. The proper way to view modern healthcare is mostly as witchdoctors, voodoo and shamans. That is what healthcare mostly is.
https://retractionwatch.com/2016/03/16/evidence-based-medicine-has-been-hijacked-a-confession-from-john-ioannidis/

Honestly this whole debate is mostly arguing about how to do insane and stupid things in a slightly less ridiculous way but no one questions the fundamental ways the whole system is setup. Single payer is just lipstick on a pig.

The U.K. health service is absolutely fantastic if you have something serious and you literally would not have to pay a pound for it. This is its main purpose.  If, on the other hand, you have a sore throat then you'd do better to just research it on the internet and resolve it yourself.

Of course, it has a lot of crap built into the system but it is still far better than what the US got.

The fact is that the pig with the lipstick which you mentioned is us.  The single payer system is the best we can come up with, just like how capitalism is the best system we can come up with considering all of our faults and biases and whatnot.  It's stinky, it has a lot of issues but damn do we look good with that lipstick on.
I actually lived in the UK for a while and I can attest that the NHS is actually pretty damn good. And no, you don't have to worry about your sore throat. I once walked into an NHS clinic with sore throat (and lungs) and walked out 30 minutes later with a diagnosis for bronchitis and a prescription.

While I disagree with Rukawa's conclusion that a single payer system is lipstick on a pig - it's not - he does make a very good point about rationing and outcomes. He's pretty much figured it out. The rationing is due to cutting capacity for non-essential items. Basically dishing out discomfort for cost savings. While anecdotal, I've seen this in my family. My dad had some back pain and had to wait 2 months to see a specialist. My mom once had a hypertensive emergency and got a cardiologist appointment for the next day. For the record, after my dad was done swearing he admitted it was the right thing for the system to do.

Over here in Canada where we have a single payer system. The issue around wait times revolves around these non-critical items. If you have cancer you'll get some pretty quick care. Doctors (looking for more money) run ads about how horrible it is for grandma to wait some for a hip replacement and people don't like it.

In Canada it is illegal to pay in order to jump the line. But I often wonder, since our healthcare costs roughly half as the US, how many of the complainers would be willing to pay double just for the procedure (let alone double for everything) just to shorten the wait time. My guess is that once they see the price tag, not many - complaining is free. 3

Another source is what Canadians consider a national embarrassment is that we ship a good number of people to the US to have procedures like hip replacement. The interpretation is that we can't fix our own people. But the reality is that due to the way the US system is set up they have a lot of excess capacity around things like hip replacements. Due to our size we can negotiate prices and get really good cut rates similar from the US - similar to a hotel that's trying to fill rooms. So really what's perceived as an embarrassment it's actually the government doing its job, saving money for the people.

Cigarbutt

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Re: Munger Says We Will Have Single Payer
« Reply #55 on: October 12, 2018, 05:27:44 AM »
^Interesting.
Few thoughts.
-International comparisons can be helpful but domestic concepts cannot be simply imported, there are no perfect systems and some systems are more broken than others.
-IMO healthcare delivery brings value but the recent trend (last 20-40 years) is based on gradually smaller incremental value gains and gradually larger costs.
-Agree that the challenge is significant but remain optimistic.
-Compounding can be slow but can be wonderful when incentives are better aligned (in the right direction).
-Value-based care is basically a capital allocation decision and we can do better (a lot better).

Recently read the following and thought it was useful:
https://www.amazon.ca/Better-Now-Improve-Health-Canadians/dp/0735232598/ref=sr_1_1?ie=UTF8&qid=1539345551&sr=8-1&keywords=danielle+martin+healthcare
Thought provoking, a lot to disagree with, but constructive grounds for progress.

SharperDingaan

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Re: Munger Says We Will Have Single Payer
« Reply #56 on: October 12, 2018, 07:12:00 AM »
You might want to consider what happens under 'right to die' legislation.
Palliative care is a lot cheaper that end-of-life medical/drug intervention, and choosing 'quality of life' over 'longevity of life' is becoming a lot more common in NA as aging boomers approach end-of-life. Reduce demand for the 20% of intevention services that add 80% of the cost, and total cost comes down rapidly.

SD

Cigarbutt

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Re: Munger Says We Will Have Single Payer
« Reply #57 on: October 12, 2018, 08:50:10 AM »
You might want to consider what happens under 'right to die' legislation.
Palliative care is a lot cheaper that end-of-life medical/drug intervention, and choosing 'quality of life' over 'longevity of life' is becoming a lot more common in NA as aging boomers approach end-of-life. Reduce demand for the 20% of intevention services that add 80% of the cost, and total cost comes down rapidly.
SD
Delicate topic, but agree.
In an era where opportunity costs are estimated and where potentially positive NPVs are discounted in the longevity escape velocity projects, perhaps some consideration should be given to the potential fact that the hospital should be a last resort solution, if quality of life is high on your list.
https://accessh.org/wp-content/uploads/2017/01/Bruce-Leff-April-4.pdf
https://www.commonwealthfund.org/sites/default/files/2018-09/1895_Klein_hospital_at_home_case_study_v2b.pdf
I would say huge opportunities for those putting customers first, single payer or not.

rukawa

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Re: Munger Says We Will Have Single Payer
« Reply #58 on: October 13, 2018, 09:57:28 AM »
The fact is that the pig with the lipstick which you mentioned is us.  The single payer system is the best we can come up with, just like how capitalism is the best system we can come up with considering all of our faults and biases and whatnot.

I've pointed out repeatedly that the Singapore system which is a Massively multiplayer system (since each person pays out of pocket for almost everything) is a vastly better system than the UK. Go on studiously ignoring this. Single payer is not the best we can come up with.

Quote
I actually lived in the UK for a while and I can attest that the NHS is actually pretty damn good...While I disagree with Rukawa's conclusion that a single payer system is lipstick on a pig - it's not

NHS, US and Canadian systems are pretty much the same when it comes to the practice of healthcare and even the incentives in the system. The big advantage of single payer is that it costs less. But I regard healthcare itself as fundamentally dysfunctional and broken. Paying less for it is the lipstick. The pig is healthcare itself in any country that practices it (Japan may be an exception).

I'll give one huge example that I keep hammering and yet no one cares...iatrogenic deaths (death due to healthcare). In the US there are estimated to be 250,000 each year. Its the third leading cause of death. In an intelligent system, you would deal with that FIRST. You would deal with that SECOND. You would deal with that THIRD. It would be your only priority until you solved it. Not increasing coverage or single payer. And yet none of you care?!

But this connect to a much larger problem...the complete lack of concern or incentives or even properly conducted research into what works in healthcare and doesn't. And the reason for this is the incentives in the system and way people think about healthcare. For doctors the incentives IN ALL SYSTEMS are to treat more patients for the treatments that have the highest dollar to time spent ratio. For patients all they want is for something to be done and done as soon as possible...whether what is done actually improves the situation is something the patients don't know and often the doctor doesn't even know. For researchers the goal is to publish flashy findings and get grants and funding from industry. Its much easier to conduct bad research and poorly supported findings than conduct good responsible research.

The result is a fundamentally broken system. Paying less money for it doesn't solve anything.

Lets give one example...routine mammogram screening. It is known to be completely ineffective:
http://theconversation.com/routine-mammograms-do-not-save-lives-the-research-is-clear-84110

And yet in Canada:
https://canadiantaskforce.ca/guidelines/published-guidelines/breast-cancer/

NOTICE that in Britain they actually invite women by mail to do this every year. Its basically going out of your way to encourage stupidity:
https://www.nhs.uk/conditions/breast-cancer-screening/when-its-offered/

As I said...healthcare itself is the pig. The mammogram example is also a great example of how all the incentives and thinking align:

1) Patients are in favor it because they remember some person they know where mammograms caught a cancer that was promptly treated or they remember a relative who died because of a cancer that wasn't caught. Obviously they just want something to be done, done quickly and for as much to be done as possible without regard for costs.

2) The doctor is incentivized positively (fees) and negatively (medical malpractice) to conduct more mammograms and treat more patients.

3) The cancer institutes are incentivized by bad press from outraged patients and doctors to keep mammogram screening recommendations in place.
« Last Edit: October 13, 2018, 10:17:10 AM by rukawa »

Cigarbutt

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Re: Munger Says We Will Have Single Payer
« Reply #59 on: October 13, 2018, 08:35:46 PM »
^Mammography is controversial and poor incentives may result in poor results. OK.

Interesting to note though that in Singapore, there are guidelines for mammographies that are comparable to Canada or the US and, on a recurrent basis, like in most places in the world, they aim to periodically improve their guidelines with best evidence. So the way that services are paid for seems to have little to do with prevention guidelines.

Here's what seems to be their latest version for mammographies:
http://www.smj.org.sg/sites/default/files/5102/5102cpg1.pdf

I would tend to agree with most of what you describe but don't tend to agree on the black and white thinking and on the implicit assumptions that healthcare actors are intrinsically bad. There are poor performers but, in the main, people simply respond to incentives. To err is human and what one may realize with relevant experience and practical involvement is that, mostly, medical errors are not made by bad people, but rather by good people working in bad systems.

I may be biased though because healthcare saved my life and significantly extended the life of several significant persons around me.