There's a difference between "selective" and "judicious" application. The margin of error in speed measurement is +/- 5 to 10 percent. So you could be going 60MPH while your speedometer shows 55. That's the reason that most speeding tickets are given when you are measured going at least 10% over the limit (62 in 55, 67 in 60, etc). You cannot use your car's speedometer (as recorded in the on-board computer) to say you weren't speeding once you hit that number.
Medical records can be divided into four major components:
1. Medico-legal documents
2. Summary documents
3. Observation documents (lab reports/xray reports, etc.)
4. Process information (progress notes, procedure notes, etc.)
In the process notes, doctors not only note what they observe, but what they are considering, planning, and anticipate. These are working notes, or, in essence, notes to the doctor from himself regarding what's going on in the patient. They can include differential diagnoses, subtle observations, or "heads up" messages that help the doctor keep track of the patient without formally documenting it.
Two quick examples:
1. the patient is anxious and defensive. The differential might include drug abuse or mental illness, as well as social emotional stress (concern about interpersonal relationships, extramarital affair, etc). Recording "potential drug abuse" or "rule out schizophrenia" as a formal diagnosis would not be the kind of item a patient would be pleased to read in their record, or would necessarily want to be reported to their insurance carrier as part of medico-legal documentation. Alternatively, if mental illness is suspected but cannot be diagnosed, the doctor would want to note changes over time without making a definitive diagnosis. If the stress is induced by social emotional distress, it may well go away without ever being overtly documented or communicated.
2. A pediatrician notes that a child has several bruises. The differential includes normal active childhood, leukemia, and child abuse. A parent would be extraordinarily upset to see leukemia mentioned in a note. Likewise, for child abuse, if there's no abuse, the parent would be offended or insulted. However, if there is, then the parent might well change physicians, putting the child at risk for continued abuse.
Medicine, like the rest of life, is not simply black and white.
Gross generalizations, ranting, and ad hominem attacks, devoid of content.
In the US. people of either party are mostly Christian.
The rest of your rant is why intellectual debate, discussion, and compromise are deteriorating in the political discourse in this country. Having a dialog with someone who starts off by labeling, gross generalizations, and name-calling is very difficult.
Both left-leaning and right-leaning political parties have their radical elements, and, it seems in recent years, that the radical ends (Occupy Wall Street and the Right-to-Lifers) have recognized that the ability to mobilize resources sufficient to influence the major constituents of both parties is sufficient to get political power. Remember that most elections in this country at the national level are decided by a less than 5% margin of difference, and frequently as low as 1%. Obama won the election by IIRC 52%/48% and that was considered a "landslide" and "mandate".
We need less politics and more statesmanship, less rancor and more discussion, and, in my opinion, slower political change that makes smaller, immediate changes with measurable expected outcomes so that we can, scientifically, evaluate our decisions and continue, advance, or eliminate programs based on their results.
Instead of letting your child see someone else's visualization, read the Redwall series of books to him. They are written with short chapters, perfect for a bedtime story that let's you do the reading and your child do the imagining. There's action, character, and morality in the stories without being condescending to what a child can absorb.
They are authored by Brian Jacques.
We introduced our children to reading and storytelling this way, as well as numerous relatives and friends.
Get some counseling!
Life isn't neat and tidy, and sometimes it's downright challenging. But there is usually a way to make things work.
Giving up is only cheating yourself out of you future opportunities.
Suffering is an attitude. You can choose not to suffer by changing your focus from what makes you unhappy to what makes you happy. Whatever you focus on seems to be larger.
And about the cat, remember, Dogs have masters, cats have staff.
You are confusing income (the movement of money into your assets), and net worth (the value of all owned assets).
Buffet and Gates' assets are in the billions. However, their income comes from either earnings or the sale of assets, and both of those are taxed.
Their contract, however, has TWO parties. Did you ask WHICH of the two parties put that into the contract?
In fact, insurance companies "negotiate" the rates with an organization (hospital or practice) and prohibit the publishing of those rates by site. For the same procedure, two different hospitals may each have very different rates for the same diagnostic and procedure code. That's why there's no standard cost for any medical charge.
The practice or hospital has a charge master, just like a car dealership has a Manufacturers Suggested Retail Price.
The insurance company negotiates, or sets, the rate for a practice or hospital to be "in network" by site.
This appears as an "allowed charge" on the bill, which is less than the "list price," which they are required to accept by contract.
Then, your contract with the insurance company obligates you to pay a "co-pay" as a dis-incentive for you to pursue services and to reduce further their costs, just like other forms of casualty insurances do.
Finally, you might pursue how the erroneous code was listed. Was it the doctor, the practice's or hospital's Health Information Management (medical records clerk), data entry error, computer error?
And if you think you have issues today, wait until the migration to ICD-10 begins later this year and next. Going from 14,000 dianosis codes to 68,000, and 11,000 to 87,000 procedure codes, estimates are that upwards of 10-20% of "administratively simplified" claims will be rejected and delays in payments to doctors and hospitals may extend out several months. Rest assured, however, that the insurance company will collect your premium promptly.
I'm almost at a loss as to how to be informative on this post because it's so lacking in facts or actual observation.
1. Doctors are primarily (with a few notable exceptions like Kaiser-Permanente and the military health system) small partnerships of under 5 physicians. They don't run "big operations with high margins."
2. Hospitals are generally not-for profits (again some exceptions) with net excess revenues less the 5-7%, about the cost of capital replacement.
3. Doctors do expect compensation for the 4 years of college, 4 years of medical school, and 3-8 years of internship, residency, and fellowship, since they give up 7-12 years of post-college years of income generation for the same life expectancy. However, huge salaries for a few do not equate to massive salaries for all. Just like baseball players, a few get the big bucks, but many more play in the minor leagues. Check out the National Bureau for Labor Statistics data.
4. Some doctors make lots (neurosurgeons, for example), but then they also pay millions of dollars (YES, MILLIONS) of dollars in malpractice insurance because people expect perfection from doctors, not acknowledging how complex and variable human biology is.
5. The most complex part of the healthcare system is the insurance system, which is completely out of the control of the medical professionals.
6. AMA is not a union, has no collective bargaining rights, and has as its membership AT BEST maybe 10-15% of all physicians. It's a voluntary professional membership society.
7. The major evolving complexity in the state of healthcare in the US is the federal government, which through tax laws, federal mandates, and regulatory actions, have created a never-ending chain of requirements, complexity, and frustration. The decades long effort at vilification of the medical profession and poor financial management coupled with government regulation will give you increasingly lower quality of medical care delivered by less trained salaried employees.
8. On the plus side, technology can assist in improvement in the application of scientific knowledge to the delivery of care, but not if legislated and dictated by Congress and political forces.
The IT profession (at least NOT YET) doesn't have state regulated boards, mandatory licensing, bureaucratic payment policies, and direct government intervention in almost every aspect of your professional career.
captcha: digits (At least a triple entendre)
Please explain why geographic dispersion doesn't affect such costs as labor markets, patient demographics, distribution of medical resources and capital access.
By law, anyone below the poverty level is eligible for Medicaid- all that has to be done is to enroll. By the Hill-Burton Act, a healthcare organization cannot deny care to anyone in an emergent situation. So, "any healthcare at at all" is legally required now.
In response to your comment about a typical American spending more than anyone else, we don't. In countries with government-provided health benefits, those benefits are paid for by the the tax dollars collected from the employed citizens or, in the case of countries like, say, Greece and Italy, borrowed with little chance to pay off the debt.
The market can sort a lot of things out, but when it's perterbed by political pressure, it doesn't sort itself out on purely economic measures. When the federal government went beyond setting rules to keep the game fair, it became a political issue solved with political processes, not a market problem addressed by market forces.
I think we agree that there's room for change and improvement, but with Medicare running out of reserves in 2017, and the reserves lent to the general budget in the form of "special class of bonds" purchases, the federal government has already spent the Medicare trust fund, and has to borrow more money or gather more taxes to pay the money back to the Trust to pay for benefits.
The federal government has a strong role to play in rule setting and refereeing, but when the referee is in the game, it's not a fair game.
Thanks for the interesting conversation.
Your per-capita expenditures and results levels are accurate. However, those statistics ignore geographic issues (healthcare for 4.8 million Norwegians in a nation the size of Montana will not be the same as for Montana, with a population of 1 million), as population density or sparsity affect service distribution.
The original comment implied that most of the people in our health care system were making lots of money, and that was the fat.
I would argue that complexity is not fat, but better defined as friction, where it takes more energy (dollars) to manage the system. Creating a simpler, more uniform (but not necessarily federally operated) system would reduce that complexity.
insurance operates at a cost plus general/administrative + profit. That G/A + profit for insurance companies is now limited to 15% by the new regulations, but it's still 15% of the cost of private healthcare.
I believe that the federal government will do no better job of managing insured costs than insurance companies, because we will be replacing government bureaucracy for the G/A + P, and then throwing in politics and vote-buying to boot.
I agree that the overarching complexity of financial reimbursement leads to very large billing and finance departments of hospitals, which are part of the cost structure. The departments are so large because of the need to manage billing and insurance for hundreds of different insurance plans, and the plans vary from state to state. A better approach, I think, would have been to standardize insurance benefits into basic, premium, and comprehensive tiers, restrict the premiums to a 3X range (highest premium no more than 3 times lowest premium in each tier), and remove state-by-state insurance regulation of health insurance. By creating a simpler system, it will eliminate state budgets for insurance regulation and approvals, reduce the complexity of the hospital and insurance financial operation, eliminate the overhead of periodic contract negotiation, and streamline cash flow.
We need to recognize that it is impossible for the federal government to provide every citizen with the same level of care. We don't currently provide citizens with the same level of food, shelter, or transportation services. If we choose to provide everyone with the same level of care, then the average cost will go up, the level of service will go down, and premium services will move out of the system.
I've seen the health system in some government-provided European countries, and there is an active, readily available private health services industry for those who want to pay for it to get better service than the government programs. And some of those countries are now crumbling under their financial obligations.
You might consider trying to gather some actual information before forming an opinion. The healthcare complex is not fat. That's not to say it's not big, but 100% of people can and do consume healthcare.
For analysis, you can break your healthcare complex down into pharmaceuticals (medications), medical and laboratory equipment (x-ray and lab equipment), and providers, further divided into hospitals and ambulatory services. The margins start highest at pharmaceuticals and decline in the listed order. But pharmaceuticals have R&D expenses, FDA approval testing, and litigation liability. Medical and laboratory equipment(CT,MRI, and lab equipment) also have to get FDA testing and certification. Hospitals generally run with an excess revenue (income minus expenses, it's not considered "profit" in a not-for-profit or community hospital) of between a negative number and maybe 8-10%, with the average in the 5-6% neighborhood) and likely 60-80% of the budget is for nursing salaries to provide your care. For doctors, after 4 years of college, 4 years of medical school, and 3 to 8 years of post-graduate training (age 29 to 34), generally have educational debts the size of a house mortgage. And their average salaries ARE good at $175,000. Sure, you can find outliers like neurosurgeons and obstetricians, but then they pay malpractice insurance between $200K to 500,000
I dislike the fact that the senior executives of health insurance companies, like most other large corporation businesses, get annual compensations the size of which could run a small hospital, but you're talking about maybe hundreds of people, and hospital executives and administration, while compensated well, are for the most part deserving of their compensation for the size of operation they manage, and likely would make a lot more in any other field.
The economic problem is that government wants to promise everyone the same set of benefits and services, so that the person on Medicaid can get the same liver transplant that someone with expensive insurance can get. While the latter is paid for by premiums paid by the insured, the former is paid for NOT by the beneficiary, but by taxes on everyone who works.
Actually, you know, I was, like, reading your note when, um, I realized, you know, that you confused vocal patterns with, like, language, you know what I mean.
An interesting parallel to Orson Scott Card's "Ender's Game"
Sorry if I missed that. It's been a day where subtlety has been lost on me!
Ask any butcher and he'll tell you:
You buy a special purpose knife (shaped handle, long blade, slightly curved, thin blade) because it's the right tool for what you're doing (filleting).
Try filleting with a 100 blade swiss army knife and you'll create lousy cuts, wear your hand out holding all that bulk, and likely cut yourself in the process.
So, a specialized service or function generally is optimized for that activity.