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Conflict of Interest in Healthcare

Posted by Sunny Jacob, Bayshore on 11/04/02 at 07:06 (099248)

John, re your recent message 'The low energy ESWT machines are coming..........':
You are raising a very important ethical and conflict of interest issue, i.e. physicians owning an expensive equipment and then referring their own patients for the procedure, which is common in U.S.A.
There is a major difference in Canada. Thought the majority of physicians in Canada are independent providers and bill the government for a fee for service, they are not employees of the government.
The Colleges of Physicians and Surgeons in Canadian provinces do not encourage physicians to own MRI/dialysis clinics, lithotriptors, etc. to avoid the mentioned conflict of interest. Our standards and guidelines for healthcare in Canada are one of the best in the Western world.
Just by comparing a simple statistical figure of child mortality rate between Canada and the United States, or primary healthcare accessibility for the total population, one will be astounded about the difference between the two neighbouring countries. This does not mean the Canadian health care system is perfect. However, the Canada Health Act with its 5 principles provides reasonable care for the whole population.
The FDA is no help in this area. What the United States may require is a health care reform.

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/04/02 at 13:35 (099289)

Sunny:

There is a law known as the 'Stark' law which prohibits many forms of 'self'-referral in the US particularly for Medicare patients. One of the exceptions is for equipment owned and used in the office by a doctor.
For example -- if I was a limited partner in our local Healthtronics venture, I probably could not treat Medicare patients. I am not a limited partner so I am in the clear on that, although HCFA has set a reimbursement level below the level it costs to provide treatment with that unit. I could, due to the lower cost of the Sonocur, provide that treatment at about a 'break even' level (some feel that docs should not make a profit).
Ed

Re: Conflict of Interest in Healthcare

Bill on 11/04/02 at 21:40 (099363)

Ed,

HCFA has not set a reimbursement yet for ESWT. It is not covered by Medicare so I do not understand your statement that 'HFCA has set a reimbursement level below the level it costs to provide treatment'

What reimbursement are you talking about?

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/04/02 at 22:24 (099372)

A bulletin released in about March 2001 by Noridian, my local Medicare carrier stated that ESWT was covered for PF at a rate of $300 inclusive of 'surgeon,' anesthesiologist and facility. Unfortunately, I do not have a copy. They have archives of their bulletins that one can obtain.
Ed

Re: p.s -- give me your name and address and I will obtain a copy of the bulletin for you

Ed Davis, DPM on 11/04/02 at 22:25 (099373)

Hah, hah.
Ed

Re: Conflict of Interest in Healthcare

john h on 11/05/02 at 18:31 (099462)

Sunny I do not know that I have ever disagreed with you but on this one we do have a difference. In the U.S. many of us or perhaps most of us are accustomed to having a choice of Physicians. I do not need a referral to go to a specialist and I can choose my own family physican anywhere anytime..I can walk into my falmily physicans office on any day of the week without an appointment and be seen within 45 minutes. Bill and Hillary Clinton attempted to create a Canadian type sytem and were almost run out of town. It is a cultural thing here. I do not want an HMO or the Government tell me which Doctor I can see. Some of our HMO posters have reported waiting months to get to see a Podiatrist.. Govenment run sytsem seem to work well where they have been long established but it cuts against the grain of Americans and will be a hard sell here for a long time. Your system has many advantages but so does ours. P.S. I sure do like your ESWT pricing and availabilty of various machines.

Re: Conflict of Interest in Healthcare

Julie on 11/06/02 at 02:54 (099478)

John, wouldn't you agree that the - individualistic - American system favours the well off and the relatively well off? Whereas the British and Canadian systems (I know they are different and I know they have drawbacks) are geared towards the needs of the entire community.

You say the latter type of system 'cuts against the grain of Americans' but I'll betcha it would be welcomed by poor Americans.

Damn. Now I've started a political thread. Ignore me everyone.

Re: Conflict of Interest in Healthcare - PS

Julie on 11/06/02 at 02:56 (099479)

Rough Justice is Preferable to No Justice. Discuss.

Re: Conflict of Interest in Healthcare

Sunny Jacob, Bayshore on 11/06/02 at 07:49 (099493)

Thank you, John. I do respect your view point. However, there seems to be a misunderstanding in some circles in U.S.A. about the health care system in Canada. There are several studies, including from Harvard, regarding this subject, - the view of AMA is different.
Any Canadian can select his/her family physician. Family physicians are not assigned by government or any other agency. Of course, they cannot simply walk into a family physician's office, except if it is an emergency, but have to make an appointment. Patients are referred to a specialist by their family physician. I assume this is the case in U.S. also.

Although the U.S. spends 14% of the GDP on health care, 30% of U.S. citizens do not have access to primary health care or a family physician. Canada spends 9.3% of the GDP on health care and provides universal health care to all Canadians.

As for health expenditure in G7 countries, the United States spends the least in public spending on health care:
US 46%
Canada 70%

Another indicator of good health care is the life expectancy. From 1999 Human Development Report by the United Nations:
Japan (first)- 80 years
Canada (second) - 79
USA (25th) 76.8

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/06/02 at 11:24 (099507)

John:
There is a big difference between Hillarycare and the Canadian system. Canadians, for the most part, can still chose their provider. The Canadian government does not do much to interfere with the provider-patient relationship (as Hillarycare attempted to do) but rather is a single payor system. The best way to describe the Canadian system is if Medicare was extended to all US citizens.
Ed

Re: Conflict of Interest in Healthcare

David L on 11/06/02 at 11:55 (099509)

This one I must weigh in on as a Canadian.
I agree with Sunny that there are tremendous misperceptions in the US about Canadian healthcare. It is actually far worse than the perception.
Misperceptions in Canada about the US health system are equally as rampant.
This notion of so many uninsured in the US doesn't take into account many self-employed people who self-insure. For low income people, there is Medicaid.
The health expenditure comparison as it relates to G7 countries is laughable. All that does is show how much money we waste in Canada. Of OECD countries, Canada ranks 3rd in % of GDP and 30th in efficiency. Life expectency and healthiness of the population is also a misnomer when comparing it to the US as Canada doesn't have some of the social and drug problems that the US has. That is not a reflection on the medical system.
This universal system that supposedly protects everyone actually hurts the people most that it is sworn to protect. There are lineups for everything (6-18 months to see an orthopedist, 6 months for an MRI etc.) Those who are connected (ie politicians, celebrities, wealthy with connections, and union leaders) don't wait. They jump the queue ahead of the average Canadian.
There are only 3 countries in the world that ban private insurance for medically necessary procedures: Canada, North Korea, and Cuba.
Government basically delivers most services. We all know how efficient a goverment monopoly can be.
One last thought......if Canada supposedly has such a great healthcare system that is admired the world over (as its proponents like to say), then why has no other country copied it?

Re: Conflict of Interest in Healthcare

john h on 11/06/02 at 14:52 (099514)

Sunny: I do not need a refertal to see any specialist. I can walk straight into any specialist office I want to without any refereal. Some specialist do require a referal but that is the specialist requirement. I am on Medicare (Julie) which whether you are rich or poor is what we all are covered under after age 65 in the U.S. The only people age 65 or older who would not be covered under this program are those who never worked and paid into the system. Wives come in under their husbands coverage. Their is a 20% copay but supplimental coverage is reasonable. Medicare limits what Doctors can charge for any given procedure and a Doctor cannot charge you more than their approved charges. Of course, some Doctors do not participate in Medicare but I have yet to run into one as anyone who excludes Medicare is excluding a large population. Those people who are not covered by Medicare are covered by Medicaid. A good/bad sort of thing is that anyone without insurance of any sort can walk into any emergeny room in the country and cannot be refused treatment. Many people use this for primary treatment and causes hospitals to lose money in their emergency room. We have many people who simply refuse to buy insurance even when they can easily afford it. Many are young and never think they will be sick. These people appear as those without insurance. Fact is that there is no one that cannot receive medical treatment if they need it. We have a lot still to be worked out but when our government in the form of President Clinton tried to introduce a government type system it was totally and soundly defeated by all groups of people.We are in need of a prescription drug program in Medicare and I think we will be getting help in that area when the new Congress convenes. Most of our large Unions and Corporations have excellent medical benefits that are carried into retirement as do Federal Government Employees. HMO's are what is a sticky point these days as you can tell by some of our posters who sometimes's wait a long time to see a specialist. Our medical system is not nearly as bad as what I think some people with totally government run systems think. We certainly can improve on it.

Re: Conflict of Interest in Healthcare

john h on 11/06/02 at 14:54 (099515)

Thanks for the clarification ED. As a Medicare covered person I am very pleased with my care along with my supplimental coverage.

Re: Conflict of Interest in Healthcare

john h on 11/06/02 at 15:11 (099517)

David L last month my back was really giving me some problems as a result of an aircraft accident during Vietnam. I walked into my family doctors office without an appointment. Saw her after a wait of 20 minutes and told her I thought an MRI might be in order. She agreed and I had the MRI the next day. I then took my MRI with me to a Neurosurgeon which I selected. It took me 4 days to get an appointment. He promptly gave me a diagnosis. I paid not a penny as Medicare and my suppliment covered all cost. I think the hospital cost for the MRI was in excess of $1200 but as you know Medicare limits what they pay and I think they paid the hospital around $375 for the procedure which they are required to accept as payment in full plus my 20% copay which was covered by my suppliment. Where else could I get this type of care. When I read about people waiting months for appointments to see a specialist it is scary. We have a lot of problems in our country including drugs, murder,etc. but our Medical system is not nearly as some think. If I want to see Dr. Zuckerman in New Jersey I just hop on a plane and fly up there. He even takes Medicare patients unfortunately like most insurance companies they are not paying for ESWT. Our Docs probably hate all the paper work with Medicare and the slow manner in which they get paid but most are hanging in there. I asked my family doctor last month did he ever think he would discontinue Medicare patients. He told me he would see me and my family as long as we lived and would always accept our Medicare coverage. Made me feel real good..

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/06/02 at 16:01 (099521)

One of the good things about the Canadian single payor system is that it is administratively simpler than Medicare. The big problem is that it is chronically underfunded (for a number of reasons) causes shortages and waits for certain treatments. The Canadian government, it seems, has an egalitarian bent to it. My podiatry school roomate is married to a woman from Ontario, also a podiatrist. They practice together in Calgary. They mentioned, when I was last there, that they recieve a stipend or allowance for each of their children (they have 3). They told me that they are doing well but feel that the government is treating them the same as people who are less fortunate.
Ed

Re: Conflict of Interest in Healthcare

David L on 11/06/02 at 17:02 (099525)

For doctors, administratively the system is simpler. However, administration consumes a HUGE bulk of healthcare costs. Vancouver General Hospital has 13 Vice Presidents....each with their own staff. Canada, with a population of of 28 million has 14 Ministers of Health. France with a population of 70 million, has one.
The system is actually way overfunded, but money doesn't get to patients. Hospitals receive a 'global budget'. A lump sum at the beginning of the year to treat patients. Every time a patient walks through the door, it costs the hospital money. Patients are a liability under this system and do not generate any revenue.
Remember, this is a government owned and operated monopoly. It is NOT efficient and therefore wastes a tremendous amount of money. Bureaucrats decide everything. The Federal Minister of Health just announced a 15 million dollar study as to why Canadians are overweight. I'll tell them for free....becuase people are consuming more energy than they are expending. If they want to do something about overweight people, they could have put that money towards education on the problem, rather than studying it.

Re: Conflict of Interest in Healthcare

Dr. Z on 11/06/02 at 17:56 (099527)

Medicare is the finest healthcare system in the world. It has the lowest administrative overhead .

Re: Conflict of Interest in Healthcare

john h on 11/06/02 at 18:14 (099529)

Dr. Z: My new Medicare Suppliment is 'Tricare For Life' and as I understand it when you file the necessary medicare papers for my treatment Tricare For Life is automatically picks the info off of the medicare papers and you do not have to fine anything to receive your supplimentary insurance. I feel most fortunate as last year retired military personnel elgible for Medicare became elgible for a prescription drug benefit whereby any prescription cost either $9 or $3 for a generic prescription. By the way our medical benefits in this country do provide for free dialysis and free drugs or insulin for diabetics. Julie maybe you can clarify some information about dialysis in the UK. I heard there were restrictions on who it was made available to? What is this about?

Re: Conflict of Interest in Healthcare

nancy s. on 11/06/02 at 18:35 (099531)

david L and anyone else interested in this topic: i noticed you posted that the number of uninsured in this country includes the self-employed, 'who self-insure.'

do you know how many of the hardworking self-employed in this country cannot afford to self-insure? i'm one of them, and so is my husband. monthly premiums for the two of us to get health insurance today would be $800+. that's like another mortgage payment; we simply don't have it. the self-employed are left out in the cold under the current health insurance system. the poor are better off than we are when it comes to health care, because at least there are programs for them.

i was considered poor enough to get help with the financial costs of health care for about a year -- after i'd come down with pf and three tendonitises and had been unable to work for nearly a year. on the one hand it was mortifying -- i've always supported myself. on the other hand, at least it was there when things got bad enough. one wonders, though, whether that would've been necessary had there been someone who cared enough in the industry and/or government to see to it that the self-employed can afford to self-insure. i'll always wonder, had i been able to afford decent care, whether my feet would ever have gotten as bad as they did (and they'll never be perfect again).

they're 80% percent or so, and i and my husband once again work like dogs, and we still can't afford health insurance. we have friends with their own businesses who are in the same boat. do you think this is right?

nancy
.

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/06/02 at 21:53 (099538)

Nancy:

There are a number of aspects of the structure of insurance in the US that makes it expensive. The tax code has been written for an employer based system. This is a whole subject unto itself.

A few suggestions. Have you tried to obtain health insurance via your local chamber of commerce? Look into policies offered by the NFIB -- National Federation of Independent Business. Also-- look at health insurance as 'true' insurance as opposed to a benefit. A benefit is something that is expected to be used but insurance is obtained with the supposition that it will not. Many can afford to pay for the small things but something major would be catastrophic. Check out the prices on high deductible policies-- $1000, $2500, $5000 deductibles -- they can often be quite reasonable, may include a discount drug benefit and have pre-negotiated prices with hospitals and providers. An individual with say, a $1000 deductible, is self-insuring for the first $1000 of medical expenses.
The first $1000 of expenses, though, would be at rates pre-negotiated by the insurer.
Ed

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/06/02 at 22:09 (099540)

Dr. Z:

The problem is that most family doctors in my area are not accepting new Medicare patients due to low reimbursements -- they are keeping the patients they already have.
Ed

Re: ~Dialysis in UK

Julie on 11/07/02 at 00:58 (099546)

John, sorry, I don't know. But if I learn anything, I'll let you know.

Re: Conflict of Interest in Healthcare

nancy s. on 11/07/02 at 06:30 (099551)

thank you for your suggestions, ed. we have very few choices in maine, but i'll research it again with your specific ideas in mind. catastrophic coverage, which we have gotten some years, had turned into a bad deal for us, because we have high out-of-pocket medication expenses and the cost of my foot care was really astronomical. if we could find a catastrophic policy with at least partial rx coverage, that might make the difference.
i didn't know of the NFIB -- only a new england association that's too expensive -- so i'll check into the NFIB too.
thanks again.
nancy
.

Re: Conflict of Interest in Healthcare

Sunny Jacob, Bayshore on 11/07/02 at 06:45 (099553)

David L., - I can debate each of your points about the Canadian vs. the U.S. health care system.
However, let us do that elsewhere and not on this message board. Just one point, - please read the definition of health by WHO.
Social well-being and drug problems are also part of health.

Universal health care was not invented in Canada. Europe had it working for years before it was introduced in Canada, and there is no perfect system which can satisfy all.
Yes, there are waiting lists in Canada for elective hip or knee replacement. Not only political leaders, even a federal prisoner, can jump the line in Canada. There are loop holes in the system.
The waiting time for an MRI, depending on the urgency, can vary from one week to 6 months in this country.
This is not satisfactory and solutions seem to be on the way through private public partnerships to open new MRI and other ambulatory clinics. Private providers can co-exist within the system and operate efficiently as long as they follow the Canada Health Act.
Dr. Dey's Orthopedic Surgery Centre, Vancouver, as you know, gets paid from the public system for eligible patients. Approx.$33 Billion services in Canadian health care is provided by the private sector. I am one of those private providers in the health care business for the past 30 years.
As I have repeatedly said, the Canadian system is not perfect. However, there is no one who had to declare bankruptcy due to health misfortune or die due to lack of availability or affordability of health care in Canada.
On a $110 billion dollar federal health budget there is nothing wrong to do a $ 15 Million study about overweight. It is worth to educate the public that overweight can also lead to complex healthcare problems. It is not as simple as balancing calorie intake and calorie output.

Re: Conflict of Interest in Healthcare

john h on 11/07/02 at 10:27 (099559)

Ed: We are having some cases of Doctors not accepting new Medicare patients but not a lot. I think I just read an article where the government is going to increase payments for Mecicare procedures as most of the Medicare HMO's are dropping out or raising their prices so that traditional Medicare is a better deal. I personally would have no problem with a raise in the annual deductable which is now only $200. As I get a copy of the statements that the Doctor's bill and what Medicare allows I am often shocked at what they allow. I do notice in some instances Doctors adding a couple of codes to their bill for a simple visit or procedure which pumps up their bill. Our current Medicare program is solvent for 40 years and in 15 years we will start dipping into the reserves so I think Congress will take up this issue soon. I think we as beneficiaries may have to pay a bit more. It really would not take a lot of pain on our part to make this thing solvent for the next 100 years. There is a tendancy to overuse things that are almost cost free. Is not a PF release something like a $350 procedure? With that cost in mind it is easy to see we are a long time down the road in getting Medicare to cover ESWT. They do not take the long view in that many people need a lot of follow on care, some are made worse and spend many many visits to Doctors after failed surgery..

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/07/02 at 21:16 (099604)

John:

The only way I see to ensure the solvency and good function of the Medicare system is some sort of needs testing. Everyone has the same level of benefits at the same rate of reimbursement. Individuals who have the means need to pay a higher percentage of costs than those who don't.
Ed

Re: Conflict of Interest in Healthcare

elliott on 11/07/02 at 22:38 (099616)

Dr. Ed, Medicare isn't a failsafe system to protect the poor like Medicaid. If you're going to needs test for Medicare, there are the usual equity issues to deal with:

1. They paid taxes (likely far more in actual dollars than those with lesser means, even if their contributions still don't pay for their future expected benefit) into the system all during their working years with the expectation of getting equal Medicare coverage upon retirement. The reason Social Security is palatable even though percentagewise it is slanted in favor of the poor is because there is a reasonable balance between social adequacy (safety net for the poor) and individual equity (pay more into the system and at least you get a bigger pension than the guy who pays less); this would be sorely missing here.

2. Such a system would penalize those who save, protect those who don't (which possibly will encourage more not to, thereby exacerbating the problem).

There are other ways to make Medicare solvent and still maintain an equal benefit, at least for newer retirees, but none are necessarily popular: raise taxes; raise the retirement/eligibility age (I hear groans and moans, not least because we still seem to burn out of work at the same age as our grandparents, but it could be argued that this is fair since we're living so much longer and are collectively a greater burden on society); larger co-pays/deductibles (with those who can't afford them possibly aided by federal programs for the poor, but that's just a sly cost shifting trick since you need to raise taxes or decrease expenditures for other programs to pay for it). It would help too if Americans would have more kids than they currently are having (the ratio of workers to Medicare beneficiaries has dramatically decreased over the years); such a turnaround may well rescue the system in the long term.

[]

Re: Conflict of Interest in Healthcare

john h on 11/08/02 at 12:26 (099637)

Elliott: I tend to weigh in on this with you. Means Testing is much to subjective. Some people would seem to have a good income but are burdened with debt, supporting parents, putting kids though college, etc. Additionaly 'Means' change almost monthly. I have no problem with increasing deductables, increasing SS taxes but think means testing would be much to difficult to assess and create class warfare

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/08/02 at 14:55 (099640)

Elliott:

Raising the age of Medicare eligibility may be effective from an actuarial standpoint but there is one major drawback. It is often difficult and expensive for individuals in the 50 to 64 y.o. age group to obtain individual policies, let alone small group policies. Two out of my seven employees are in that group and as a consequence, my office was rejected for coverage by several national insurers. Potential employees in that age group are less attractive to employers over the insurability issue. If anything, from a standpoint of public benefit, I would like to see the age at which citizens become eligible decrease.

Medicaid is a subsidized system in the sense that that system reimburses at less than the cost of many services causing providers to attempt to cost shift to others. Medicare reimbursements have, for the most part, decreased on a regular basis to the point which a number of services are reimbursed at a level lower than the cost to provide such services. One question to ask is that if a provider's office was 100% Medicare patients, would he/she be able to stay in business. My answer is possibly yes, based on the mix of services but 'no' in a number of scenarios. A lot would depend on the location of the office. Supposedly there is some allowance for geographic variations but it is really inconsequential.

It is a bit hard to accept that Bill Gates, after turning 65, will have services reimbursed at the same discounted level that a poor retiree.
Ed

Re: Conflict of Interest in Healthcare

elliott on 11/09/02 at 20:10 (099686)

Dr. Ed, good intentions are one thing, but paying for them is another. There were indeed studies during the Clinton era that looked into allowing those aged 55-64 who did not have other insurance to enter into the Medicare program. It started as an idea for those 62-64, it was extended to age 55-64, and in classic Clintonian fashion, since it would include their families, it came out that we could see newborn babies covered under Medicare for the elderly!! The proposal had to remain budget-neutral (politics aside, you don't add water to a sinking ship), and other factors were taken into account, e.g. predictable side effects as other insurers tending to drop coverage of this age group due to the very institution of the program. The beneficiaries would have had to pay in annual premiums the expected value of their annual costs based on their age until they reached 65, with favorable deferrment of some premiums allowed over their lifetime to make it more affordable. So zero profit to the 'insurer' and favorable terms to the insured. Even so, the studies showed that due to the expense of the premiums and often lower income of the beneficiaries, the healthier would opt out, leaving only the sicker to remain, setting into motion what's called an insurance premium spiral, whereby you have to keep raising the premiums to cover the cost of those who would remain, leaving an even sicker group remaining, necessitating raising the premiums even further, leaving an even sicker group, and so on. In other words, there was no such premium that would make the program work out. Sorry, but a very, very, bad idea, and fortunately it was rejected.

Concerning your own experience, there are some basic and sound actuarial principles as to why smaller groups are more expensive to insure than larger ones; sorry, that's just the way it is.

Doctors didn't seem to mind double-digit annual growth in their income for many years, nor did they offer a way to slow the tide; now things are tougher, but so they are in many other professions. The current situation is not necessarily permanent nor should it be, but given the past it's not an outrage either.

I have no problem with Bill Gates getting Medicare just like everyone else. He paid his taxes for it, and then some; that was exactly the idea behind the program.

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Re: Conflict of Interest in Healthcare

nancy s. on 11/09/02 at 21:31 (099687)

wow, elliott, no problem with bill gates getting the exact same Medicare coverage as everyone else? really?

truly, i can't imagine being a multi-billionaire -- or even having an annual income, whether retired or not, of $50,000, $100,000, $500,000, or $1,000,000 -- and believing that i need the same amount of money (in the form of health coverage) given to me as others who are in dire straits or even simply living on the edge, whether or not i'd 'earned' it. that's just ego and pride at their worst. to me in that situation the issue wouldn't be whether i'd earned it or not, but whether i NEED it or not, and whether or not my getting it -- a drop in my bucket -- would deprive of coverage other hardworking but not so savvy or, more often, not so lucky people far needier in their later years than i might be. i would feel ridiculous, frivolous, and as though i were spitting on the society whose structure enabled me to become so rich, a structure that *depends* on the lower and middle classes to help the rich become rich, remain rich, and grow even richer.

sure, the mathematics superficially make sense, and the principle superficially makes sense, but isn't life a little more complicated than that? i mean, where's the heart and soul of such a system? (we already can identify the 'logic' of such a system.) the system works and makes sense for some; but if it worked for me because i stuck my neck out farther and opened my mouth wider than the other little birdies so i'd get fed more often and fat more quickly, i would be bothered by the fact that other good, intelligent, hardworking individuals crawl and scrounge for every penny and still can't really make it comfortably, in any sense of the word. i would be bothered -- deeply bothered. i assume you have the health-care bases covered for yourself, or else the mathematics might not be the bottom line for you as they seem to be.

on a related note, my town just did a property tax reassessment. our taxes, after less than a year here, more than doubled. my husband and i will figure it out, since we're still working. but i have some older, including downright elderly, neighbors who are terrific people who can't figure it out; i mean, it Will Not Work on their fixed incomes. they are looking to sell their homes, at the age of 66 or 71 or 84, after living here their whole lives and after working for decades to own those homes. it's a sorry state of affairs when it comes to this, all based on mathematics and on some abstract principle applied to everyone, rich or poor.

it would be nice if the mathematics were fair to all, but they simply aren't. some people, bless 'em, are bigger than others who want 'what's coming to them' whether they need it or not, everyone else be damned.

my 81-year-old father, who lives near us in a teeny-tiny, humble, rather shabby apartment in a modest retirement circle and has little extra money to spend, voted on tuesday for the candidate in his district who will work to disperse health-care and other monies according to need and years worked, whether the workers were garbage collectors, teachers, or ceo's. this means my father will receive *less* in the form of benefits than he would have under the representation of other politicians he could have voted for. my father actually thinks about his neighbors and cares about them, and doesn't want to live high on the hog compared to them just because he worked for IBM for decades and could've been a bigger honcho if he hadn't taken early retirement in order to work in the education field at a much lower salary.

i wish there were more like him.

nancy
.

Re: Conflict of Interest in Healthcare

elliott on 11/09/02 at 23:50 (099690)

Nancy S, you speak from your heart, and I appreciate your sincerity. Of course, when worded such, it comes out sounding like you are good and I am bad (what else is new?). But before you paint me out to be some kind of cold, hard, insensitive, calculating [insert more adjectives] guy, in case anyone forgot, this thread was supposed to be about the various health care systems of different countries.

A system such as U.S. Medicare has to be solvent. It's got to be payed for. You mentioned that your property taxes doubled. Why do you think that was so? Because your government did not have sufficient funds to pay for services for the needy (not to mention other, sometimes more questionable, programs). Cover everyone's needs as you deem fit, and you might find your taxes quadrupled to pay for it. Think about that.

The reason Medicare is acceptable to the public is because everyone pays a fixed percentage of their taxes to the program and then receives medical coverage in their old age. Bill Gates paid his taxes, a lot of them. I hate to tell you, but even if it makes you feel good and you were to charge the very rich more for their Medicare benefits, it would barely make a dent, because there aren't that many of them. Anyway, start making exceptions and you'll find the middle class who worked hard and payed Medicare taxes all their working lives will watch their savings in retirement dwindle away due to unreasonable wealth limits because they dared to save for retirement. That's not fair either. And if you think every last dime should be taken from those who have more to pay for health care for those who have less, well, the Democrats just got repudiated at the polls.

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Re: Conflict of Interest in Healthcare

nancy s. on 11/10/02 at 00:53 (099692)

dear elliott, i don't speak from the heart to make me look good and you look bad. i think your view of the subject isn't broad enough, it's as simple as that: just a difference of opinion, not a condemnation. i didn't use any of those adjectives that you supplied to describe yourself, and i assume you don't mean to describe yourself that way either.

i suspect the property taxes in my town doubled not to support the needy but to support the whims and private interests of our town council, town manager, and town tax assessor. i attend town meetings; i follow their agenda and listen to their proposals and their discussions and their votes on the issues, so my opinion isn't based on nothing or on preconceived notions. it might be wrong, of course, but i personally don't think so. :-}

i do think that if the rich were charged more for medicare benefits, it would make a dent. there may not be a lot of people, percentage-wise, who fall into the rich category, but the amount of money we're talking is huge. large money being held by few people: that's kind of the basis of the problem discussed in this thread.

i don't think we should 'start making exceptions.' i think the entire health-care system in this country needs an overhaul, and not only because it doesn't serve me well personally despite the high taxes, including self-employment and my own social security taxes, that i pay. i'm just one person. there are many many people it doesn't serve well.

i also don't think 'every last dime should be taken from those who have more.' of course not. but I do think the wealthy could pay, or forgo, more than they do now and not miss it -- and not miss a moment's sleep over it. i know bill gates pays a lot in taxes. i also know he's still left with billions. have you seen his house? let's not waste potential pity on someone who has done incredibly well for himself and will always live in extreme luxury even if he is called upon to support u.s. society as a whole more than he does now.

the democrats did just get repudiated at the polls, as you say. in this time of post-9/11 and the identification of a locateable (i know, must not be a word!) scapegoat (who i do think is despicable), i wasn't the least bit surprised by the election results. people are not interested in the foundering economy; they're interested in allaying their larger fears and protecting their personal safety. war talk often accomplishes that. i don't think the elections had anything at all to do with health care or the clearly deepening pockets of the rich. any tough-talking president, whether republican or democrat or independent or martian, would almost certainly have enjoyed support demonstrated in elections following 9/11.

nancy
.

Re: Conflict of Interest in Healthcare

Bill on 11/10/02 at 06:48 (099693)

Really guys. I know that you are enjoying this political discussion but what does this have to do with PF? You were very critical of me for discussing machines that treat PF but Medicare politics and whether Bill Gates receives Medicare coverage has nothing to do with PF!

Re: Conflict of Interest in Healthcare

elliott on 11/10/02 at 08:03 (099694)

No, Bill, we weren't very critical of you discussing machines that treat PF. We were critical of your posting the same thing thousands of times over in omenous fashion and not identifying yourself.

[]

Re: Conflict of Interest in Healthcare

elliott on 11/10/02 at 08:28 (099695)

The money you're talking about if the very rich were charged more for their benefits is not huge; it's been looked into. If you don't believe me, fine. Complete overhall? State what you propose and watch it get torn to shreds by others who will object strenuously about something or other.

Your government doesn't use its tax dollars wisely? Naw, can't be! I thought we need them to use the money wisely when they take from the rich and give to the poor.

I believe you said both you and your husband are self-employed. There are alternatives: one of you could take a job where you work for someone else, simply to get the family covered by health insurance. You would not be the first couple to make a decision based solely on that; in fact, you'd be more typical. I'm not telling you at all what kind of job you must take, only that you are aware of the circumstances and that there are alternatives. Others disappointingly make such decisions out of necessity too. No one said life, whether here or abroad, is ideal.

We made history here in Maryland, one of the Democrats' bastions, by voting in Bob Ehrlich, the first Republican governor in 36 years. It wasn't because of 9/11, but because the Democrat was viewed even by many Democrats as, well, not fit for the job, likely to raise taxes, and same old same old. The Kennedy name wasn't even enough. Sure, at the national level, there is post 9/11 fear, as there should be, and most felt safer with Republicans because maybe they are safer with Republicans.

[]

Re: Conflict of Interest in Healthcare

john h on 11/10/02 at 08:45 (099697)

Real Property taxes in Arkansas go to the school system and not to Medicaid or Meicare or any other social program. Nancy and Elliott are you all talking Real Propterty taxes?

Re: Conflict of Interest in Healthcare

elliott on 11/10/02 at 08:55 (099699)

John H, right, I think we're talking taxes rather loosely, that they often charge too much on specious grounds. The point was that it's not obvious that a government--any government--is always going to solve its problems with huge tax increases. In Baltimore, a large chunk, but not all, of property taxes goes to schools, I think it's 40%. We have one of the highest property tax rates in the country. A while back, the city got the great idea of raising the rates to yet higher astronomical proportions to pay for all its beloved programs. The result was that many fled the city for the suburbs, and had to sell their houses for far less. The result was that the city brought in less revenue than had it not raised taxes that high in the first place. The new administration has actually *lowered* the rate somewhat.

][

Re: Conflict of Interest in Healthcare

Bill on 11/10/02 at 10:49 (099708)

Elliot,

Again, how does this relate to ESWT and PF? Can't you take this off-line and have your discussions privately. They are interesting but more appropriate elsewhere, perhaps over a few beers in a bar.

Unless you are arguing that Bob Ehrlich a supporter of ESWT, or that republicans more likely to get insurance reimbursement for ESWT, or that
raising property taxes makes it more likely that my insurance will cover ESWT. Otherwise, I don't see how this is related to the focus of this eswt board.

Re: 'Bill', isn't it time you identified yourself?

Julie on 11/10/02 at 15:59 (099727)

.

Re: Conflict of Interest in Healthcare

john h on 11/10/02 at 16:37 (099730)

In Arkansas real estate taxes for individuals is frozen at what ever level you are at age 65. We frequently have reassessments here so that is a big deal. I think 100% of our property taxes goes to support the school systems. We had an ammendment on the ballot this year to removes sales taxes on food and medicine which would have really put a burden on the state to fund all their many programs including Medicaid. I was supprised that the public soundly defeated an ammendment to drop taxes.

Re: 'Bill', isn't it time you identified yourself?

Bill on 11/10/02 at 18:55 (099737)

It looks like many people post with the name Bill. Which Bill
do you want to know about? Orthotics Bill? Tax Bill? FDA Bill?
PMA Bill? It's just so confusing.

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/10/02 at 20:34 (099748)

Elliott:

Your concern stems from the 'slippery slope' process that would allow coverage to expand faster than the ability to pay for it. There are a couple ways to look at this -- incremental expansion of Medicare or using the Medicare model for the basis of a single payor system for the US.

Milton Friedman, a staunch conservative, long ago advocated a single payor catastrophic system. He was advocating a safety net as opposed to a comprehensive single payor system. My version of that would be that the government provides what amounts to a high deductible policy for everyone.
Lets start with some arbitrary numbers for the point of illustration.
A single payor high deductible policy is formed with a $5000 deductible for citizens, ages birth through 18, $10,000 deductible for ages 19 through 50 and a $5000 deductible for ages 51 through 64. Private insurance either via individual policies are still obtained individually or through employer groups. The lower stop loss makes policies for children more affordable and makes policies for the 51 through 64 age group more affordable since private insurers have a lower stop-loss level.
Ed

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/10/02 at 20:40 (099749)

Elliott:

It is easy to get worried when politicians propose programs without reasonable means to pay for them. The above numbers are for illustration only. I do have to question whether current Medicare deductibles are way too low. That is the area where needs testing may need to be invoked in the sense that the current low deductibles would be in place only for those with limited resources.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/10/02 at 20:44 (099750)

Bill:
Overzealous regulation (something you are a fan of) and litigation has driven the cost of healthcare so high that increasing numbers of citizens cannot afford coverage.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/10/02 at 21:57 (099751)

The way I see it, the physicians are equally to blame. Physicians form partnerships and force hospitals to pay inflated prices to use the partnership's equipment. They use their power of referal as a lever to inflate the cost of services. It started with MRI partnerships. We continue to see this in lithotripsy and we see it in ESWT.

Look at what Healthtronics has done. For the first two years of business with the Ossatron they would mainly sale Ossatron's to physician partnerships that Healthtronics would organize. Healthtronics was also a partner. These partnerships would charge $4,000-5,000 for ESWT. Most insurance companies balked and were slow to reimburse.

Litigation and regulations, like Stark II and Federal Fraud and Abuse, have helped keep these activities in check. It is unfortunate that good physicians find themselves grouped with the crooks.

Re: Bill -- YOU may be part of the healthcare access problem

nancy s. on 11/10/02 at 22:29 (099752)

bill, who knows, you may be right about this. but i recommend that you have a few beers in a bar, loosen up a little, and come back when your linear thinking has been interrupted and enriched by the endlessly varied parade of humanity out there.

Re: Conflict of Interest in Healthcare

nancy s. on 11/10/02 at 22:42 (099754)

i agree with you, elliott. there will be no health-care overhaul in this country. sad.

we made minor history in my state: we elected the first democratic governor since the early 1980s. i voted for him. i also voted twice for the two-term independent governor we've had for the past eight years.

and, believe it or not, i voted for the two-term republican governor we had before him. i voted for him because he was the best candidate running; i didn't care for the democratic candidate or his particular views at all.

special for bill!: i'm calling our new governor-elect tomorrow to educate him about eswt and to demand that he discuss pf in his inaugural address.

nancy
.

Re: 'Bill', it's getting less and less confusing ...

Julie on 11/11/02 at 01:41 (099757)

....and the 'Bill' I'd like to see stand up and show his face is the (one and only) Real Bill.

Maybe after you've had a few beers???

Re: 'Bill', it's getting less and less confusing ...

john h on 11/11/02 at 08:07 (099766)

Bill drinks soy milk.

Re: Conflict of Interest in Healthcare

elliott on 11/11/02 at 08:52 (099773)

Actually, Nancy S, I didn't say that an overhaul was good. I said that if you try, people will complain, and sometimes with merit. We could end up with worse. Could you loosely outline what you have in mind for an overhaul (with special attention given as to how we pay for it)? I am curious what you have in mind and am willing to listen (as if that will change our health system). And please do speak up the next time a doc says everything will be all right if only ESWT were covered by insurance--ever more unaffordable insurance.

I do agree that Bill should have a few beers.

Isn't it possible that at least this time around, the Republicans overall were the better candidates? Oops, sorry, nothing to do with ESWT. :-)

[]

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/11/02 at 12:25 (099793)

Bill:

A very small percent of US physicians were involved in such financial relationships. The current regulatory burden and state of litigation affects virtually all medical practitioners and their patients.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

BGCPed on 11/11/02 at 12:51 (099797)

Nancy, that was a well thought out, sound advice. I think that more people in this world would benefit from your advice. I also think that maybe if we made it open season and had a bounty on trial lawyers 2 weeks per year we would be all set.

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/11/02 at 13:24 (099799)

Within specialities that is just not true. Most of the Urologists that I know are invested in some sort of lithotripsy venture. There are currently three companies soliciting investment from DPM's and they are targeting all of the local DPMs. If these companies are successful then most of the local DPMs will be invested in an orthopedic lithotripsy machine. The market will not be open and competition will be reduced.

Re: Conflict of Interest in Healthcare

nancy s. on 11/11/02 at 13:33 (099801)

yes, elliott, i know you didn't say that an overhaul of the health care system would be good. (i can read -- even between lines!) i was fishing around trying to find a piece of common ground with you, and i found it: i agree with you that health care overhaul won't happen. the 'sad' part was my own editorial comment, of course.

gosh, you want an outline from me as to how to accomplish an overhaul, with special attention to how we'd pay for it? hillary spent months, and that bombed, so i might need a little longer. i'll have to get back to you on that one.

but i will say this: the uninsured self-employed are not the only people not well served by the current system. (by the way, you want us to take jobs with companies simply in order to receive health care benefits? do you think the coverage would extend to the mental health coverage we'd need if we were to do that? i don't think so. besides, what about the entrepreneurial spirit that's so fundamental to the growth of this country and to the economy in general? you're not discouraging that, are you? :-} )

to continue: the hmo system appears to be abominable in a number of ways/situations, so even if one IS covered, quality health care isn't guaranteed, and waste of money does appear guaranteed.

forgive my continual self-examples -- they're what i know best. we were able to afford self-paid hmo coverage for about a year and a half in the mid- to late 1990s. during that time, i believe i was given often-needless tests and re-tests -- probably because the risk of a possible condition i might have, though minutely small, was large enough to worry my doctor about malpractice should it turn out that she'd missed following up on something important. on the other hand, when pf reared its ugly head and my life came to a screeching halt, she was not too bad, but i'd still say 'slow,' at referring me to what turned out to be an incompetent podiatrist. this guy ordered lousy ice-scraper orthotics (at $300, even charging me the $15 co-pay for the twenty seconds it took for me to walk into his office, pick up the orthotics in a plastic bag from his speechless assistant, and go home and make my feet worse by wearing them).

after eight months of really debilitating pf, i was refused a referral from him for physical therapy. he wanted to do surgery instead, which would put money in his pocket; a referral for PT would, i guess, have earned him some demerits from the hmo and no money. i think that's only partly his fault: what kind of system even tempts a doctor to make such a decision?

the next year, when i 'earned' coverage from a special state program for people put out of work by medical conditions, i was referred by another doctor (a good one) for six months of physical therapy, which did help -- a lot. even if the incompetent pod had referred to PT, how much PT do you think the hmo would have approved? maybe three weeks. three weeks is far too little; six months may have been overkill, i don't know. but it seems to me that something is seriously askew if people paying for hmo coverage can't get needed PT (or enough of it), and those in special programs can get all they need and maybe more. shouldn't there be a middle ground, where i might have paid for a reasonable amount of PT via self-paid health insurance, and probably paid more but been able to do it, rather than getting it for 'free' after i'd become too debilitated to get it any other way?

in my three years on the board, i've seen hundreds, maybe thousands, of posts from people who do have health insurance but have been stuck in nowhereland because of it -- they are covered for a little care here, a little there, but not enough to deal decisively with a debilitating condition.

i don't claim to have all the answers, not by a long shot. but i do see a big problem, a nationwide problem, and i'd be stupid not to point it out, especially after my own experience with foot hell, and after becoming aware of that of many many others here on the board who *are* covered by health insurance. and i wonder how many never even find their way here.

in relation to medicare, i think ed davis's idea of raising the low deductibles, except for those really unable to pay them, would be a good start.

yes, it's possible that the republicans had the better candidates this time around. anything's possible. but i emphatically think that they did not. actually, the best candidates were nowhere to be found, in my opinion; i'm still waiting for them to summon the courage to throw their personal lives to the wolves and run for office.

nancy
.
p.s. eswt.
.

Re: Bill -- YOU may be part of the healthcare access problem

nancy s. on 11/11/02 at 13:52 (099802)

BGC: huh? did i defend lawyers and the litigation industry here? no sir!
but thank you very much. your post was well thought out too. keep on thinking.
say, what does the 'b' in your initials stand for?

nancy
.

Re: Conflict of Interest in Healthcare

elliott on 11/11/02 at 15:04 (099824)

Nancy s, regarding getting the mental health coverage you'll need if you work for someone else, Congress actually has been mandating the necessity to provide mental health coverage (something often abused), at the expense of 'trivial' things like care for severe sufferers of PF enabling them to walk. No, I'm not stopping your entrepreneurial spirit; that spirit just has to earn more these days, that's all. :-) Take what job you want, but realize there are implications.

HMOs were an attempt to gain control on costs, but yes, they have problems. Fee-for-service plans can be costly to the beneficiary as well. As much as you complain about our system, we spend more on health care than all other countries by a longshot. Economists claim we pay more for health care than other countries because we want to. I'll be waiting for your outline of a viable alternative.

Orthotics are a great help to many. The value of PT for various ailments is often way overblown. It seems like you're picking and choosing based on your own circumstances, which is understandable.

High deductibles for Medicare is an idea, but there are probably far too many elderly who are poor that this might prove too controversial, or expensive.

Do you applaud Clinton for rebuilding North Korea's economy in exchange for promising to be good (no nukes), and now (surprise, suprise) we found out they were not good (they have nukes)? Sometimes a tougher position, the kind you think of as warmongering, is just what we need to promote security.

Re: Bill -- YOU may be part of the healthcare access problem

BGCPed on 11/11/02 at 16:22 (099827)

No the beer advice was sound. I just interjected my personal views on the trial lawyers. Sorry didnt mean to make it sound like you were endorsing those guys. As I have stated before, if you look at the laser eye surgery history. The first machines were $500 thousand and had a 'royalty fee' of about $400 per patient. The average cost in the states was several thousand per eye.

Many folks would go to Canada to get a better price not to mention it was approved there first. Now there are chains opening and many Doctors doing ads on tv, radio and newspaper. Now there are price wars and you can get it at some places for $500 per eye. I may be dumb but I would think that is an example of free market. If several Doctors have an interest in a certain machine or facility are you saying that there will be some type of price fixing or overly high fees?

Stark Laws aside any piece of expensive equipment needs to run often to make money. If one group had the machine and was charging an excessive fee then another group would be able to move in a charge less. Competition or lack of can drive prices up or down. I think the best aspect is there will be many less inclined to do fascia releases which is a good thing.

I would think that the laser field would be a good model since there are many similar aspects with the eswt machines

Re: Bill -- YOU may be part of the healthcare access problem

john h on 11/11/02 at 17:39 (099831)

Ed: I have no idea nationally how may physicans may be involved in such relationships but I sure have an idea about my small city of L.R. with a population of around 300,000. A friend of mine worked in a company with me as a salesman. He leased some cars to a few doctors and being a bright guy introduced them to the idea of leasing equipment such as Catscan,MRI, Lithotriptos,etc. to hospitals. The doctors had the ins to the hospitals and my friend took an owership position and set up the leasing company with the doctors furnishing the capital. He is now a multi millionaire many times over. Two other friends came up with the idea of starting up a dialysis center with the major player being a nephrologist. They ended up with around ten dialysis centers in 4 states and several years ago sold out to a large public company. All are multi millionaires many times over. The doctor retired and probably under age 50. These are people I know and I am very familiar with how they proceeded and what a really small amount of capital was required to start these businesses. Bottom line on all this is patients paid a very large premium to have dialysis, cat scans mri's, lithotripsy. Something is wrong here. Too many middle men. To many people with conflicts of interest. Unfortunately it is all legal. I have no reason not to believe this is occuring all over the country.

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/11/02 at 19:18 (099835)

You are assuming that the patients shop for the best price. I agree that this happens with laser eye surgery. But in this case it is not covered by insurance.

I believe that when insurance covers a procedure then patients go where their doctor recommends. There is no concern for price since it is covered by insurance.

I am guilty of this with prescriptions. I don't shop for price since it is covered by insurance. I think that the same thought process goes for lithotripsy and other covered services.

Expensive equipment does not need to be run often if the reimbursements are high enough and there is limited competition. I don't believe that the prospect of less fascia releases will motivate insurance companies to approve ESWT. Insurance companies will act to decrease their costs until ESWT becomes standard of care then they will have no choice but to cover it.

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/11/02 at 20:20 (099839)

If you keep products off the market, you limit competition.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/11/02 at 20:24 (099841)

Bill:
There is one DPM in my state invested in the Ossatron. One out of about 250 licensed podiatrists. Most of the urologists I know are not invested in some sort of lithotripsy venture. I cannot speak for your area as you will not reveal where it is. Your hypotheticals are not consistent with what is happening.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/11/02 at 20:35 (099842)

John:

I really do not have statisitics on this but would prefer not to guess or make assumptions. Your millionaire entrepreneur doctor aside, I do not see this happening in my area. Additionally, we have a capitalistic system that encourages that form of entrepreneurship so we really need to think twice concerning value judgements unless one wants a fundamental change in the system. Patients, in most areas cannot pay 'a very large premium to have dialysis, cat scans, mri's, lithotripsy' because the rates, for the most part are fixed by third parties. Medicare, Blue Cross, Blue Shield, etc. pay a fixed rate or allowance for that service so 'large premiums' are really not possible in most areas. A larger concern is that of overutilization -- ordering more services than are necessary due to the potential to profit from ownership in the entities providing those services.
Ed

Re: What happens when the strings are so long that we run off the right margin?

Ed Davis, DPM on 11/11/02 at 20:42 (099843)

Just curious.
Ed

Re: What happens when the strings are so long that we run off the right margin?

Scott R on 11/11/02 at 23:13 (099846)

It's supposed to word wrap wthout a problem.

To everybody:
let me know if youi didn't get the heel pain newsletter this month.

Re: What happens when the strings are so long that we run off the right margin?

wendyn on 11/12/02 at 07:21 (099850)

Scott - I did not.

Re: What happens when the strings are so long that we run off the right margin?

Scott R on 11/12/02 at 07:25 (099851)

Wendy, you have to sign up for the newsletter. I didn't see your email address on the list.

Re: What happens when the strings are so long that we run off the right margin?

Julie on 11/12/02 at 07:29 (099852)

Scott, I got mine, no problem, but as you're actively reading today I want to say that I like your suggestion that people point out Good Posts to you. I would add only that many Good Posts are not usually stand-alones, but are stimulated by Interesting Threads and are part of a Good Conversation. So maybe people should draw your attention to Interesting Threads.

Re: Bill -- YOU may be part of the healthcare access problem

john h on 11/12/02 at 09:04 (099868)

Ed: I am a Capitalist through and through. Over utilization sort of gets us back to the trial lawyers as Doctors are forced to practice defensive medicine or worse yet leave states that have histories of large awards.

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/12/02 at 14:19 (099902)

In Chicago, the market was dominated by Parkside, a physician owned lithotripsy venture. This lithotripsy venture was prosecuted by the FTC. You can check their web site for the details it is file number 9310028.

In my state, most of the urologists are invested. It is not hypothetical, I know this for a fact. Unless you have a very large circle of friends or are also in the lithotripsy business, I can't imagine how you would know the situation with urologists. Aren't you busy enough with your podiatry practice?

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/12/02 at 14:29 (099907)

Keeping unsafe products off the market does not limit competition.

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/12/02 at 14:33 (099908)

Ed,

There really isn't any concern about overutilization of renal lithotripsy. Either the patient has a stone or he doesn't. You can't treat air.

Diagnostic procedures are a different story and that is why the Stark law prohibits most physician ownership from diagnostic procedures.

Re: Conflict of Interest in Healthcare

nancy s. on 11/12/02 at 15:48 (099916)

elliott, i agree that mental health coverage (what little there is of it) is often abused, but so are many other kinds of coverage. i'm one who believes in a certain amount of mental health coverage for those who really need it. i have personal experience with the need, for one thing, but i see enough other people with major clinical depression and other dangerous disorders who can't get treatment. i don't think it should take a backseat to other medical disorders; it can and does result in death, for example. we lost our beautiful 37-year-old niece to it two years ago, at least partly due to lack of coverage and also to the stigma still attached to it after all these years. she chose to behave according to the stigma and not seek help openly, but still....

i do know there are trade-offs in any kind of work a person chooses. i accept the trade-offs i have to make, but i'll also speak out if i think there's a wide-ranging unfairness taking place.

it's true that orthotics are a great help to many. i would encourage anyone with pf who is an appropriate candidate for them to give them a major try. i did give them a major try (two pairs, one bad, one great), to no avail. just unfortunate. i really don't know the statistics on how helpful pt is to people with pf only. my pf problem was compounded by achilles, peroneal, and post tib tendonitis, and pt did help a lot. at the same time, if i'd had good treatment for pf in the first place, i'm not convinced that the tendonitises would have developed at all.

i'm not surprised that the north koreans turned out to be untrustworthy. but remember that we had a big hand in making saddam hussein who he is today, because it benefited us at the time, and noriega in panama before him, and others. clinton did not make those people; they were created with u.s. help well before his time. so the blame for the current situation extends back well before him.

nancy
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Re: Bill -- YOU may be part of the healthcare access problem

nancy s. on 11/12/02 at 16:01 (099918)

oh ok, bcg, i'm glad you thought the beer advice was sound and that you didn't misunderstand my view of the litigation situation today. i think it's dreadful. i forget now how he put it, but i read today that ed davis referred to something like doctors being forced to practice defensive medicine. and, like him, i think it's a rotten situation. lawyers are, of course, sometimes needed -- and sometimes for true medical malpractice -- but here's a situation that's abused to the max, and we all pay for it.

this isn't really medical, but a few years ago a guy in portland sued a friend and got millions of dollars for falling off the friend's boat. whose responsibility was that? the friend who hadn't put 206 railings around his boat, or the guy who chose of his own free will to get on the boat and then apparently didn't pay enough attention to avoid falling off? i cannot believe that people get paid, even get wealthy, for this sort of refusal to take responsiblity for their own choices and actions. it's sickening, and it affects our society in countless ways, including medically -- in terms of both coverage and quality of care.

ok, i'll stop preaching to the already converted now!

nancy
.

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/12/02 at 18:46 (099946)

Sonocur is not an unsafe product.
Ed

Re: What state?

Ed Davis, DPM on 11/12/02 at 18:49 (099947)

What state are you in?
Ed

Re: Bill -- YOU may be part of the healthcare access problem

BGCPed on 11/12/02 at 18:55 (099951)

There is a attorney from the US that has filed suit against the US border patrol/forest service/government. There was a group of illegal mexicans that died of dehydration in an area of Texas. The forest service uses big water tanks that are filled to allow a rare antelope type creature to survive. They are about 10 miles apart and one of them was not filled and this group of illegals dies of dehydration several miles from the one that was empty.

This shark fin lawyer claims the forest service is at fault for not maintaining water supply????????

I am not making this up

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/12/02 at 19:19 (099962)

Ed,

I'm not saying that it is unsafe. I am questioning its effectiveness.
I assume that it is safe since it passed FDA safety testing for tennis elbow.

Re: Bill is Bill Clinton? -- Can't be!

Ed Davis, DPM on 11/12/02 at 22:13 (099978)

Bill:
You are waffling so much, it reminds me of
Bill Clinton. Not safe? Not saying it is unsafe. Go back and read a string of your posts. It depends on what 'is' is.
Ed

Re: Bill is Bill Clinton? -- Can't be!

Bill on 11/13/02 at 08:07 (100003)

Ed,

I guess that we must both be waffling then. You should proably read carefully my posts and see what you think. You have attributed many beliefs to me that are not true. Anyways, when you start equating me to Bill Clinton I can see that its time to stop and since you are one of those persons who needs to get the final word, I'll let you have it. Please respond how you will to this message. I won't respond. You get a free shot.

Re: Bill -- YOU may be part of the healthcare access problem

john h on 11/13/02 at 10:16 (100013)

Having had two kidney stones I will firmly state when you need a lithotripsy you need a lithotripsy. unrelenting pain level of 10 you can take for only so long. the doctors tried to wait but I could no longer wait. my second stone the pain subsided and i passed about 8 days later without incident. it is difficult to imagine mis using lithotripsy. even as you are placed on the table for lithotripsy the doctor attempts to grab the stone if it is in the urter with a small cage. if he can you are out of there in 15 minutes..

Re: Bill

Julie on 11/13/02 at 11:16 (100022)

But Bill - it's you who has had the last word (as you surely intended).

You've come to these boards to stir things up, and succeeded. You've refused several requests by me, Dr Ed Davis and others, to identify yourself, which is deceptive. You've been discourteous.

If I were the webmaster of this board I would have cautioned you. I can't do that, but I can express my distaste for the disharmony you have brought here. And that's what I am doing.

Re: Bill is Bill Clinton? -- Can't be!

Ed Davis, DPM on 11/13/02 at 14:40 (100052)

Lighten up Bill. I am just pulling your leg.
Ed

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/04/02 at 13:35 (099289)

Sunny:

There is a law known as the 'Stark' law which prohibits many forms of 'self'-referral in the US particularly for Medicare patients. One of the exceptions is for equipment owned and used in the office by a doctor.
For example -- if I was a limited partner in our local Healthtronics venture, I probably could not treat Medicare patients. I am not a limited partner so I am in the clear on that, although HCFA has set a reimbursement level below the level it costs to provide treatment with that unit. I could, due to the lower cost of the Sonocur, provide that treatment at about a 'break even' level (some feel that docs should not make a profit).
Ed

Re: Conflict of Interest in Healthcare

Bill on 11/04/02 at 21:40 (099363)

Ed,

HCFA has not set a reimbursement yet for ESWT. It is not covered by Medicare so I do not understand your statement that 'HFCA has set a reimbursement level below the level it costs to provide treatment'

What reimbursement are you talking about?

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/04/02 at 22:24 (099372)

A bulletin released in about March 2001 by Noridian, my local Medicare carrier stated that ESWT was covered for PF at a rate of $300 inclusive of 'surgeon,' anesthesiologist and facility. Unfortunately, I do not have a copy. They have archives of their bulletins that one can obtain.
Ed

Re: p.s -- give me your name and address and I will obtain a copy of the bulletin for you

Ed Davis, DPM on 11/04/02 at 22:25 (099373)

Hah, hah.
Ed

Re: Conflict of Interest in Healthcare

john h on 11/05/02 at 18:31 (099462)

Sunny I do not know that I have ever disagreed with you but on this one we do have a difference. In the U.S. many of us or perhaps most of us are accustomed to having a choice of Physicians. I do not need a referral to go to a specialist and I can choose my own family physican anywhere anytime..I can walk into my falmily physicans office on any day of the week without an appointment and be seen within 45 minutes. Bill and Hillary Clinton attempted to create a Canadian type sytem and were almost run out of town. It is a cultural thing here. I do not want an HMO or the Government tell me which Doctor I can see. Some of our HMO posters have reported waiting months to get to see a Podiatrist.. Govenment run sytsem seem to work well where they have been long established but it cuts against the grain of Americans and will be a hard sell here for a long time. Your system has many advantages but so does ours. P.S. I sure do like your ESWT pricing and availabilty of various machines.

Re: Conflict of Interest in Healthcare

Julie on 11/06/02 at 02:54 (099478)

John, wouldn't you agree that the - individualistic - American system favours the well off and the relatively well off? Whereas the British and Canadian systems (I know they are different and I know they have drawbacks) are geared towards the needs of the entire community.

You say the latter type of system 'cuts against the grain of Americans' but I'll betcha it would be welcomed by poor Americans.

Damn. Now I've started a political thread. Ignore me everyone.

Re: Conflict of Interest in Healthcare - PS

Julie on 11/06/02 at 02:56 (099479)

Rough Justice is Preferable to No Justice. Discuss.

Re: Conflict of Interest in Healthcare

Sunny Jacob, Bayshore on 11/06/02 at 07:49 (099493)

Thank you, John. I do respect your view point. However, there seems to be a misunderstanding in some circles in U.S.A. about the health care system in Canada. There are several studies, including from Harvard, regarding this subject, - the view of AMA is different.
Any Canadian can select his/her family physician. Family physicians are not assigned by government or any other agency. Of course, they cannot simply walk into a family physician's office, except if it is an emergency, but have to make an appointment. Patients are referred to a specialist by their family physician. I assume this is the case in U.S. also.

Although the U.S. spends 14% of the GDP on health care, 30% of U.S. citizens do not have access to primary health care or a family physician. Canada spends 9.3% of the GDP on health care and provides universal health care to all Canadians.

As for health expenditure in G7 countries, the United States spends the least in public spending on health care:
US 46%
Canada 70%

Another indicator of good health care is the life expectancy. From 1999 Human Development Report by the United Nations:
Japan (first)- 80 years
Canada (second) - 79
USA (25th) 76.8

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/06/02 at 11:24 (099507)

John:
There is a big difference between Hillarycare and the Canadian system. Canadians, for the most part, can still chose their provider. The Canadian government does not do much to interfere with the provider-patient relationship (as Hillarycare attempted to do) but rather is a single payor system. The best way to describe the Canadian system is if Medicare was extended to all US citizens.
Ed

Re: Conflict of Interest in Healthcare

David L on 11/06/02 at 11:55 (099509)

This one I must weigh in on as a Canadian.
I agree with Sunny that there are tremendous misperceptions in the US about Canadian healthcare. It is actually far worse than the perception.
Misperceptions in Canada about the US health system are equally as rampant.
This notion of so many uninsured in the US doesn't take into account many self-employed people who self-insure. For low income people, there is Medicaid.
The health expenditure comparison as it relates to G7 countries is laughable. All that does is show how much money we waste in Canada. Of OECD countries, Canada ranks 3rd in % of GDP and 30th in efficiency. Life expectency and healthiness of the population is also a misnomer when comparing it to the US as Canada doesn't have some of the social and drug problems that the US has. That is not a reflection on the medical system.
This universal system that supposedly protects everyone actually hurts the people most that it is sworn to protect. There are lineups for everything (6-18 months to see an orthopedist, 6 months for an MRI etc.) Those who are connected (ie politicians, celebrities, wealthy with connections, and union leaders) don't wait. They jump the queue ahead of the average Canadian.
There are only 3 countries in the world that ban private insurance for medically necessary procedures: Canada, North Korea, and Cuba.
Government basically delivers most services. We all know how efficient a goverment monopoly can be.
One last thought......if Canada supposedly has such a great healthcare system that is admired the world over (as its proponents like to say), then why has no other country copied it?

Re: Conflict of Interest in Healthcare

john h on 11/06/02 at 14:52 (099514)

Sunny: I do not need a refertal to see any specialist. I can walk straight into any specialist office I want to without any refereal. Some specialist do require a referal but that is the specialist requirement. I am on Medicare (Julie) which whether you are rich or poor is what we all are covered under after age 65 in the U.S. The only people age 65 or older who would not be covered under this program are those who never worked and paid into the system. Wives come in under their husbands coverage. Their is a 20% copay but supplimental coverage is reasonable. Medicare limits what Doctors can charge for any given procedure and a Doctor cannot charge you more than their approved charges. Of course, some Doctors do not participate in Medicare but I have yet to run into one as anyone who excludes Medicare is excluding a large population. Those people who are not covered by Medicare are covered by Medicaid. A good/bad sort of thing is that anyone without insurance of any sort can walk into any emergeny room in the country and cannot be refused treatment. Many people use this for primary treatment and causes hospitals to lose money in their emergency room. We have many people who simply refuse to buy insurance even when they can easily afford it. Many are young and never think they will be sick. These people appear as those without insurance. Fact is that there is no one that cannot receive medical treatment if they need it. We have a lot still to be worked out but when our government in the form of President Clinton tried to introduce a government type system it was totally and soundly defeated by all groups of people.We are in need of a prescription drug program in Medicare and I think we will be getting help in that area when the new Congress convenes. Most of our large Unions and Corporations have excellent medical benefits that are carried into retirement as do Federal Government Employees. HMO's are what is a sticky point these days as you can tell by some of our posters who sometimes's wait a long time to see a specialist. Our medical system is not nearly as bad as what I think some people with totally government run systems think. We certainly can improve on it.

Re: Conflict of Interest in Healthcare

john h on 11/06/02 at 14:54 (099515)

Thanks for the clarification ED. As a Medicare covered person I am very pleased with my care along with my supplimental coverage.

Re: Conflict of Interest in Healthcare

john h on 11/06/02 at 15:11 (099517)

David L last month my back was really giving me some problems as a result of an aircraft accident during Vietnam. I walked into my family doctors office without an appointment. Saw her after a wait of 20 minutes and told her I thought an MRI might be in order. She agreed and I had the MRI the next day. I then took my MRI with me to a Neurosurgeon which I selected. It took me 4 days to get an appointment. He promptly gave me a diagnosis. I paid not a penny as Medicare and my suppliment covered all cost. I think the hospital cost for the MRI was in excess of $1200 but as you know Medicare limits what they pay and I think they paid the hospital around $375 for the procedure which they are required to accept as payment in full plus my 20% copay which was covered by my suppliment. Where else could I get this type of care. When I read about people waiting months for appointments to see a specialist it is scary. We have a lot of problems in our country including drugs, murder,etc. but our Medical system is not nearly as some think. If I want to see Dr. Zuckerman in New Jersey I just hop on a plane and fly up there. He even takes Medicare patients unfortunately like most insurance companies they are not paying for ESWT. Our Docs probably hate all the paper work with Medicare and the slow manner in which they get paid but most are hanging in there. I asked my family doctor last month did he ever think he would discontinue Medicare patients. He told me he would see me and my family as long as we lived and would always accept our Medicare coverage. Made me feel real good..

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/06/02 at 16:01 (099521)

One of the good things about the Canadian single payor system is that it is administratively simpler than Medicare. The big problem is that it is chronically underfunded (for a number of reasons) causes shortages and waits for certain treatments. The Canadian government, it seems, has an egalitarian bent to it. My podiatry school roomate is married to a woman from Ontario, also a podiatrist. They practice together in Calgary. They mentioned, when I was last there, that they recieve a stipend or allowance for each of their children (they have 3). They told me that they are doing well but feel that the government is treating them the same as people who are less fortunate.
Ed

Re: Conflict of Interest in Healthcare

David L on 11/06/02 at 17:02 (099525)

For doctors, administratively the system is simpler. However, administration consumes a HUGE bulk of healthcare costs. Vancouver General Hospital has 13 Vice Presidents....each with their own staff. Canada, with a population of of 28 million has 14 Ministers of Health. France with a population of 70 million, has one.
The system is actually way overfunded, but money doesn't get to patients. Hospitals receive a 'global budget'. A lump sum at the beginning of the year to treat patients. Every time a patient walks through the door, it costs the hospital money. Patients are a liability under this system and do not generate any revenue.
Remember, this is a government owned and operated monopoly. It is NOT efficient and therefore wastes a tremendous amount of money. Bureaucrats decide everything. The Federal Minister of Health just announced a 15 million dollar study as to why Canadians are overweight. I'll tell them for free....becuase people are consuming more energy than they are expending. If they want to do something about overweight people, they could have put that money towards education on the problem, rather than studying it.

Re: Conflict of Interest in Healthcare

Dr. Z on 11/06/02 at 17:56 (099527)

Medicare is the finest healthcare system in the world. It has the lowest administrative overhead .

Re: Conflict of Interest in Healthcare

john h on 11/06/02 at 18:14 (099529)

Dr. Z: My new Medicare Suppliment is 'Tricare For Life' and as I understand it when you file the necessary medicare papers for my treatment Tricare For Life is automatically picks the info off of the medicare papers and you do not have to fine anything to receive your supplimentary insurance. I feel most fortunate as last year retired military personnel elgible for Medicare became elgible for a prescription drug benefit whereby any prescription cost either $9 or $3 for a generic prescription. By the way our medical benefits in this country do provide for free dialysis and free drugs or insulin for diabetics. Julie maybe you can clarify some information about dialysis in the UK. I heard there were restrictions on who it was made available to? What is this about?

Re: Conflict of Interest in Healthcare

nancy s. on 11/06/02 at 18:35 (099531)

david L and anyone else interested in this topic: i noticed you posted that the number of uninsured in this country includes the self-employed, 'who self-insure.'

do you know how many of the hardworking self-employed in this country cannot afford to self-insure? i'm one of them, and so is my husband. monthly premiums for the two of us to get health insurance today would be $800+. that's like another mortgage payment; we simply don't have it. the self-employed are left out in the cold under the current health insurance system. the poor are better off than we are when it comes to health care, because at least there are programs for them.

i was considered poor enough to get help with the financial costs of health care for about a year -- after i'd come down with pf and three tendonitises and had been unable to work for nearly a year. on the one hand it was mortifying -- i've always supported myself. on the other hand, at least it was there when things got bad enough. one wonders, though, whether that would've been necessary had there been someone who cared enough in the industry and/or government to see to it that the self-employed can afford to self-insure. i'll always wonder, had i been able to afford decent care, whether my feet would ever have gotten as bad as they did (and they'll never be perfect again).

they're 80% percent or so, and i and my husband once again work like dogs, and we still can't afford health insurance. we have friends with their own businesses who are in the same boat. do you think this is right?

nancy
.

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/06/02 at 21:53 (099538)

Nancy:

There are a number of aspects of the structure of insurance in the US that makes it expensive. The tax code has been written for an employer based system. This is a whole subject unto itself.

A few suggestions. Have you tried to obtain health insurance via your local chamber of commerce? Look into policies offered by the NFIB -- National Federation of Independent Business. Also-- look at health insurance as 'true' insurance as opposed to a benefit. A benefit is something that is expected to be used but insurance is obtained with the supposition that it will not. Many can afford to pay for the small things but something major would be catastrophic. Check out the prices on high deductible policies-- $1000, $2500, $5000 deductibles -- they can often be quite reasonable, may include a discount drug benefit and have pre-negotiated prices with hospitals and providers. An individual with say, a $1000 deductible, is self-insuring for the first $1000 of medical expenses.
The first $1000 of expenses, though, would be at rates pre-negotiated by the insurer.
Ed

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/06/02 at 22:09 (099540)

Dr. Z:

The problem is that most family doctors in my area are not accepting new Medicare patients due to low reimbursements -- they are keeping the patients they already have.
Ed

Re: ~Dialysis in UK

Julie on 11/07/02 at 00:58 (099546)

John, sorry, I don't know. But if I learn anything, I'll let you know.

Re: Conflict of Interest in Healthcare

nancy s. on 11/07/02 at 06:30 (099551)

thank you for your suggestions, ed. we have very few choices in maine, but i'll research it again with your specific ideas in mind. catastrophic coverage, which we have gotten some years, had turned into a bad deal for us, because we have high out-of-pocket medication expenses and the cost of my foot care was really astronomical. if we could find a catastrophic policy with at least partial rx coverage, that might make the difference.
i didn't know of the NFIB -- only a new england association that's too expensive -- so i'll check into the NFIB too.
thanks again.
nancy
.

Re: Conflict of Interest in Healthcare

Sunny Jacob, Bayshore on 11/07/02 at 06:45 (099553)

David L., - I can debate each of your points about the Canadian vs. the U.S. health care system.
However, let us do that elsewhere and not on this message board. Just one point, - please read the definition of health by WHO.
Social well-being and drug problems are also part of health.

Universal health care was not invented in Canada. Europe had it working for years before it was introduced in Canada, and there is no perfect system which can satisfy all.
Yes, there are waiting lists in Canada for elective hip or knee replacement. Not only political leaders, even a federal prisoner, can jump the line in Canada. There are loop holes in the system.
The waiting time for an MRI, depending on the urgency, can vary from one week to 6 months in this country.
This is not satisfactory and solutions seem to be on the way through private public partnerships to open new MRI and other ambulatory clinics. Private providers can co-exist within the system and operate efficiently as long as they follow the Canada Health Act.
Dr. Dey's Orthopedic Surgery Centre, Vancouver, as you know, gets paid from the public system for eligible patients. Approx.$33 Billion services in Canadian health care is provided by the private sector. I am one of those private providers in the health care business for the past 30 years.
As I have repeatedly said, the Canadian system is not perfect. However, there is no one who had to declare bankruptcy due to health misfortune or die due to lack of availability or affordability of health care in Canada.
On a $110 billion dollar federal health budget there is nothing wrong to do a $ 15 Million study about overweight. It is worth to educate the public that overweight can also lead to complex healthcare problems. It is not as simple as balancing calorie intake and calorie output.

Re: Conflict of Interest in Healthcare

john h on 11/07/02 at 10:27 (099559)

Ed: We are having some cases of Doctors not accepting new Medicare patients but not a lot. I think I just read an article where the government is going to increase payments for Mecicare procedures as most of the Medicare HMO's are dropping out or raising their prices so that traditional Medicare is a better deal. I personally would have no problem with a raise in the annual deductable which is now only $200. As I get a copy of the statements that the Doctor's bill and what Medicare allows I am often shocked at what they allow. I do notice in some instances Doctors adding a couple of codes to their bill for a simple visit or procedure which pumps up their bill. Our current Medicare program is solvent for 40 years and in 15 years we will start dipping into the reserves so I think Congress will take up this issue soon. I think we as beneficiaries may have to pay a bit more. It really would not take a lot of pain on our part to make this thing solvent for the next 100 years. There is a tendancy to overuse things that are almost cost free. Is not a PF release something like a $350 procedure? With that cost in mind it is easy to see we are a long time down the road in getting Medicare to cover ESWT. They do not take the long view in that many people need a lot of follow on care, some are made worse and spend many many visits to Doctors after failed surgery..

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/07/02 at 21:16 (099604)

John:

The only way I see to ensure the solvency and good function of the Medicare system is some sort of needs testing. Everyone has the same level of benefits at the same rate of reimbursement. Individuals who have the means need to pay a higher percentage of costs than those who don't.
Ed

Re: Conflict of Interest in Healthcare

elliott on 11/07/02 at 22:38 (099616)

Dr. Ed, Medicare isn't a failsafe system to protect the poor like Medicaid. If you're going to needs test for Medicare, there are the usual equity issues to deal with:

1. They paid taxes (likely far more in actual dollars than those with lesser means, even if their contributions still don't pay for their future expected benefit) into the system all during their working years with the expectation of getting equal Medicare coverage upon retirement. The reason Social Security is palatable even though percentagewise it is slanted in favor of the poor is because there is a reasonable balance between social adequacy (safety net for the poor) and individual equity (pay more into the system and at least you get a bigger pension than the guy who pays less); this would be sorely missing here.

2. Such a system would penalize those who save, protect those who don't (which possibly will encourage more not to, thereby exacerbating the problem).

There are other ways to make Medicare solvent and still maintain an equal benefit, at least for newer retirees, but none are necessarily popular: raise taxes; raise the retirement/eligibility age (I hear groans and moans, not least because we still seem to burn out of work at the same age as our grandparents, but it could be argued that this is fair since we're living so much longer and are collectively a greater burden on society); larger co-pays/deductibles (with those who can't afford them possibly aided by federal programs for the poor, but that's just a sly cost shifting trick since you need to raise taxes or decrease expenditures for other programs to pay for it). It would help too if Americans would have more kids than they currently are having (the ratio of workers to Medicare beneficiaries has dramatically decreased over the years); such a turnaround may well rescue the system in the long term.

[]

Re: Conflict of Interest in Healthcare

john h on 11/08/02 at 12:26 (099637)

Elliott: I tend to weigh in on this with you. Means Testing is much to subjective. Some people would seem to have a good income but are burdened with debt, supporting parents, putting kids though college, etc. Additionaly 'Means' change almost monthly. I have no problem with increasing deductables, increasing SS taxes but think means testing would be much to difficult to assess and create class warfare

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/08/02 at 14:55 (099640)

Elliott:

Raising the age of Medicare eligibility may be effective from an actuarial standpoint but there is one major drawback. It is often difficult and expensive for individuals in the 50 to 64 y.o. age group to obtain individual policies, let alone small group policies. Two out of my seven employees are in that group and as a consequence, my office was rejected for coverage by several national insurers. Potential employees in that age group are less attractive to employers over the insurability issue. If anything, from a standpoint of public benefit, I would like to see the age at which citizens become eligible decrease.

Medicaid is a subsidized system in the sense that that system reimburses at less than the cost of many services causing providers to attempt to cost shift to others. Medicare reimbursements have, for the most part, decreased on a regular basis to the point which a number of services are reimbursed at a level lower than the cost to provide such services. One question to ask is that if a provider's office was 100% Medicare patients, would he/she be able to stay in business. My answer is possibly yes, based on the mix of services but 'no' in a number of scenarios. A lot would depend on the location of the office. Supposedly there is some allowance for geographic variations but it is really inconsequential.

It is a bit hard to accept that Bill Gates, after turning 65, will have services reimbursed at the same discounted level that a poor retiree.
Ed

Re: Conflict of Interest in Healthcare

elliott on 11/09/02 at 20:10 (099686)

Dr. Ed, good intentions are one thing, but paying for them is another. There were indeed studies during the Clinton era that looked into allowing those aged 55-64 who did not have other insurance to enter into the Medicare program. It started as an idea for those 62-64, it was extended to age 55-64, and in classic Clintonian fashion, since it would include their families, it came out that we could see newborn babies covered under Medicare for the elderly!! The proposal had to remain budget-neutral (politics aside, you don't add water to a sinking ship), and other factors were taken into account, e.g. predictable side effects as other insurers tending to drop coverage of this age group due to the very institution of the program. The beneficiaries would have had to pay in annual premiums the expected value of their annual costs based on their age until they reached 65, with favorable deferrment of some premiums allowed over their lifetime to make it more affordable. So zero profit to the 'insurer' and favorable terms to the insured. Even so, the studies showed that due to the expense of the premiums and often lower income of the beneficiaries, the healthier would opt out, leaving only the sicker to remain, setting into motion what's called an insurance premium spiral, whereby you have to keep raising the premiums to cover the cost of those who would remain, leaving an even sicker group remaining, necessitating raising the premiums even further, leaving an even sicker group, and so on. In other words, there was no such premium that would make the program work out. Sorry, but a very, very, bad idea, and fortunately it was rejected.

Concerning your own experience, there are some basic and sound actuarial principles as to why smaller groups are more expensive to insure than larger ones; sorry, that's just the way it is.

Doctors didn't seem to mind double-digit annual growth in their income for many years, nor did they offer a way to slow the tide; now things are tougher, but so they are in many other professions. The current situation is not necessarily permanent nor should it be, but given the past it's not an outrage either.

I have no problem with Bill Gates getting Medicare just like everyone else. He paid his taxes for it, and then some; that was exactly the idea behind the program.

[]

Re: Conflict of Interest in Healthcare

nancy s. on 11/09/02 at 21:31 (099687)

wow, elliott, no problem with bill gates getting the exact same Medicare coverage as everyone else? really?

truly, i can't imagine being a multi-billionaire -- or even having an annual income, whether retired or not, of $50,000, $100,000, $500,000, or $1,000,000 -- and believing that i need the same amount of money (in the form of health coverage) given to me as others who are in dire straits or even simply living on the edge, whether or not i'd 'earned' it. that's just ego and pride at their worst. to me in that situation the issue wouldn't be whether i'd earned it or not, but whether i NEED it or not, and whether or not my getting it -- a drop in my bucket -- would deprive of coverage other hardworking but not so savvy or, more often, not so lucky people far needier in their later years than i might be. i would feel ridiculous, frivolous, and as though i were spitting on the society whose structure enabled me to become so rich, a structure that *depends* on the lower and middle classes to help the rich become rich, remain rich, and grow even richer.

sure, the mathematics superficially make sense, and the principle superficially makes sense, but isn't life a little more complicated than that? i mean, where's the heart and soul of such a system? (we already can identify the 'logic' of such a system.) the system works and makes sense for some; but if it worked for me because i stuck my neck out farther and opened my mouth wider than the other little birdies so i'd get fed more often and fat more quickly, i would be bothered by the fact that other good, intelligent, hardworking individuals crawl and scrounge for every penny and still can't really make it comfortably, in any sense of the word. i would be bothered -- deeply bothered. i assume you have the health-care bases covered for yourself, or else the mathematics might not be the bottom line for you as they seem to be.

on a related note, my town just did a property tax reassessment. our taxes, after less than a year here, more than doubled. my husband and i will figure it out, since we're still working. but i have some older, including downright elderly, neighbors who are terrific people who can't figure it out; i mean, it Will Not Work on their fixed incomes. they are looking to sell their homes, at the age of 66 or 71 or 84, after living here their whole lives and after working for decades to own those homes. it's a sorry state of affairs when it comes to this, all based on mathematics and on some abstract principle applied to everyone, rich or poor.

it would be nice if the mathematics were fair to all, but they simply aren't. some people, bless 'em, are bigger than others who want 'what's coming to them' whether they need it or not, everyone else be damned.

my 81-year-old father, who lives near us in a teeny-tiny, humble, rather shabby apartment in a modest retirement circle and has little extra money to spend, voted on tuesday for the candidate in his district who will work to disperse health-care and other monies according to need and years worked, whether the workers were garbage collectors, teachers, or ceo's. this means my father will receive *less* in the form of benefits than he would have under the representation of other politicians he could have voted for. my father actually thinks about his neighbors and cares about them, and doesn't want to live high on the hog compared to them just because he worked for IBM for decades and could've been a bigger honcho if he hadn't taken early retirement in order to work in the education field at a much lower salary.

i wish there were more like him.

nancy
.

Re: Conflict of Interest in Healthcare

elliott on 11/09/02 at 23:50 (099690)

Nancy S, you speak from your heart, and I appreciate your sincerity. Of course, when worded such, it comes out sounding like you are good and I am bad (what else is new?). But before you paint me out to be some kind of cold, hard, insensitive, calculating [insert more adjectives] guy, in case anyone forgot, this thread was supposed to be about the various health care systems of different countries.

A system such as U.S. Medicare has to be solvent. It's got to be payed for. You mentioned that your property taxes doubled. Why do you think that was so? Because your government did not have sufficient funds to pay for services for the needy (not to mention other, sometimes more questionable, programs). Cover everyone's needs as you deem fit, and you might find your taxes quadrupled to pay for it. Think about that.

The reason Medicare is acceptable to the public is because everyone pays a fixed percentage of their taxes to the program and then receives medical coverage in their old age. Bill Gates paid his taxes, a lot of them. I hate to tell you, but even if it makes you feel good and you were to charge the very rich more for their Medicare benefits, it would barely make a dent, because there aren't that many of them. Anyway, start making exceptions and you'll find the middle class who worked hard and payed Medicare taxes all their working lives will watch their savings in retirement dwindle away due to unreasonable wealth limits because they dared to save for retirement. That's not fair either. And if you think every last dime should be taken from those who have more to pay for health care for those who have less, well, the Democrats just got repudiated at the polls.

[]

Re: Conflict of Interest in Healthcare

nancy s. on 11/10/02 at 00:53 (099692)

dear elliott, i don't speak from the heart to make me look good and you look bad. i think your view of the subject isn't broad enough, it's as simple as that: just a difference of opinion, not a condemnation. i didn't use any of those adjectives that you supplied to describe yourself, and i assume you don't mean to describe yourself that way either.

i suspect the property taxes in my town doubled not to support the needy but to support the whims and private interests of our town council, town manager, and town tax assessor. i attend town meetings; i follow their agenda and listen to their proposals and their discussions and their votes on the issues, so my opinion isn't based on nothing or on preconceived notions. it might be wrong, of course, but i personally don't think so. :-}

i do think that if the rich were charged more for medicare benefits, it would make a dent. there may not be a lot of people, percentage-wise, who fall into the rich category, but the amount of money we're talking is huge. large money being held by few people: that's kind of the basis of the problem discussed in this thread.

i don't think we should 'start making exceptions.' i think the entire health-care system in this country needs an overhaul, and not only because it doesn't serve me well personally despite the high taxes, including self-employment and my own social security taxes, that i pay. i'm just one person. there are many many people it doesn't serve well.

i also don't think 'every last dime should be taken from those who have more.' of course not. but I do think the wealthy could pay, or forgo, more than they do now and not miss it -- and not miss a moment's sleep over it. i know bill gates pays a lot in taxes. i also know he's still left with billions. have you seen his house? let's not waste potential pity on someone who has done incredibly well for himself and will always live in extreme luxury even if he is called upon to support u.s. society as a whole more than he does now.

the democrats did just get repudiated at the polls, as you say. in this time of post-9/11 and the identification of a locateable (i know, must not be a word!) scapegoat (who i do think is despicable), i wasn't the least bit surprised by the election results. people are not interested in the foundering economy; they're interested in allaying their larger fears and protecting their personal safety. war talk often accomplishes that. i don't think the elections had anything at all to do with health care or the clearly deepening pockets of the rich. any tough-talking president, whether republican or democrat or independent or martian, would almost certainly have enjoyed support demonstrated in elections following 9/11.

nancy
.

Re: Conflict of Interest in Healthcare

Bill on 11/10/02 at 06:48 (099693)

Really guys. I know that you are enjoying this political discussion but what does this have to do with PF? You were very critical of me for discussing machines that treat PF but Medicare politics and whether Bill Gates receives Medicare coverage has nothing to do with PF!

Re: Conflict of Interest in Healthcare

elliott on 11/10/02 at 08:03 (099694)

No, Bill, we weren't very critical of you discussing machines that treat PF. We were critical of your posting the same thing thousands of times over in omenous fashion and not identifying yourself.

[]

Re: Conflict of Interest in Healthcare

elliott on 11/10/02 at 08:28 (099695)

The money you're talking about if the very rich were charged more for their benefits is not huge; it's been looked into. If you don't believe me, fine. Complete overhall? State what you propose and watch it get torn to shreds by others who will object strenuously about something or other.

Your government doesn't use its tax dollars wisely? Naw, can't be! I thought we need them to use the money wisely when they take from the rich and give to the poor.

I believe you said both you and your husband are self-employed. There are alternatives: one of you could take a job where you work for someone else, simply to get the family covered by health insurance. You would not be the first couple to make a decision based solely on that; in fact, you'd be more typical. I'm not telling you at all what kind of job you must take, only that you are aware of the circumstances and that there are alternatives. Others disappointingly make such decisions out of necessity too. No one said life, whether here or abroad, is ideal.

We made history here in Maryland, one of the Democrats' bastions, by voting in Bob Ehrlich, the first Republican governor in 36 years. It wasn't because of 9/11, but because the Democrat was viewed even by many Democrats as, well, not fit for the job, likely to raise taxes, and same old same old. The Kennedy name wasn't even enough. Sure, at the national level, there is post 9/11 fear, as there should be, and most felt safer with Republicans because maybe they are safer with Republicans.

[]

Re: Conflict of Interest in Healthcare

john h on 11/10/02 at 08:45 (099697)

Real Property taxes in Arkansas go to the school system and not to Medicaid or Meicare or any other social program. Nancy and Elliott are you all talking Real Propterty taxes?

Re: Conflict of Interest in Healthcare

elliott on 11/10/02 at 08:55 (099699)

John H, right, I think we're talking taxes rather loosely, that they often charge too much on specious grounds. The point was that it's not obvious that a government--any government--is always going to solve its problems with huge tax increases. In Baltimore, a large chunk, but not all, of property taxes goes to schools, I think it's 40%. We have one of the highest property tax rates in the country. A while back, the city got the great idea of raising the rates to yet higher astronomical proportions to pay for all its beloved programs. The result was that many fled the city for the suburbs, and had to sell their houses for far less. The result was that the city brought in less revenue than had it not raised taxes that high in the first place. The new administration has actually *lowered* the rate somewhat.

][

Re: Conflict of Interest in Healthcare

Bill on 11/10/02 at 10:49 (099708)

Elliot,

Again, how does this relate to ESWT and PF? Can't you take this off-line and have your discussions privately. They are interesting but more appropriate elsewhere, perhaps over a few beers in a bar.

Unless you are arguing that Bob Ehrlich a supporter of ESWT, or that republicans more likely to get insurance reimbursement for ESWT, or that
raising property taxes makes it more likely that my insurance will cover ESWT. Otherwise, I don't see how this is related to the focus of this eswt board.

Re: 'Bill', isn't it time you identified yourself?

Julie on 11/10/02 at 15:59 (099727)

.

Re: Conflict of Interest in Healthcare

john h on 11/10/02 at 16:37 (099730)

In Arkansas real estate taxes for individuals is frozen at what ever level you are at age 65. We frequently have reassessments here so that is a big deal. I think 100% of our property taxes goes to support the school systems. We had an ammendment on the ballot this year to removes sales taxes on food and medicine which would have really put a burden on the state to fund all their many programs including Medicaid. I was supprised that the public soundly defeated an ammendment to drop taxes.

Re: 'Bill', isn't it time you identified yourself?

Bill on 11/10/02 at 18:55 (099737)

It looks like many people post with the name Bill. Which Bill
do you want to know about? Orthotics Bill? Tax Bill? FDA Bill?
PMA Bill? It's just so confusing.

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/10/02 at 20:34 (099748)

Elliott:

Your concern stems from the 'slippery slope' process that would allow coverage to expand faster than the ability to pay for it. There are a couple ways to look at this -- incremental expansion of Medicare or using the Medicare model for the basis of a single payor system for the US.

Milton Friedman, a staunch conservative, long ago advocated a single payor catastrophic system. He was advocating a safety net as opposed to a comprehensive single payor system. My version of that would be that the government provides what amounts to a high deductible policy for everyone.
Lets start with some arbitrary numbers for the point of illustration.
A single payor high deductible policy is formed with a $5000 deductible for citizens, ages birth through 18, $10,000 deductible for ages 19 through 50 and a $5000 deductible for ages 51 through 64. Private insurance either via individual policies are still obtained individually or through employer groups. The lower stop loss makes policies for children more affordable and makes policies for the 51 through 64 age group more affordable since private insurers have a lower stop-loss level.
Ed

Re: Conflict of Interest in Healthcare

Ed Davis, DPM on 11/10/02 at 20:40 (099749)

Elliott:

It is easy to get worried when politicians propose programs without reasonable means to pay for them. The above numbers are for illustration only. I do have to question whether current Medicare deductibles are way too low. That is the area where needs testing may need to be invoked in the sense that the current low deductibles would be in place only for those with limited resources.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/10/02 at 20:44 (099750)

Bill:
Overzealous regulation (something you are a fan of) and litigation has driven the cost of healthcare so high that increasing numbers of citizens cannot afford coverage.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/10/02 at 21:57 (099751)

The way I see it, the physicians are equally to blame. Physicians form partnerships and force hospitals to pay inflated prices to use the partnership's equipment. They use their power of referal as a lever to inflate the cost of services. It started with MRI partnerships. We continue to see this in lithotripsy and we see it in ESWT.

Look at what Healthtronics has done. For the first two years of business with the Ossatron they would mainly sale Ossatron's to physician partnerships that Healthtronics would organize. Healthtronics was also a partner. These partnerships would charge $4,000-5,000 for ESWT. Most insurance companies balked and were slow to reimburse.

Litigation and regulations, like Stark II and Federal Fraud and Abuse, have helped keep these activities in check. It is unfortunate that good physicians find themselves grouped with the crooks.

Re: Bill -- YOU may be part of the healthcare access problem

nancy s. on 11/10/02 at 22:29 (099752)

bill, who knows, you may be right about this. but i recommend that you have a few beers in a bar, loosen up a little, and come back when your linear thinking has been interrupted and enriched by the endlessly varied parade of humanity out there.

Re: Conflict of Interest in Healthcare

nancy s. on 11/10/02 at 22:42 (099754)

i agree with you, elliott. there will be no health-care overhaul in this country. sad.

we made minor history in my state: we elected the first democratic governor since the early 1980s. i voted for him. i also voted twice for the two-term independent governor we've had for the past eight years.

and, believe it or not, i voted for the two-term republican governor we had before him. i voted for him because he was the best candidate running; i didn't care for the democratic candidate or his particular views at all.

special for bill!: i'm calling our new governor-elect tomorrow to educate him about eswt and to demand that he discuss pf in his inaugural address.

nancy
.

Re: 'Bill', it's getting less and less confusing ...

Julie on 11/11/02 at 01:41 (099757)

....and the 'Bill' I'd like to see stand up and show his face is the (one and only) Real Bill.

Maybe after you've had a few beers???

Re: 'Bill', it's getting less and less confusing ...

john h on 11/11/02 at 08:07 (099766)

Bill drinks soy milk.

Re: Conflict of Interest in Healthcare

elliott on 11/11/02 at 08:52 (099773)

Actually, Nancy S, I didn't say that an overhaul was good. I said that if you try, people will complain, and sometimes with merit. We could end up with worse. Could you loosely outline what you have in mind for an overhaul (with special attention given as to how we pay for it)? I am curious what you have in mind and am willing to listen (as if that will change our health system). And please do speak up the next time a doc says everything will be all right if only ESWT were covered by insurance--ever more unaffordable insurance.

I do agree that Bill should have a few beers.

Isn't it possible that at least this time around, the Republicans overall were the better candidates? Oops, sorry, nothing to do with ESWT. :-)

[]

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/11/02 at 12:25 (099793)

Bill:

A very small percent of US physicians were involved in such financial relationships. The current regulatory burden and state of litigation affects virtually all medical practitioners and their patients.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

BGCPed on 11/11/02 at 12:51 (099797)

Nancy, that was a well thought out, sound advice. I think that more people in this world would benefit from your advice. I also think that maybe if we made it open season and had a bounty on trial lawyers 2 weeks per year we would be all set.

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/11/02 at 13:24 (099799)

Within specialities that is just not true. Most of the Urologists that I know are invested in some sort of lithotripsy venture. There are currently three companies soliciting investment from DPM's and they are targeting all of the local DPMs. If these companies are successful then most of the local DPMs will be invested in an orthopedic lithotripsy machine. The market will not be open and competition will be reduced.

Re: Conflict of Interest in Healthcare

nancy s. on 11/11/02 at 13:33 (099801)

yes, elliott, i know you didn't say that an overhaul of the health care system would be good. (i can read -- even between lines!) i was fishing around trying to find a piece of common ground with you, and i found it: i agree with you that health care overhaul won't happen. the 'sad' part was my own editorial comment, of course.

gosh, you want an outline from me as to how to accomplish an overhaul, with special attention to how we'd pay for it? hillary spent months, and that bombed, so i might need a little longer. i'll have to get back to you on that one.

but i will say this: the uninsured self-employed are not the only people not well served by the current system. (by the way, you want us to take jobs with companies simply in order to receive health care benefits? do you think the coverage would extend to the mental health coverage we'd need if we were to do that? i don't think so. besides, what about the entrepreneurial spirit that's so fundamental to the growth of this country and to the economy in general? you're not discouraging that, are you? :-} )

to continue: the hmo system appears to be abominable in a number of ways/situations, so even if one IS covered, quality health care isn't guaranteed, and waste of money does appear guaranteed.

forgive my continual self-examples -- they're what i know best. we were able to afford self-paid hmo coverage for about a year and a half in the mid- to late 1990s. during that time, i believe i was given often-needless tests and re-tests -- probably because the risk of a possible condition i might have, though minutely small, was large enough to worry my doctor about malpractice should it turn out that she'd missed following up on something important. on the other hand, when pf reared its ugly head and my life came to a screeching halt, she was not too bad, but i'd still say 'slow,' at referring me to what turned out to be an incompetent podiatrist. this guy ordered lousy ice-scraper orthotics (at $300, even charging me the $15 co-pay for the twenty seconds it took for me to walk into his office, pick up the orthotics in a plastic bag from his speechless assistant, and go home and make my feet worse by wearing them).

after eight months of really debilitating pf, i was refused a referral from him for physical therapy. he wanted to do surgery instead, which would put money in his pocket; a referral for PT would, i guess, have earned him some demerits from the hmo and no money. i think that's only partly his fault: what kind of system even tempts a doctor to make such a decision?

the next year, when i 'earned' coverage from a special state program for people put out of work by medical conditions, i was referred by another doctor (a good one) for six months of physical therapy, which did help -- a lot. even if the incompetent pod had referred to PT, how much PT do you think the hmo would have approved? maybe three weeks. three weeks is far too little; six months may have been overkill, i don't know. but it seems to me that something is seriously askew if people paying for hmo coverage can't get needed PT (or enough of it), and those in special programs can get all they need and maybe more. shouldn't there be a middle ground, where i might have paid for a reasonable amount of PT via self-paid health insurance, and probably paid more but been able to do it, rather than getting it for 'free' after i'd become too debilitated to get it any other way?

in my three years on the board, i've seen hundreds, maybe thousands, of posts from people who do have health insurance but have been stuck in nowhereland because of it -- they are covered for a little care here, a little there, but not enough to deal decisively with a debilitating condition.

i don't claim to have all the answers, not by a long shot. but i do see a big problem, a nationwide problem, and i'd be stupid not to point it out, especially after my own experience with foot hell, and after becoming aware of that of many many others here on the board who *are* covered by health insurance. and i wonder how many never even find their way here.

in relation to medicare, i think ed davis's idea of raising the low deductibles, except for those really unable to pay them, would be a good start.

yes, it's possible that the republicans had the better candidates this time around. anything's possible. but i emphatically think that they did not. actually, the best candidates were nowhere to be found, in my opinion; i'm still waiting for them to summon the courage to throw their personal lives to the wolves and run for office.

nancy
.
p.s. eswt.
.

Re: Bill -- YOU may be part of the healthcare access problem

nancy s. on 11/11/02 at 13:52 (099802)

BGC: huh? did i defend lawyers and the litigation industry here? no sir!
but thank you very much. your post was well thought out too. keep on thinking.
say, what does the 'b' in your initials stand for?

nancy
.

Re: Conflict of Interest in Healthcare

elliott on 11/11/02 at 15:04 (099824)

Nancy s, regarding getting the mental health coverage you'll need if you work for someone else, Congress actually has been mandating the necessity to provide mental health coverage (something often abused), at the expense of 'trivial' things like care for severe sufferers of PF enabling them to walk. No, I'm not stopping your entrepreneurial spirit; that spirit just has to earn more these days, that's all. :-) Take what job you want, but realize there are implications.

HMOs were an attempt to gain control on costs, but yes, they have problems. Fee-for-service plans can be costly to the beneficiary as well. As much as you complain about our system, we spend more on health care than all other countries by a longshot. Economists claim we pay more for health care than other countries because we want to. I'll be waiting for your outline of a viable alternative.

Orthotics are a great help to many. The value of PT for various ailments is often way overblown. It seems like you're picking and choosing based on your own circumstances, which is understandable.

High deductibles for Medicare is an idea, but there are probably far too many elderly who are poor that this might prove too controversial, or expensive.

Do you applaud Clinton for rebuilding North Korea's economy in exchange for promising to be good (no nukes), and now (surprise, suprise) we found out they were not good (they have nukes)? Sometimes a tougher position, the kind you think of as warmongering, is just what we need to promote security.

Re: Bill -- YOU may be part of the healthcare access problem

BGCPed on 11/11/02 at 16:22 (099827)

No the beer advice was sound. I just interjected my personal views on the trial lawyers. Sorry didnt mean to make it sound like you were endorsing those guys. As I have stated before, if you look at the laser eye surgery history. The first machines were $500 thousand and had a 'royalty fee' of about $400 per patient. The average cost in the states was several thousand per eye.

Many folks would go to Canada to get a better price not to mention it was approved there first. Now there are chains opening and many Doctors doing ads on tv, radio and newspaper. Now there are price wars and you can get it at some places for $500 per eye. I may be dumb but I would think that is an example of free market. If several Doctors have an interest in a certain machine or facility are you saying that there will be some type of price fixing or overly high fees?

Stark Laws aside any piece of expensive equipment needs to run often to make money. If one group had the machine and was charging an excessive fee then another group would be able to move in a charge less. Competition or lack of can drive prices up or down. I think the best aspect is there will be many less inclined to do fascia releases which is a good thing.

I would think that the laser field would be a good model since there are many similar aspects with the eswt machines

Re: Bill -- YOU may be part of the healthcare access problem

john h on 11/11/02 at 17:39 (099831)

Ed: I have no idea nationally how may physicans may be involved in such relationships but I sure have an idea about my small city of L.R. with a population of around 300,000. A friend of mine worked in a company with me as a salesman. He leased some cars to a few doctors and being a bright guy introduced them to the idea of leasing equipment such as Catscan,MRI, Lithotriptos,etc. to hospitals. The doctors had the ins to the hospitals and my friend took an owership position and set up the leasing company with the doctors furnishing the capital. He is now a multi millionaire many times over. Two other friends came up with the idea of starting up a dialysis center with the major player being a nephrologist. They ended up with around ten dialysis centers in 4 states and several years ago sold out to a large public company. All are multi millionaires many times over. The doctor retired and probably under age 50. These are people I know and I am very familiar with how they proceeded and what a really small amount of capital was required to start these businesses. Bottom line on all this is patients paid a very large premium to have dialysis, cat scans mri's, lithotripsy. Something is wrong here. Too many middle men. To many people with conflicts of interest. Unfortunately it is all legal. I have no reason not to believe this is occuring all over the country.

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/11/02 at 19:18 (099835)

You are assuming that the patients shop for the best price. I agree that this happens with laser eye surgery. But in this case it is not covered by insurance.

I believe that when insurance covers a procedure then patients go where their doctor recommends. There is no concern for price since it is covered by insurance.

I am guilty of this with prescriptions. I don't shop for price since it is covered by insurance. I think that the same thought process goes for lithotripsy and other covered services.

Expensive equipment does not need to be run often if the reimbursements are high enough and there is limited competition. I don't believe that the prospect of less fascia releases will motivate insurance companies to approve ESWT. Insurance companies will act to decrease their costs until ESWT becomes standard of care then they will have no choice but to cover it.

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/11/02 at 20:20 (099839)

If you keep products off the market, you limit competition.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/11/02 at 20:24 (099841)

Bill:
There is one DPM in my state invested in the Ossatron. One out of about 250 licensed podiatrists. Most of the urologists I know are not invested in some sort of lithotripsy venture. I cannot speak for your area as you will not reveal where it is. Your hypotheticals are not consistent with what is happening.
Ed

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/11/02 at 20:35 (099842)

John:

I really do not have statisitics on this but would prefer not to guess or make assumptions. Your millionaire entrepreneur doctor aside, I do not see this happening in my area. Additionally, we have a capitalistic system that encourages that form of entrepreneurship so we really need to think twice concerning value judgements unless one wants a fundamental change in the system. Patients, in most areas cannot pay 'a very large premium to have dialysis, cat scans, mri's, lithotripsy' because the rates, for the most part are fixed by third parties. Medicare, Blue Cross, Blue Shield, etc. pay a fixed rate or allowance for that service so 'large premiums' are really not possible in most areas. A larger concern is that of overutilization -- ordering more services than are necessary due to the potential to profit from ownership in the entities providing those services.
Ed

Re: What happens when the strings are so long that we run off the right margin?

Ed Davis, DPM on 11/11/02 at 20:42 (099843)

Just curious.
Ed

Re: What happens when the strings are so long that we run off the right margin?

Scott R on 11/11/02 at 23:13 (099846)

It's supposed to word wrap wthout a problem.

To everybody:
let me know if youi didn't get the heel pain newsletter this month.

Re: What happens when the strings are so long that we run off the right margin?

wendyn on 11/12/02 at 07:21 (099850)

Scott - I did not.

Re: What happens when the strings are so long that we run off the right margin?

Scott R on 11/12/02 at 07:25 (099851)

Wendy, you have to sign up for the newsletter. I didn't see your email address on the list.

Re: What happens when the strings are so long that we run off the right margin?

Julie on 11/12/02 at 07:29 (099852)

Scott, I got mine, no problem, but as you're actively reading today I want to say that I like your suggestion that people point out Good Posts to you. I would add only that many Good Posts are not usually stand-alones, but are stimulated by Interesting Threads and are part of a Good Conversation. So maybe people should draw your attention to Interesting Threads.

Re: Bill -- YOU may be part of the healthcare access problem

john h on 11/12/02 at 09:04 (099868)

Ed: I am a Capitalist through and through. Over utilization sort of gets us back to the trial lawyers as Doctors are forced to practice defensive medicine or worse yet leave states that have histories of large awards.

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/12/02 at 14:19 (099902)

In Chicago, the market was dominated by Parkside, a physician owned lithotripsy venture. This lithotripsy venture was prosecuted by the FTC. You can check their web site for the details it is file number 9310028.

In my state, most of the urologists are invested. It is not hypothetical, I know this for a fact. Unless you have a very large circle of friends or are also in the lithotripsy business, I can't imagine how you would know the situation with urologists. Aren't you busy enough with your podiatry practice?

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/12/02 at 14:29 (099907)

Keeping unsafe products off the market does not limit competition.

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/12/02 at 14:33 (099908)

Ed,

There really isn't any concern about overutilization of renal lithotripsy. Either the patient has a stone or he doesn't. You can't treat air.

Diagnostic procedures are a different story and that is why the Stark law prohibits most physician ownership from diagnostic procedures.

Re: Conflict of Interest in Healthcare

nancy s. on 11/12/02 at 15:48 (099916)

elliott, i agree that mental health coverage (what little there is of it) is often abused, but so are many other kinds of coverage. i'm one who believes in a certain amount of mental health coverage for those who really need it. i have personal experience with the need, for one thing, but i see enough other people with major clinical depression and other dangerous disorders who can't get treatment. i don't think it should take a backseat to other medical disorders; it can and does result in death, for example. we lost our beautiful 37-year-old niece to it two years ago, at least partly due to lack of coverage and also to the stigma still attached to it after all these years. she chose to behave according to the stigma and not seek help openly, but still....

i do know there are trade-offs in any kind of work a person chooses. i accept the trade-offs i have to make, but i'll also speak out if i think there's a wide-ranging unfairness taking place.

it's true that orthotics are a great help to many. i would encourage anyone with pf who is an appropriate candidate for them to give them a major try. i did give them a major try (two pairs, one bad, one great), to no avail. just unfortunate. i really don't know the statistics on how helpful pt is to people with pf only. my pf problem was compounded by achilles, peroneal, and post tib tendonitis, and pt did help a lot. at the same time, if i'd had good treatment for pf in the first place, i'm not convinced that the tendonitises would have developed at all.

i'm not surprised that the north koreans turned out to be untrustworthy. but remember that we had a big hand in making saddam hussein who he is today, because it benefited us at the time, and noriega in panama before him, and others. clinton did not make those people; they were created with u.s. help well before his time. so the blame for the current situation extends back well before him.

nancy
.

Re: Bill -- YOU may be part of the healthcare access problem

nancy s. on 11/12/02 at 16:01 (099918)

oh ok, bcg, i'm glad you thought the beer advice was sound and that you didn't misunderstand my view of the litigation situation today. i think it's dreadful. i forget now how he put it, but i read today that ed davis referred to something like doctors being forced to practice defensive medicine. and, like him, i think it's a rotten situation. lawyers are, of course, sometimes needed -- and sometimes for true medical malpractice -- but here's a situation that's abused to the max, and we all pay for it.

this isn't really medical, but a few years ago a guy in portland sued a friend and got millions of dollars for falling off the friend's boat. whose responsibility was that? the friend who hadn't put 206 railings around his boat, or the guy who chose of his own free will to get on the boat and then apparently didn't pay enough attention to avoid falling off? i cannot believe that people get paid, even get wealthy, for this sort of refusal to take responsiblity for their own choices and actions. it's sickening, and it affects our society in countless ways, including medically -- in terms of both coverage and quality of care.

ok, i'll stop preaching to the already converted now!

nancy
.

Re: Bill -- YOU may be part of the healthcare access problem

Ed Davis, DPM on 11/12/02 at 18:46 (099946)

Sonocur is not an unsafe product.
Ed

Re: What state?

Ed Davis, DPM on 11/12/02 at 18:49 (099947)

What state are you in?
Ed

Re: Bill -- YOU may be part of the healthcare access problem

BGCPed on 11/12/02 at 18:55 (099951)

There is a attorney from the US that has filed suit against the US border patrol/forest service/government. There was a group of illegal mexicans that died of dehydration in an area of Texas. The forest service uses big water tanks that are filled to allow a rare antelope type creature to survive. They are about 10 miles apart and one of them was not filled and this group of illegals dies of dehydration several miles from the one that was empty.

This shark fin lawyer claims the forest service is at fault for not maintaining water supply????????

I am not making this up

Re: Bill -- YOU may be part of the healthcare access problem

Bill on 11/12/02 at 19:19 (099962)

Ed,

I'm not saying that it is unsafe. I am questioning its effectiveness.
I assume that it is safe since it passed FDA safety testing for tennis elbow.

Re: Bill is Bill Clinton? -- Can't be!

Ed Davis, DPM on 11/12/02 at 22:13 (099978)

Bill:
You are waffling so much, it reminds me of
Bill Clinton. Not safe? Not saying it is unsafe. Go back and read a string of your posts. It depends on what 'is' is.
Ed

Re: Bill is Bill Clinton? -- Can't be!

Bill on 11/13/02 at 08:07 (100003)

Ed,

I guess that we must both be waffling then. You should proably read carefully my posts and see what you think. You have attributed many beliefs to me that are not true. Anyways, when you start equating me to Bill Clinton I can see that its time to stop and since you are one of those persons who needs to get the final word, I'll let you have it. Please respond how you will to this message. I won't respond. You get a free shot.

Re: Bill -- YOU may be part of the healthcare access problem

john h on 11/13/02 at 10:16 (100013)

Having had two kidney stones I will firmly state when you need a lithotripsy you need a lithotripsy. unrelenting pain level of 10 you can take for only so long. the doctors tried to wait but I could no longer wait. my second stone the pain subsided and i passed about 8 days later without incident. it is difficult to imagine mis using lithotripsy. even as you are placed on the table for lithotripsy the doctor attempts to grab the stone if it is in the urter with a small cage. if he can you are out of there in 15 minutes..

Re: Bill

Julie on 11/13/02 at 11:16 (100022)

But Bill - it's you who has had the last word (as you surely intended).

You've come to these boards to stir things up, and succeeded. You've refused several requests by me, Dr Ed Davis and others, to identify yourself, which is deceptive. You've been discourteous.

If I were the webmaster of this board I would have cautioned you. I can't do that, but I can express my distaste for the disharmony you have brought here. And that's what I am doing.

Re: Bill is Bill Clinton? -- Can't be!

Ed Davis, DPM on 11/13/02 at 14:40 (100052)

Lighten up Bill. I am just pulling your leg.
Ed