This came in the email. It’s an ad, but I thought it could be of interest to some of you so I’m sharing:
Recently, we [the National Opinion Research Center] announced a new generation research tool: Foresight 50+, the largest high-quality research panel of Americans 50 and over.
Foresight 50+ combines the consumer expertise of AARP with the scientific rigor of NORC to amplify the voice of the fastest-growing age group in the country.
NORC worked with AARP, one of the most trusted names among older Americans, to address the lack of reliable research about this influential demographic. The result is Foresight 50+, which gives clients like you reliable, actionable insights into the views and behaviors of this influential American demographic — everything from what they buy to what they think.
Building on NORC’s probability-based AmeriSpeak survey panel, Foresight 50+ goes the extra mile to hear from every segment of the diverse and evolving 50-and-older population. We do this by combining proven sample acquisition methods, such as address-based sampling, mailings, and phone calls, with in-person, face-to-face recruitment of participants to ensure that we’re reaching the undercounted in our society.
For clients seeking rapid results, we offer Foresight 50+ Omnibus: a high-quality, cost-effective option for clients needing quick turnaround surveys. And for those seeking even larger sample sizes or support low-incidence surveys, we use NORC’s affordable TrueNorth Calibration to reliably incorporate data from nonprobability, opt-in panels with probability-based Foresight 50+ survey data.
Need a direct line to the one of the most influential demographics in America? Use Foresight 50+ for your next research project. Contact Martha Cowley at [email protected].
The only funny thing about this is that they say they want to “amplify the voice” of our age group. We’re a third of the population and, I assume, more than half the voters. Our voice is amplified enough as it is, no?
NORC has a good reputation, so I’m guessing this will be a high-quality survey tool.
One thing I don’t really understand is why they do this separate panel of over-50s. Why not just do a panel of all adults and then sell the slices of over-50s for clients who only want that group? Maybe someone in the comments can explain?
Also kind of a waste that they didn’t give the survey some clever name with the acronym OKBOOMER.
“Also kind of a waste that they didn’t give the survey some clever name with the acronym OKBOOMER.”
Andrew:
This may be your answer. From https://en.m.wikipedia.org/wiki/OK_boomer
OK boomer” is a catchphrase and Internet meme often used by teenagers and young adults to dismiss or mock attitudes typically associated with baby boomers, people born in the two decades following World War II.
Also, the Boomers are not all of the “over 50” population. The over 50’s include some of the “silent generation” (older than boomers), and some of “generation X” (younger than boomers).
Yes, it was a joke :)
Senior voices are not amplified enough. The very old (80+) are invisible to the “move fast and break things” world we live in. How many senior seniors with flip phones are left behind when 3G goes away and the replacement phones are different and have fewer features? How many senior seniors who need hearing aids are offered high-tech ones that must be controlled through a smartphone (often, specifically an iPhone)? How many medical scheduling interactions can only be completed over a home computer? How many senior seniors could learn to type on a smartphone virtual keyboard, or use voice recognition well enough to dictate a message on one?
Senior seniors are so invisible that the single (mooted) tech innovation that would serve them, selfdriving cars, has never even f*ckin mentioned them.
And since I’m on this tear, why don’t apartment building codes call for walk-in showers? Not the ludicrous ones being hawked on TV, but simple cabana-like ones? A friend of mine was able to live alone to the age of 103 in part because she showered every day in her sill-less shower, narrow enough to save her if she ever fell, in an old Jackson Heights apartment building.
Thanks for listening.
+1
I’m not 80+, but will soon be there — I’m part of the “silent generation”, just before the boomers. I believe I am more computer, etc. savvy than most people my age, but smart phones are still beyond me. Cataract surgery has helped a tiny bit in using devices, but not as much as I had hoped.
“smart phones are still beyond me.”
Not much of a loss. I don’t have a single app on mine beyond what was supplied with the phone. I don’t use my phone for anything but a phone and occasional blog reading in line at the supermarket. I just can’t stand that little screen. It makes me feel like I’m trying to look out the bathroom window of a 1950s Route 66 motel in Tucumcari or something.
But I think I’d like to try being a glasshole at some point – that might work better for me.
You’re 8/9 of the way there already!
j/k
I would like to help NORC in their work. Contacting people via address based sampling, mailings, and phone calls leads to low response rates and must skew the sample. Everybody knows that broad opinion sampling is nearly worthless. I meet with some friends for coffee on a regular basis. We have sapient in-depth discussions on many topics. Hire us as a focus-group. For the price of a few coffees, often decaf due to blood pressure issues, and some pastries, just a few due to AODM, we will generate robust opinions reflecting our demographic.
To your point about surveying everyone and just offering 50+ results as an option: I think this reflects the real purpose – to promote the interests of this demographic group as if they are a distinct group with different preferences/behaviors than others. I question that. As Julia suggests, many actions and designs seem oblivious to the interests of older people. While I believe that is true, I don’t necessarily believe the answer is to bolster older adults as a specific interest group. Don’t we have enough interest groups as it is? The reference to AARP struck a nerve for me. I’ve had mixed feelings about AARP – I’m glad they exist, but I am always disappointed in them. They are guilty of commercial agreements that seem (to me) to take advantage of the very group they supposedly represent. And, their “analysis” of issues (take health as a prime example) often is of poor quality. They are an influential enough organization to do better, but they seem content to take advantage of the huge demographic they ‘represent’ and the leverage it gives them to partner with commercial entities.
At the same time that seniors’ needs are downplayed or ignored by designers and the media, too many of our public policies are dictated by this presumed voting block. Don’t touch Medicare, a third rail of politics! Medicare pricing is a sad joke – which allows the myth of ‘Medicare for all’ to be disseminated. Medicare pricing only exists because non-Medicare services are overpriced (cost-shifting) and other Medicare services (mostly in the last 2 years of life) are highly lucrative, though perhaps wasteful. But rather than engage worthwhile debate about the future of Medicare and what rational policies might look like, AARP perpetuates the sanctity of not touching Medicare. So, a group that will highlight the needs and views of the senior demographic group does not excite me. I’d rather see a group that helps merge different views or engage them in meaningful discussion and debate, rather than promoting another segment in competition with all the others.
Thanks for letting me vent.
Right on, Dale. Sounds like a tool designed to support surveillance capitalism aimed at a demographic that doesn’t participate fully in social media.
Medicare is really complicated and we are in the open enrollment period when, as we all are aware, an irrevocable decision for 2022 has to be made by December 7, 2021. We elderly followers of this blog all know this but it is not true.
“Medicare & You 2022” is thicker than its predecessors and I suggest you look at page 72 (if you live in Minnesota–perhaps a different page in another state). There you will see that for a so-called Medicare Advantage Plan (a confusing oodles of them exist in Minnesota), there is an additional enrollment period such that a switch is possible within the first three months of 2022.
At the bottom of that same page, is a mysterious reference to a “5-star Special Enrollment Period” which goes from “December 8 to November 30.” Mysterious, because no “5-star Special Plan” exists in Minnesota and perhaps, never has. One needs to contact Medicare to find out where such plans exist in the U.S.
As always, choose your grandparents carefully.
Thanks for the heads-up; I hadn’t looked at my ““Medicare & You 2022” yet, but now have looked at things starting with p. 72.
Another problem for Medicare eligible people: Many primary care physicians will not accept new patients who are 65 or over. I found this out only recently when I decided it was time to find a new primary care physician, since on two occasions, the old one had botched something that he was confident he could treat, but he really needed to refer me to a specialist. However, the new primary care physician I have tried seems to be worse than the previous one, so I need to start over again finding a pcp.
The reason it is hard to find primary care physicians under Medicare (in some places) is due to the pitifully low reimbursement rates – a warning for anyone that likes “Medicare for all.” I actually support a single payer plan, but it has to be realistic about the rates – current Medicare reimbursement only works because other payers pay much more. Medicare has other problems – the complexity that Paul Alper refers to is unnecessary and a horrible statement about how the US medical system/insurance industry works. The choices are nearly unintelligible and it ends up being an invitation to gamble – just how much care do you think you will need? And, every year you get to change your gamble. Just take a look at part D prescription drug plans – every year you have to look at the list of drugs and preferred prices on each plan and decide what bets to place for the next year. Exactly what benefits the “marketplace” for such plans provide eludes me. The evidence is that over half of people on these plans do not shop for a new plan – but since the approved drugs on each plan change virtually every year, they should be shopping. Failure to shop is an indication, not that they are happy with their plan, but that the system is too complex to work for them. The design of these plans should be an embarrassment for all those involved in the system. And, where is AARP in this? They will give you advice (some of it is good) about how to choose a plan. What I really think they should be doing is working to change the ridiculous part D system – but that would not make the insurance industry happy.
Dale, a proposal: The govt sets up a “medical billing clearinghouse” (they can outsource the operations via contract perhaps but basically have the authority over it). Anyone who provides medical services must bill *through the clearinghouse*. ie. your doctor sends his/her bill for services to the clearinghouse tagged with your SSN. No bills sent directly to a patient are legally payable, and in fact there could be a fine for doing so.
The clearinghouse then provides summary bills to your insurance company of record, and the insurance company must pay first. Only after the insurance company has processed any given bill will the clearinghouse attach it to your monthly bill which they send to you personally for payment of the remainder. If the insurance company denies coverage they must explain exactly why to the clearinghouse before the clearinghouse will bill the individual.
The clearinghouse tracks individual out of pocket expense, and any amount in a given year over (GDP/capita/4*(n+k/2)) for a family of n adults and k children is paid entirely by the government as stop-loss insurance.
Furthermore, the clearinghouse rejects any bill for services which is more than 120% of the minimum provider bill for equivalent services in the state or metropolitan region where the services were provided (can use census regions so long as they include at least say 300k people or something like that)
Furthermore, the clearinghouse may fine the billing entity 100% of any excess billing amounts (amounts beyond the published rates they provide regularly to the clearinghouse for the services) billing mistakes are on the billing entity.
Well, I appreciate your intent. Ensuring minimum (and adequate) insurance regardless of income is a worthy feature, as well as relating it to family size. Prohibiting extraordinarily high prices is also worthwhile. I particularly like published rates – provided that they are actually the rates charged insurers and not the rack rates. But it sounds like this is a proposal to reform the entire US medical system, not just Medicare. Several politicians have tried – and failed – to accomplish this. I can envision the details that would need to be worked out for your proposal and many of the details already exist in the current system. Comparable or prevailing charges in a region is one of my favorites – not an insurmountable problem, but fraught with hideous details and complications.
At some point, it just becomes simpler to give up on the idea that private markets for health care services and insurance make any sense. My brethren economists would be horrified, but I’ve reached just such a conclusion.
> Comparable or prevailing charges in a region is one of my favorites – not an insurmountable problem, but fraught with hideous details and complications.
Not necessarily so hard if each provider must provide an updated price list and the clearinghouse has *100%* of the billing data.
Yes, my proposal is to completely rehaul the system. The idea not being that it’s so easy to do, but just more as a proof that there are designed mechanisms which would be both simpler and better. It’s often said that people try to fix things by adding stuff… my proposal is to take away as much complexity as possible and simplify the system down to the essentials.
I think we want as much benefit of markets as we can get, but in the context of a system that is open, transparent, reviewable, and in which a centralized clearinghouse eliminates the incredible obfuscation we have now. I’d argue that the clearinghouse would be required to publish open statistics and datasets on what had occurred, so that researchers would be able to evaluate effectiveness etc.
“And, where is AARP in this? ”
Hauling in the cash. AARP has long ceased to be any kind of senior assistance program. Now it’s just a cash cow for the management.
The best system is a system where everyone pays their own way and possibly buys insurance against the risk of a large expenditure. In the current system, prices rise relentlessly because there is no check on demand because the users of the product don’t pay direct costs. Not only is there no check on the cost of the medical services, there’s no check on the cost of the massive bureaucracy that decides who can have what services, both in the government and in private companies. Total waste.
If you need a physical, just go get one. You pay cash, the doctor is very happy bcz s/he doesn’t have to wait 500 days for insurance to pay out or pay a person to figure out how to bill the insurance or pay for software the does the billing – h/her cost is already down X% – you’re happy because you paid $200 for your physical instead of $500/mo for your insurance, and you’re getting an extra $500/mo bcz your employer is paying you instead of your medical coverage.
BYOMC.
jim
I saw this post after your other one. Now I know where you are coming from – as usual, the free market is best. I actually agree with your first several points – about AARP, about the wasted costs in our current system, and about some of the absurdities of our insurance system. However, your solution of just having “everyone pay their own way,” possibly with catastrophic insurance is seriously off-base. If you look at the health care expenditures, you will see that there is a relatively small portion of the population that incurs the really big costs. Some people are just unfortunate – bad genes, bad luck (I am going to ignore the favorite target of libertarians, that these people choose bad lifestyles – I don’t think that is a credible argument for the vast majority of those with serious and costly health care needs). Voluntary catastrophic insurance will not work – not enough of the lucky people will buy it to support those that will need it. This is why the private insurance industry is a game – designed to attract the relatively healthy and avoid insuring those that are likely to need long-term expensive care. In fact, this is a large part of why serious mental illness has traditionally received less beneficial insurance than other health care needs (despite legislation outlawing such practices).
Much as I like the idea of having people make their own choices and paying their own way, several features of health care make that a poor policy, in my opinion. This is one area where behavioral economics is quite relevant – people often behave irrationally when it comes to health care decisions (and I’m not sure what or how we can do anything about that). Inequities in terms of genetic and financial endowment also loom large – too large to leave it to the market. Personally, I favor a universal government run single payer system, albeit with a private insurance system for those that want, and can afford, to go beyond the benefits that 90%+ of the population will get from the single payer system. Yes, sort of like the NHS. I don’t underestimate the issues associated with such a system – it is far from a panacea. But the bar is low – we only need a system better than the current one!
“people often behave irrationally when it comes to health care decisions”
I have mixed feelings about that. The current anti-vax rage shows this is true. The question is: is it the rest of society’s job to fix that? People make bad financial decisions, career decisions, home purchases, driving decisions etc. The government doesn’t intervene on those decisions. It provides some guidelines, but it doesn’t – at least not quite yet – take the wheel.
It’s nice for the government to provide accurate information that people can use to make choices – or in some cases direct regulations to protect people, like licensing for surgeons and “No Jumping Allowed” signs on bridges so people don’t kill themselves jumping on to rocks. That’s all good. But there’s only so far it makes sense to go with that. The same decision is bad for one person and good for the next, depending on circumstances, and the gov should let people make those decisions for themselves.
BTW, while I do think having free healthcare incentivizes people to make bad health decisions (like choosing to smoke or be overweight), I don’t believe that this is a major contribution to the high cost of health care. If people paid their own way some of this would be eliminated but probably most overweight people would still be overweight, smokers would still smoke etc. IMO there are ample other justifications for market-based health care.
jim
I don’t disagree with what you are saying – but I think you are not being realistic in assessing the situation. Cases where people are irrational and government advice to prevent them from harming themselves are real, but I don’t think are the real problem. I’m thinking of cases where your close relative is dying and there is an expensive treatment that can prolong their life for a month, perhaps without much quality. These cases are common and they involve large expenditures of resources. We can intellectually discuss what should be done in such cases, but when people are faced with these realities, they cease to be rational. Having them bear the full cost of the 1 month life extension will certainly “solve” the problem, but in a particularly inhumane way. Allowing them to have the state pay for the treatment invites them to make very costly decisions that they don’t pay for, and that may not help their loved one. I don’t really like either approach. I’d rather see reasoned decisions about what to do under these circumstances, divorced from one’s ability to pay, but recognizing the real costs and effectiveness of the treatment options. Society will need to draw the line somewhere about what to spend in such cases. Lines get drawn now, but in especially opaque and unfair ways, and often dictated by the political power of organizations such as AARP.
On another point you raise; catastrophic insurance surely does have a market, even among health people. But I think you underestimate what such insurance would cost – if it is made available to everyone. If you are unfortunate and borne with genes that will lead to chronic illness that costs a lot, then you would need to be part of this pool, and the rates that you would pay for this coverage would need to cover the costs of treatment for these individuals. Good data is hard to come by, but I seem to recall that something like 80% of health care costs are attributed to around 20% of the population (I know – those particular numbers are the 80/20 rule often cited, so the health care numbers might not be those – but I suspect they are at least that skewed). Catastrophic insurance costs would need to cover this. So, even if you are a health bike rider and want to purchase catastrophic insurance, you might balk at the price. Of course, you’d prefer to have an insurance policy that doesn’t include these expensive people in the pool – a pool of health risk averse bike riders like yourself. But that system quickly degenerates into what we currently have – an insurance market that becomes an excuse to avoid paying for the health care costs of the unhealthy.
To add some data to my comment: According to a KFF report (https://www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/#item-discussion-of-health-spending-often-focus-on-averages-but-a-small-share-of-the-population-incurs-most-of-the-cost_2016), 5% of people incur 50% of health care costs; the top 1% incur over 20% of the total. The lowest 50% incur only 3% of the total. Costs are very skewed. Political and economic challenges derive from this. They are not easy. But they do make me leery of a market-based “solution.”
Hi Dale, thanks for those references. Yes I agree that costs are VERY skewed. But I also think that we do a terrible job of managing these costs in part because of bad incentives. My sister works as a Psych Nurse Practitioner. She used to work for the VA and now for a company that specifically manages a group of these very high utilizers. For example elderly people with diabetes, congestive heart failure, kidney failure, and major depression. In other circumstances, these people are kind of “cash cows” for providers. Bring them to the ER, treat their emergency, bill Medicaid for $100k, wait a few months, repeat… As the manager of a provider, the incentives are to not permit your doctors to really take control of this person’s problems because letting them routinely get out of control equals hundreds of thousands of dollars billed, whereas putting them on injectable long-acting psych meds so that they can function well enough to monitor their diabetes and get to their dialysis appointments and assigning them a case manager who comes to their house once a week to check on their health status and make adjustments would cost you money both in hiring extra people and reducing your billing.
Most of the high expense people are in this kind of situation, and the existing incentives make them into suffering cash cows. That could definitely be changed and would correct part of what you’re talking about.
Daniel
I can’t just give you the benefit of the doubt here – “most of the high expense people are in this type of situation.” Do you have any real evidence of this (other than your anecdote)? I’ve spent a fair amount of time around medical providers and many do not engage in what you are claiming. Surely some do. Just as surely, many do not. I don’t know of any credible evidence regarding how much of what you claim occurs. It is a form of malpractice and my experience with providers is that most do not do that. The ones that withhold proper treatment in order to collect more could certainly run up the expenses. But I just don’t know if I buy that that is a significant part of the cost problem.
I used to teach health economics. A good part of the texts was devoted to “supplier induced demand.” This is the idea that physicians create a demand for their services, taking advantage of asymmetric demand to provide unnecessary and financially rewarding services. It isn’t hard to imagine, and I think excessive testing is perhaps the easiest example to think of (especially when you add in malpractice suits and the ease of believing that testing people does little harm). However, missing from all those texts was any evidence of how much supplier induced demand actually occurs. But the concept literally took up a significant portion of the texts – even more than coverage of topics such as single payer systems or competition between insurers – much more important issues, in my opinion. Your reference to failing to provide the right treatment because it would reduce reimbursement strikes me similarly.
According to appendix II here the 2015 NHIS adult response rate is only ~55%: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2015/srvydesc.pdf
I’d tend to assume non-responders are also less likely to interact with the healthcare system, which would mean the spending is even more skewed.
It is also interesting to browse through this:
https://www.thennt.com/home-nnt/
It seems most treatments (that appear to “work”) have NNT of 10-100. Meaning that 90-99% of what is getting spent on healthcare is not actually benefiting the patient.
Ie, something like $2.5 trillion each year could possibly be saved by figuring out how to direct the treatments only towards the small percentage who would benefit.
My view is that the cash cows analysis is too generalized and simplistic to be terribly useful. Of course perverse incentives has some relevance, but I think that full extent of the problem is much, much more complex. For example, the difficulty that people have in seeing that short term, large expenditures can be cost-effective in the long term is a problem that affects many fields and certainly isn’t alway attributable to perverse incentives. It can be a kind of cognitive bias – somewhat related to a recency bias (or a negativity bias).
This discussion makes me think of this article from way back:
https://www.newyorker.com/magazine/2011/01/24/the-hot-spotters
Dale. It’s not about “withholding proper treatment” it’s about narrowly defining “proper treatment” as “whatever is needed to stabilize the patient in the short term, then pass the patient back to “someone else” as their problem”. It’s not about “padding the billing” intentionally, it’s just about not actually caring holistically for their actual problem, but only ever treating the proximal issue that is most acute *today*.
I have heard enough of these stories, including about a 10 year saga of one of my wife’s college friends who has severe bipolar disorder… in and out of ERs every few months for years on end, no one ever looking at the big picture, on 5 or 6 different meds prescribed by different doctors none of whom even knew what the other was prescribing. Constantly being kicked out of one group living situation or another… each event leading eventually to a breakdown and hospitalization.
It’s a similar kind of story on a monthly basis from my sister. A severe homicidal schizophrenic patient qualified for an injectable long acting form of psych meds while a minor under 18, and then on his 18th birthday he didn’t because they were too expensive and the VA wouldn’t cover expensive meds that could be replaced by oral ones. He was placed on an oral form, within days he had stopped taking them, within a few weeks he had murdered someone and will likely spend life in prison. Patients who were given an air mattress to sleep on and each night they would take a hatchet and hatchet the air mattress into little pieces. After the 4th air mattress they stopped giving her any more air mattresses… so she sleeps on the floor, and every few weeks the sherriff stops by to do a welfare check because she doesn’t show up to her psych appointment because she’s too tired from getting bad sleep on the floor and freaking out each night because she’s not on her psych meds… stuff like that is just *routine* day to day issues in the care of the severely mentally ill…
It’s particularly the case with severe psych issues that they lead to incredibly large amounts of utilization most of which is avoidable. For these most severe cases if you simply hire a $50,000 social worker case manager for each say 5 people, and this person checks in on each patient every 2 days, you could easily save a couple million a year. No one ever does this because the people paying the $50,000 for the case manager are not paying out of the same budget as the people paying the $200,000 for each hospitalization.
Let’s also not forget my own grandfather, who at age 92 collapsed and was hospitalized. He had multiple organ failure and was under weight, but his heart doctor who had treated him for decades breezed in, declared that if he had a simple ablation surgery he would recover (obviously not true to the rest of the family but gave huge hope to his wife) then breezed out to a multi-week vacation leaving the associate to perform the surgery the next day, after $150,000 surgery he was moved, delirious, to skilled nursing, where he become psychotic as a result of the pain meds, after being removed from those meds, he lasted about 4 days conscious and miserable, and then died.
Daniel –
My “wife” has been a hospice nurse and nurse manager for years. Certainly I have heard many stories of the type you describe with your grandfather.
But reasoning by anecdote is problematic. I have heard many stories that are quite different in their nature.
I’ve all, my impression is that there has been some progress with greater use of hospice, and viewing end of life care more broadly. Some doctors get it. And there are many, many families that, apparently unlike many members of your family, push explicitly for all forms of extraordinary measures taken, up until the very last minute. It’s not just a problem I clueless doctors or profit motives.
“I’m thinking of cases where your close relative is dying and there is an expensive treatment that can prolong their life for a month, perhaps without much quality…when people are faced with these realities, they cease to be rational”
I agree. But there is **no** solution to this issue. Nothing will make the person live longer. Society can’t afford the astronomical costs and quite frankly the person shouldn’t expect that. I don’t see how this person not getting treatment because they can’t afford it is “inhumane.” I think that’s where we differ.
“If you are unfortunate and borne with genes that will lead to chronic illness that costs a lot…”
But this is a chronic condition. This would not be covered by the insurance I propose. These people would be on their own to provide for themselves. I’m sure you think this is inhumane, and perhaps it is. But to me it’s equally inhumane to deny other people the means to take care of themselves which they earned with their own labor, so that one chronically ill person can survive – all the more so when much of what’s taken from people is frittered away on highly paid administrators and doctors for little gain for the patient.
Our state recently passed a “right to defense” law for people who are evicted. Now the state is going to hire a pool of lawyers to defend the evicted. Who are the main beneficiaries? THE LAWYERS!!!!!! The cost benefit ratio is astronomical. It’s similar in public health care. We have an immense misallocation of resources for health care. So what are we doing about it? Hiring “health care economists”! Creating an entire health care management bureaucracy! That’s a big improvement – for the economists and bureaucrats – they can comfortably ponder on a nice salary unsolvable problems like what to do about 1-month-to-live cancer patients (“Cecil! Whatever should we do about this terrible problem!” “I do not know, Frederick. Lets have a sherry and consider it”). But it’s a big fat negative for everyone else who has to pay for that pondering.
So really I think you’re dramatically, massively underestimating the waste.
Daniel writes:
“I have heard enough of these stories, including about a 10 year saga of one of my wife’s college friends who has severe bipolar disorder… in and out of ERs every few months for years on end, no one ever looking at the big picture,”
This is just like Dale’s “one-month-to-live” cancer patient. It’s an unsolvable problem. Why do you believe social services agencies would be the only ones to act exclusively and ideally in the patient’s interest? They won’t. They’ll screw things up just like everyone else does – then the state will be held responsible. Our state human services department is forever being sued for it’s “screwups” and forever “reforming” itself because it can’t fix the world’s worst problems.
What’s happening to this person is tragic but it’s not a solvable problem. If the person won’t take the meds, there’s nothing you can do for them. Meanwhile, instead of helping this person with the one shot you say they need, NGOs are spending $$BB on people to sit around in offices and babble about what the government should do for these people.
jim, Daniel, all others
We all have anecdotes. I am married to a psychiatrist and I have plenty of stories I’ve heard about system waste, failures to coordinate care, mistakes made, administrative atrocities, etc etc etc. But reading through these comments I am struck by the apparent abandonment of our usual insistence on evidence and sensitivity to the quality of that evidence. Our health care system is huge – there are many stupid, inefficient, and unfair aspects to it. And, there are competing ethical views we bring to the table. These are all worthy of debate and analysis. But I am struck by our collective failure to consider the extent to which these (very real) problems are typical, exceptional, or the complexity of trying to improve the system.
I’ll offer an analogy. On this blog we have discussed many gross failures associated with empirical work – think of the Surgisphere or Wasnink episodes as good examples. Does that mean that most (or even a large fraction) of statistical studies are fraudulent, based on manufactured data? I’d like to think these are still the exceptions and not the rule, although I sometimes do wonder about that. Still, my belief is that most researchers do not make up their data or lie about it. The (hopefully) relatively few bad apples does not excuse the systems from needing to improve (systems like academic and research employment practices, journal policies, etc.). But it does require some reticence to brand these entire systems as useless or wasteful beyond worth improving.
My experience with the medical profession leads me to believe that the moral compass of most providers as better than that of most academics. We can mock the oath that medical practitioners take, but at least they have one. And I believe that most genuinely care about their patients – even the administrators of these systems (hospitals, insurers (though I do struggle with that one), pharma companies, etc.) I would say are trying to improve health. I’m not sure I would as readily believe in the integrity of most academics.
Of course, the systems we have created to deal with health are horribly flawed and wasteful. But let’s be realistic about the scope of the problems. Jim would have chronically ill people left to deal with their own needs based on their own ability and willingness to pay for treatment. Yes, I would call that inhumane. I would say that a society practicing that is not one I want to participate in. I personally pay a Medicare tax on my part D drug plan that is much larger than the subscription fee for the plan itself. It really bothers me, but I am willing (but irritated, to say the least) to subsidize those with less ability to pay – even if their “need” for drugs may be due to poor lifestyle choices or physicians handing them pills instead of taking care of their holistic needs. Daniel appears to be willing to label the entire health care system as failing due to very real (and too common) failures of the system to treat the whole person and do it in the best interest of that person (sort of like a fiduciary relationship).
I think the reality is that we have a diverse population of flawed human beings with extensive health care needs and ever expanding (and expensive) ways in which we could potentially improve their health. We have a huge health care system fraught with terrible incentives, but with the majority of providers struggling to improve the lives of their patients. Our collective political will is not at all clear, laced with political and ethical dimensions, and very much affected by our individual circumstances. I can tell you that my attitudes changes dramatically when I became a patient rather than just an observer. It is a messy and complex business.
I think we should avoid simplistic analysis that relies on easy generalizations about either the patients or the providers. I sincerely think our health care system is a mess and sorely needs massive change – but I don’t believe leaving it to the “free” market or blaming the motives of providers and/or patients will get us far towards improving things. In many ways, I think health care and statistics are quite similar (aside from the obvious overlap in content) – many current practices are terrible, but improvement isn’t so easy. It makes me think of the citation from the editor-compiler of 1,045 grand summary findings about human behavior (cited in Tufte’s Beautiful Evidence, attributed to Bernard Berelson and Gary Steiner, 1964, “Human Behavior: An Inventory of Scientific Findings”). That citation offered a threefold grander summary of social science knowledge:
1. Some do, some don’t.
2. The differences aren’t very great.
3. It’s more complicated than that.
Dale, thanks for your summary.
I feel like you don’t answer my criticisms. With regard to chronic health care, you don’t answer my concern that many of the people who would pay for the chronic health problems of others have serious problems of their own – health or otherwise – for which they would be denied some of the resources they earned and would otherwise use to help themselves solve their own problems. So these people are suffering real damage. But it’s not even a straight tradeoff because health management is taking a slice of the payment at every level, so the payer is also paying for management, and it’s worse yet because with no competitive check on cost, there is also extensive waste.
So I guess I feel like you’re ignoring that there’s real damage to many of the people who pay for others; your ignoring that it’s not even a clean tradeoff, it’s a trade minus fees and waste; and ultimately ignoring the fact that you could freely contribute to the welfare of people with chronic health care needs by donating to a charity. But what you want is for everyone else to be forced to pay for you personal values. I’d love to have your money to spend on my values! :)
jim
Regarding your criticisms this will be my only reply. Yes, I don’t respond to them. I don’t have the time or energy to debate with you. Suffice it to say I do not agree with you. But I respect your right to hold those opinions. Free market principles are difficult to debate – there is truth in everything you say. Freedom is to be cherished and there are terrible things done in the name of protecting some group by violating the freedom of others (such as taxing one group to provide free services to others). I understand the logic and issues – I was trained to appreciate the values of free (or less than perfect) markets and the deficiencies of alternative institutions. I don’t find the pure debates about the market vs. the state particularly useful, and ultimately they are not resolvable.
On the other hand, I do believe is some kind of community. Unfortunately, there are few good examples and (too) many examples of failure (such as the Marxist ideals that we have seen fail repeatedly). Community values are particularly hard for markets to adequately provide for – not necessarily impossible, but I’d say market struggle with things such as citizenship, the rights of other species, ecosystems, and health care. I am not an optimist – I don’t see humans as evolving to deal with crisis that requires cooperation, compromise, or community values (particularly when the community becomes large, such as global). Free market ideology just doesn’t convince me that markets can address these issues. Neither do any of the other institutions humans have thus far created. That is why I am not optimistic.
jim –
> So I guess I feel like you’re ignoring that there’s real damage to many of the people who pay for others; your ignoring that it’s not even a clean tradeoff, it’s a trade minus fees and waste; and ultimately ignoring the fact that you could freely contribute to the welfare of people with chronic health care needs by donating to a charity. But what you want is for everyone else to be forced to pay for you personal values
My guess is that the reason you feel that way is largely because of a binary mindset that you’re bringing to the discussion.
Just because someone doesn’t address your rhetorical constructions doesn’t mean that they are “ignoring” the obvious fact that trade-offs exist, that no system is perfect, etc.
I think if you re-read what Dale has written (obviously including his subsequent response to that comment or yours), you’ll see that you’re overreaching to characterize his views.
Anoneuoid
The Medical Expenditure Panel Survey does have response rates as you indicated, but it is worth noting that they go to considerable lengths to derive meaningful weights, including non-response as one of the factors (for example see section 3.3 of https://meps.ahrq.gov/mepsweb/data_stats/download_data_files_detail.jsp?cboPufNumber=HC-216). I’m not saying they have done that correctly, but they at least made a serious attempt. Your speculation on what the non-responders expenditures might look like could well be right. But I think it is a further unfortunate thing that data like this is so hard to come by. I know of one entity that has very good data on health care expenditures – that is the insurance industry. But trying to get that data for the purposes of analysis or policy making is, unfortunately, quite hard.
The point is how can you ask most of the population to pay for the other 10-25% to spend trillions of dollars to get moonshot treatments with 10-1 or 100-1 odds of benefit? Would they take those odds themselves rather than leave more resources for their family?
How about limit it to treatments with 2-1 odds of benefit (which is basically none of them)? Maybe 3-1 or 4-1 would still be acceptable to most people.
Personally, I would get rid of the entire NHST-based system all together. But that does not seem to be an option.
Ian Harris, an orthopedic surgeon, has written two stellar books: Surgery, The Ultimate Placebo, and Hippocracy. One of the underlying themes of both books is that some physicians continue to perform surgeries that have been proven to have no more benefit than doing nothing. Another major theme is that for many procedures and treatments there is no good data/evidence. Ian Harris goes further to suggest that physicians should learn to evaluate medical research in medical school b/c we conflate medical education with science. Now that doesn’t sit right with the medical establishment. However, the efforts to replicate cancer studies should yield a cautionary note: not to mention the measurement crises that have been unfolding in statistics.
At least in many European countries, there are more efforts to expand evidence-based medicine. There is an annual conference Prevent Overdiagnosis and Overtreatment. The next one is in June 2022. The US lags in such fora. In 2019, there was one evidence-based conference in Chicago. I recall Doug Altman’s presentation. But forgot the exact title of the conference.
The underlying reality is that medical education should be even more Socratic than it is. More recently, the younger crop of physicians does relate the challenges they face in determining appropriate diagnoses and treatments.
” The design of these plans should be an embarrassment for all those involved in the system. ”
On the contrary, they’re quite proud of it. From their perspective, it’s not a bug, it’s a feature. The technical term, I believe, is price obfuscation. You make it difficult for the customer to know what they will pay and you can squeeze more profit out of them. It also discourages shopping around, because, what’s the point. That way you can have a “market” without real competition.
Health care is almost certainly the most egregious example, but there are other industries that are founded on a price obfuscation model: airfares, insurance and some other financial services come rapidly to mind.
Totally agree. But it is a tragedy for this to be true for a government created system with the purposes of Medicare. And it is a tragedy that organizations like AARP become part of the continuation of the problem rather than improving the system. The Kaiser Family Foundation has documented the lack of shopping behavior by Medicare recipients and, not surprisingly, the older, poorer, more diverse, and sicker the individual the less they shop. For prescription drug plans this is particularly disturbing since the benefits change annually in meaningful ways. It isn’t hard to see that this system is not designed for the benefit of its stated clients – as you say, it is designed for the providers (in this case, insurers).
“The Kaiser Family Foundation has documented….”
And just think, if everyone paid their own way then all the TTTT of $$$$ horded by NGOs to obfuscate everything even more (why would they want to solve any problems when that would remove the incentive to donate and pay salaries?) could be spent on something useful rather than stupid studies about how people respond the Annual Medicare 5000p manual that everyone knows is barely intelligible to begin with?
I wonder: what if we made a law dictating that NGOs all had to go out of business and give their horded cash back to the public. How much would every individual get?
You’re an economist right Dale? Care to venture a guess how much is spent on health management administration in the US every year? I have no real idea, but it must be north of $100B.
jim
Can you please be more direct? I can’t figure out what your point is. The Kaiser Family Foundation actually does quite good work but it sounds like you are dismissing them – on the basis of what? That they are an NGO? I actually can’t see what your point is. But your last point I think I understand. I completely agree that there is a huge amount wasted on “health management administration in the US.” I prefer to call it “administrative costs.” I’ve seen some estimates, but I don’t think they are very credible. To do a proper study of those costs requires understanding the entire process of health care delivery. From my experience, every step of that process is influenced by the arcane reimbursement systems in the US – most, in my mind, dictated by our insistence that we have a “competitive insurance industry.”
Regarding the latter point, most economists, myself included, value the marketplace for its ability to innovate, satisfy consumer desires, and efficiently provide goods and services, compared to any other system we have thus far managed to see. I share those views – but don’t see them working in health care. Ultimately insurers profit by insuring less risky people – it is hard to make money off people that require a lot of expensive care. So, profitable insurers have to play a game to try to insure the people that least need health care – and complex administrative systems are a good way to accomplish that. The “innovation” I see is insurers that are happy to provide you with chiropractic care, but when something serious happens they insist on you getting the cheapest care you can get (and often of inferior quality, in my opinion). I actually left my employer’s insurance plan and signed on to Medicare in order to avoid those standard insurance practices. With Medicare, I can go to whatever provider I want – though it is embarrassing to see what they get as reimbursement. So, I know that what I am getting is not a sustainable practice for the whole population.
Dale! :)
Thanks for your reply. Apologies for being cryptic.
I don’t dispute the quality of Kaiser’s work. I dispute the necessity of it in the sense that while the current system needs outside critique, a market based system would provide that critique implicitly through the cost control exercised by the consumer. So the cost of healthcare watchdogs is redundant.
And I agree that insurers would rather not pay for anything. But I don’t agree with your argument that most people wouldn’t buy insurance against a high cost event. If it was cheap enough, even I would buy it – I hike and bicycle. What if some raging anti-bike nutcase runs me over with her car? I’d like to be able to cover that cost. What if I fall off a cliff hiking in Mexico and need a chopper back to San Diego? I’d like to be able to not go broke covering the cost. That’s the kind of thing healthy people would insure against. There is enough uncertainty beyond one’s genes to generate demand.
But beyond that, with waste and ineffectual treatments squeezed out of the system, the cost of such insurance could be quite a bit lower than we think from our perspective now.
On the logistical question of why do a separate panel of over-50s instead of doing all adults and sectioning off the over-50s – my assumption would be cost? More expensive to maintain/do data collection on a larger panel, especially if the expectation is that the content of data collection will be very targeted to this age group (i.e. no point in asking younger people about their experiences with Medicare).
Dale said, “My experience with the medical profession leads me to believe that the moral compass of most providers as better than that of most academics. We can mock the oath that medical practitioners take, but at least they have one. And I believe that most genuinely care about their patients – even the administrators of these systems (hospitals, insurers (though I do struggle with that one), pharma companies, etc.) I would say are trying to improve health. I’m not sure I would as readily believe in the integrity of most academics.”
I can only partly agree with this, based on my experiences with primary care providers. I have encountered less-than-appropriate medical care from primary care physicians several times — things like giving me a prescription for prilosec (instead of referral to a physical therapist) when I had pulled an abdominal muscle in an exercise class; trying to remove a growth in my nose by trying to freeze it off with liquid nitrogen (which damaged the membranes in my nose) rather than referring me to an ENT , and (most recently) being given a prescription for high dose vitamin D without informing me that the capsules have a dye that some people are allergic to, nor that there had not been enough over-65 patients (i.e., like me) in clinical trials of the pills to make any conclusions about the effect on them — the PCP didn’t seem to care about this — just saying that “That’s the way we always do it.”