If doctors seem greedy, it's because they come out of medical school with massive loans to repay. I know: one of my daughters and both sons-in-law are doctors, and this is a huge burden. They are living decent middle-class lives but they assuredly are not living high off the hog. Though I suppose all is relative: they do have (mortgaged) homes instead of apartments or Joy Junction; and they do have large family vehicles. Large enough to hold all the child seats and cargo a growing family has.

Originally Posted by Brian Rush

I wasn't aware of that.

I suspect that regulation won't be necessary. If everyone has policies that cover psychiatry, everyone will expect psychiatrists to accept insurance payments. Those who will not, can instead get by with none.

I will say that if the power balance between psychiatrists and their patients is so lopsided that psychiatrists can actually dictate not only how much they will be paid but whether their patients can use their medical coverage or must bankrupt themselves, then it's time to rectify that balance, one way or another.

I suggest you tread a little lighter into something you have never experienced. Psychiatry, particularly child psychiatry, could be a model for the future. The demand exceeds the supply and the reimbursements and hassle of insurance do not justify the effort of dealing with insurance. As Rani has said, a lot of psychiatry gets done by the internists who are generally comfortable with prescribing stimulants (Ritalin, Adderal, etc) and antidepressants (Prozac, Lexapro, etc). If you go beyond that into mood stabilizers such as Lithium,Lamictal, and Depakote or anti-psychotics such as Zyprexa, Seroquel, or Abilify; you need a psychiatrist. Finding the right "med cocktail" requires experience, knowledge, and intuition.

Treating mental illness has always been undervalued in the insurance world. Just getting mental health parity has been an ongoing struggle. I doubt this will change in the future. We will see if the situation in other specialties deteriorates. The ability to coerce doctors is more limited than you imagine.

James50

Originally Posted by The Grey Badger

If doctors seem greedy, it's because they come out of medical school with massive loans to repay. I know: one of my daughters and both sons-in-law are doctors, and this is a huge burden. They are living decent middle-class lives but they assuredly are not living high off the hog.

Plenty of doctors (and lawyers) around here have nice big houses.

Originally Posted by independent

America is what, like 50th in doctors per capita?

Obviously: doctors are overpaid, have too much freedom, and too much free time. We'll have to use the lawyers and insurers to take them down (another) notch before they try to complicate this reform with their own selfish interests.

'Cuz god knows its those paper pushing lawyers, insurance middle-men, and bankers that we really value here in America.

Your broadside against doctors needs to be a lot more selective. It is the procedure based physicians that are largely paid out of proportion to everyone else. The "thinking" doctors such as internists, neurologists,physiatrists, and psychiatrists are not near as good at gaming the system. 20 minutes spent with a patient in an office visit is reimbursed no where near what 20 minutes in the operating room is paid.

I would not be surprised to see the internists begin to leave the insurance system. They already have in the case of Medicare. What we would have instead is something where you go in and pay $100 out of pocket for 10 minutes with a doctor. No insurance, no copays. Clean and simple if you have the $100.

James50

Originally Posted by The Rani

Originally Posted by Marx & Lennon

Why? So far, the Medicare crowd has been happy for over 40 years, and that program is still morphing. This plan can do the same.

Oh dear. Ask any physician whether or not Medicare reimbursement is worth the bother.

I wasn't talking about MDs or even health providers in general. The power in a politically defined system rests with the voters - all of whom are patients.

There is always a potential tyranny of the majority, but it beats the hell out of a tyranny controlled by a small minority. Doctors have had the upper hand for a long time, but that time may be passing. Healthcare and pharmaceutical CEOs are likely to see their power diminish too. Top down control only works until the bottom gets good and mad. We may have crossed that line

Check back in 20 years.

Originally Posted by James50

The physicians I know, especially the internists, say it is not. They say the lose money on every Medicare patient and must limit the number to stay in business. For the procedure people (cardiologists, radiologists, orthopods, etc) , it may not be so bad, but then that is the problem. Docs are reimbursed for procedures not results.

I have no clue about psychiatry, but expect it can't be all that good.

And of course, I think one of the big money savers is to cut reimbursements even further. It doesn't do you much good to have free care if there is no one available to provide it.

James50

Let's consider the possiblity that the issue of reimbursements not matching costs is really a cost problem. Typically, health care is still provided in a manner not dramatically different from what it was 50 or 100 years ago, with small independent practices - each having its own overhead costs to cover. Physicians tend to act like master craftsmen, rushing from project to project, rather than as the most senior members of the health team. Patients, in turn, get little face time from their doctors and waste hours waiting.

Practices that use the clinic model tend to do much better. The Cleveland Clinic is probably the best example, but there are certainly many others. I participated in both models simultaneously, when I needed brachytherapy. The urologist practice was the standard model, the radiation oncologist practiced in a clinic setting. Based strictly on my own observations, clinics are definitely more efficient and likely to be the wave of the future.

Originally Posted by The Rani

Usually takes place in nursing homes. From what I've heard (from patients) they wait for months to see their doc and spend very little time with him/her. Often, primary care docs take over psych meds, for the simple reason that there are no shrinks available. That usually doesn't work so well either.

That's why I wonder if they will eventually try and regulate private practice, to "force" docs to accept these rates. If so, look for a massive and immediate decline in med school enrollments, not to mention defaults on med school loans.

Med school should be free, like it is in France. If you qualify for a slot, you're in.

For some reason, we consider it a net plus to force future docs to carry huge debt loads, forcing them to practice for $$$ rather than more humanitarian reasons. Stupid!

Originally Posted by Marx & Lennon

I wasn't talking about MDs or even health providers in general. The power in a politically defined system rests with the voters - all of whom are patients.

There is always a potential tyranny of the majority, but it beats the hell out of a tyranny controlled by a small minority. Doctors have had the upper hand for a long time, but that time may be passing. Healthcare and pharmaceutical CEOs are likely to see their power diminish too. Top down control only works until the bottom gets good and mad. We may have crossed that line

Check back in 20 years.

I agree with you. The only thing is, you don't realize life is a two way street. How many people hate their doctors? How many like them? What happens if/when the American tax payers get really mad at this government?

Originally Posted by Publius

Jerko absurdum ad infinitum.

Thus the sickos take over the asylum. , I guess. I mean, what better describes the current nutty scene in Washington D.C.?

... or we could just build more med schools.

Originally Posted by James50

I suggest you tread a little lighter into something you have never experienced. Psychiatry, particularly child psychiatry, could be a model for the future. The demand exceeds the supply and the reimbursements and hassle of insurance do not justify the effort of dealing with insurance. As Rani has said, a lot of psychiatry gets done by the internists who are generally comfortable with prescribing stimulants (Ritalin, Adderal, etc) and antidepressants (Prozac, Lexapro, etc). If you go beyond that into mood stabilizers such as Lithium,Lamictal, and Depakote or anti-psychotics such as Zyprexa, Seroquel, or Abilify; you need a psychiatrist. Finding the right "med cocktail" requires experience, knowledge, and intuition.

Treating mental illness has always been undervalued in the insurance world. Just getting mental health parity has been an ongoing struggle. I doubt this will change in the future. We will see if the situation in other specialties deteriorates. The ability to coerce doctors is more limited than you imagine.

James50

Other countries do a much better job. We could have had a similar system, but the compromisers in Congress insisted that we maintain the insurance kluge we know and love. That may change with time; I hope it does. I'm one of the least supportive proponents of the system we just created.

Originally Posted by The Rani

It's funny how many socialists seem to forget that you need doctors who are willing and able to participate in the system, and that PATIENTS are the ones demanding high quality (i.e. the best that money can buy) medical care. This has nothing to do with health care at all. It's a power grab by the have-nots against the haves.

I might buy that if there was any indication that the medical providers were in any way interested in making it possible for their patients to actually obtain care at a reasonable price. Since I can go just about anywhere else and get good - often superior care for a fraction of what we spend here, tell me: what's unique about the USA? Why is our care so pricey? Why is it less effective?

Originally Posted by K-I-A 67

I agree with you. The only thing is, you don't realize life is a two way street. How many people hate their doctors? How many like them? What happens if/when the American tax payers get really mad at this government?

What makes you assume the two are related?

Homeowners Facing Foreclosure Take Own Lives

http://www.politico.com/news/stories/0310/34934.html

Looks like the political violence just ratcheted up a notch.

Originally Posted by Brian Rush

Looks like the political violence just ratcheted up a notch.

Oh, wow... I didn't expect politicians to be targeted this drastically. Have we seen that in other 4T?

Originally Posted by Marx & Lennon

What makes you assume the two are related?

What is one without the other?

Originally Posted by Xer H

Oh, wow... I didn't expect politicians to be targeted this drastically. Have we seen that in other 4T?

Lincoln was assassinated.

Originally Posted by Xer H

Originally Posted by Brian Rush

Looks like the political violence just ratcheted up a notch.

Oh, wow... I didn't expect politicians to be targeted this drastically. Have we seen that in other 4T?

Perriello is my Congressman, and he lives in the only liberal enclave in the entire district - Charlottesville. If te Universtiy of Virginia wasn't there, that wouldn't be liberal either.

The entire balance of this district is red-meat conservative. That something happened here is not surprising to me.

Originally Posted by Brian Rush

Lincoln was assassinated.

REALLY??? Gee, didn't know that.

Seriously, someone here has to know whether colonials actually killed British governors/representatives.

Can't think of any such activities in the Civil War (Lincoln was assassinated after much of it was over) or the Great Depression/WWII.

Anyone?

Originally Posted by The Rani

Ask them how many years of school they went to, and how many hours per week they work now.

IMO the problem is that tuition of medical school is so expensive that doctors NEED that high pay, to pay off all the loans. In other countries doctors' salaries are significantly lower precisely because of this.

Originally Posted by Brian Rush

http://www.politico.com/news/stories/0310/34934.html

Looks like the political violence just ratcheted up a notch.

And here we go...

Originally Posted by The Rani

Originally Posted by Marx & Lennon

I might buy that if there was any indication that the medical providers were in any way interested in making it possible for their patients to actually obtain care at a reasonable price. Since I can go just about anywhere else and get good - often superior care for a fraction of what we spend here, tell me: what's unique about the USA? Why is our care so pricey? Why is it less effective?

Everything costs more in the U.S., AND people have no incentive NOT to get more medical care (whether or not it's worth it) when someone else is paying for it.

Baloney! The highest per capita use of health care in the world is in Japan, which also has great longevity, a high percentage of seniors, and a population that smokes like chimneys. Yet for all of that, they spend roughly half per capita what we do. Even the Swiss, with a fully private system and universal coverage, spend far less. Here's the entire list.

We have a very poor system from several perspectives, and tremendous resistance to making it better. The medical community leads the pack for intransigence. They're still fighting.

Originally Posted by The Rani

Everything costs more in the U.S., AND people have no incentive NOT to get more medical care (whether or not it's worth it) when someone else is paying for it.

Except that the vast majority of people usually don't obsess about all the "free" medical care they might be getting at any particular moment.

I think the Lincoln assassination does have to be considered 4T domestic violence. I don't agree at all with the authors' 1865 date for the end of the Crisis era that time around; too much radical change followed on that and too much continued conflict, furor, and violence. The second part of that Crisis only looks peaceful by contrast with the first part, which was of course incredibly violent. I would actually extend the 4T all the way to 1877, when federal troops were withdrawn from their occupation of the south. In that case, Lincoln's assassination took place five years into a 17-year Turning, which is later than we are now but not much later.

FDR was also targeted with at least one assassination attempt in 1933, but he wasn't actually injured. Also, that wasn't political violence, it was just a loony.

In the American Revolution, besides the Revolutionary War itself the violence took the form of local militias (we'd call them terrorist units today) on both sides of the issue making raids on settlements, killing people, or sometimes tarring and feathering people. I found a reference to a Lieutenant Governor of Massachusetts whose home was sacked and burned by a Sons of Liberty group, but that was actually before the Crisis started, in the late Unraveling. Other than that, I don't know about assaults on government officials per se, but there was plenty of civil violence between loyalists and patriots, outside of the big battles between the Continental Army and the British regulars and Hessian mercenaries.

The last Crisis was remarkably peaceful in terms of domestic political violence, compared to its predecessors, and possibly to this one as well if these early signs predict anything. If not for World War II it would have been an almost wholly peaceful 4T, although that's a pretty big "if not."

Originally Posted by Brian Rush

In the American Revolution, besides the Revolutionary War itself the violence took the form of local militias (we'd call them terrorist units today) on both sides of the issue making raids on settlements, killing people, or sometimes tarring and feathering people. I found a reference to a Lieutenant Governor of Massachusetts whose home was sacked and burned by a Sons of Liberty group, but that was actually before the Crisis started, in the late Unraveling. Other than that, I don't know about assaults on government officials per se, but there was plenty of civil violence between loyalists and patriots, outside of the big battles between the Continental Army and the British regulars and Hessian mercenaries.

That's what I thought... I ask because most of the far-right insurgency groups I've been watching model themselves as "Patriots" following the Revolutionary example. I've seen pamphlets out there on everything from counter-insurgencies to guerrilla tactics. There's discussion of organizing militias. It's almost as if they're strategically planning this, using the Internet to mobilize across groups. So far, though, there hasn't been enough to set them off, except in high-tension areas (as M&L observed).

I still think, if it comes down to an offensive attack, most of these people would back out of their little groups. Only the most radical would take it to a level of domestic terrorism.

I hope.