It's so bad you have to pay people to move to Vermont

[BenedictGomez]

I think the average person has absolutely no idea how much time, money, and effort goes into creating a single new drug. People are quick to say "well it only costs $1 to manufacture drug xyz so why do they charge $100 for it". Meanwhile they completely ignore the cost of the R&D and clinical trials and paperwork to get it discovered and approved in the first place. Who pays for that if we demand lower drug costs? Do we then rely on government grants to fund research? In which case we're now back to everyone paying for the R&D anyway (albeit indirectly so the cost is just part of that big black hole where taxes go).

Oh, lord, THIS.

People are completely clueless about how much it costs to bring a new medication to market. And clueless is the polite word. You also have the real morons of society out there who think cancer would be cured, but if pharma cured cancer then it couldn't profit from it. Those people are so stupid they shouldn't be allowed to slice a bagel unsupervised.

That said, I do think pharma as an industry should have a marketing campaign to educate the masses, and shame on pharma for not doing so. Given most people have "absolutely no idea" what it costs to bring a new therapy to market as you say, it makes it simple for lying politicians to demonize the entire pharma industry as "greedy", or to try to take one evil pharma example (opioid misuse, etc..) and make it seem like every company is doing this to tar-and-feather all pharma & biotech companies.

BG.....apologies for deleting your post

I still see it.

 

[Orca]

"But the lack of primary care providers in Vermont is a looming crisis. In rural Vermont, some practices have been unsuccessfully recruiting new physicians for more than six years. Recent workforce data shows that there is a need for 69 new primary care providers in Vermont right now. With 36% of Vermont’s primary care doctors over age 60, this need will only escalate."

-- Fay Homan, VTDigger, 8 January 2020 (today)

 

[Orca]

"The tax commissioner is forecasting a 6% hike in education taxes next year. Nearly 40% of the projected rise in school spending is tied to healthcare."

-- VTDigger, 10 December 2019

 

[deadheadskier]

Let's talk about capitalism a minute because I don't think our healthcare system is particularly capitalistic. As the guy with the flowery language about hitting trees mentioned, the consumer has no idea how much their healthcare will cost before they get it. Therefore, they have no way to determine which provider offers the best value. Clinics seem to be helping to break this mold, but we're far from a price transparent system. Without price transparency, it's very difficult to argue you're dealing with a functioning capitalist industry. Fixing prices is rarely the answer; enabling competition is a much more efficient solution.

Before we go assuming that more government is the answer, I wanted to highlight that medicine and education costs are rising the fastest of just about any industry I can think of (I could genuinely be missing one though). Government has its hands all over these - medicine is well documented here, and the advent of government baked student debt has fueled skyrocketing education costs. My generation was sold a load of nonsense when we were told it didn't matter what we majored because our education was priceless. Just sign on the dotted line. I notice you cited that government subsidises these smaller offices that run perpetual losses. I have a feeling they've given hospitals perverse inventives to over spend, but that's just a hunch from reading the tea leaves of what you wrote.

Pharma is a huge issue, too. 100% agree. We subsidize the rest of the world's pharma costs. I don't know how it can get fixed the way our patent laws are set up. I'm no lawyer. Still, I don't see why nationalizing medicine is necessary to achieve pharma remuneration changes.

Regarding people who point to foreigners coming to America for care. Actions speak louder than words. It's the same concept I brought up about Vail not being bought in on catastrophic climate change. There's a reason why people come to the US for treatment: universality ultimately leads to rationing. It's plenty noble to want care for everyone, but it's not wise to dismiss this simple fact as the misguided utterances of toothless fact-hating conservatives.

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Yep, the healthcare unicorn is out there. Damn trying to even replicate proven, better performance standards achieved elsewhere around the world. Waste of time. Go for the unproven ideology or bust!

All them capitalist docs are going to run to the ski hills, set up shop and offer two for one transparently priced colonoscopies. May the doc who drives the scope for the cheapest price win!

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[thetrailboss]

"But the lack of primary care providers in Vermont is a looming crisis. In rural Vermont, some practices have been unsuccessfully recruiting new physicians for more than six years. Recent workforce data shows that there is a need for 69 new primary care providers in Vermont right now. With 36% of Vermont’s primary care doctors over age 60, this need will only escalate."

-- Fay Homan, VTDigger, 8 January 2020 (today)

True story. I attended the UVM College of medicine graduation in 2011. The keynote speaker raved about how awesome Vermont was in trying to put together a single-payer system. You could hear an audible grown from the medical graduates. Nearly all of them were packed up and leaving the state because of this. With a good size amount of student debt no one could afford to work in Vermont. Did folks want to stay? You bet.

And that single payer healthcare plan? Well Shumlin scrapped that literally days after he got the supporters to vote for him for his last term. Even he realized the cost was simply too ridiculously high and not sustainable. But hell, he played to the supporters to get their votes and then ditched them.


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[Orca]

Yep, the healthcare unicorn is out there. Damn trying to even replicate proven, better performance standards achieved elsewhere around the world. Waste of time. Go for the unproven ideology or bust!

All them capitalist docs are going to run to the ski hills, set up shop and offer two for one transparently priced colonoscopies. May the doc who drives the scope for the cheapest price win!

Healthcare is complex and any healthcare system is extremely complex. Does any system on Earth really have it figured out?

 

[deadheadskier]

"But the lack of primary care providers in Vermont is a looming crisis. In rural Vermont, some practices have been unsuccessfully recruiting new physicians for more than six years. Recent workforce data shows that there is a need for 69 new primary care providers in Vermont right now. With 36% of Vermont’s primary care doctors over age 60, this need will only escalate."

-- Fay Homan, VTDigger, 8 January 2020 (today)

It's a HUGE investment and debt load to go to med school + enrollment is limited due to lack of residency programs. So kids are bowing out of that track.

I'd argue we need to realign our medical training focus though and suggest the bigger problem with care accessibility and affordability is due to a lack of NPs and PAs more so than docs. We've got 1.1M physicians in the US. About 400k NPs and PAs, yet those professionals can do 90% of what a Physician can do.

We should be working to more than flip those numbers. Drop down to 400K docs and increase the number of PAs and NPs to 2 million workers? Quality of care would go up, costs would go down.





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[deadheadskier]

Healthcare is complex and any healthcare system is extremely complex. Does any system on Earth really have it figured out?

Cost/Outcome (meaning length of natural life)

would be the best formula right?







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[EPB]

Yep, the healthcare unicorn is out there. Damn trying to even replicate proven, better performance standards achieved elsewhere around the world. Waste of time. Go for the unproven ideology or bust!

All them capitalist docs are going to run to the ski hills, set up shop and offer two for one transparently priced colonoscopies. May the doc who drives the scope for the cheapest price win!

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We actually have evidence of capitalism driving costs down in areas like Lasik surgery. Freestanding ORs have also become cheaper ways to take your kids in for a broken arm down here in the NJ suburbs. So, if you're paying attention, this is about much more than class warfare sloganeering. Taking your kid to see a professional for half the cost of the hospital is a wonderful thing for everyone.

I'm decidedly not saying our system is prefect - even satisfactory. It's certainly missing key elements of capitalism, so I really don't think it's correct to call it capitalistic without heavy caveats.

If you think socialized anything is the best option, I'd suggest examining the issue again. Even the smartest and best intentioned planning boards are not capable of figuring out what individuals want better than the individuals do when left to their own devices. That's a major reason why freer societies are more prosperous. Individual decision-making is like the using big data (billions of transactions) to planning boards' broad brush model.

You're clearly more involved in medicine than I am. Can you even address my basic question of why pharma reform and socializing medicine are necessarily related? If you take over healthcare and don't change patent law, aren't we in the exact same place regarding pharma prices? Conversely, if we reform patent law on it's own, we'd see the benefits of lower drug pieces unless I'm missing something.

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[deadheadskier]

We actually have evidence of capitalism driving costs down in areas like Lasik surgery. Freestanding ORs have also become cheaper ways to take your kids in for a broken arm down here in the NJ suburbs. So, if you're paying attention, this is about much more than class warfare sloganeering. Taking your kid to see a professional for half the cost of the hospital is a wonderful thing for everyone.

I'm decidedly not saying our system is prefect - even satisfactory. It's certainly missing key elements of capitalism, so I really don't think it's correct to call it capitalistic without heavy caveats.

If you think socialized anything is the best option, I'd suggest examining the issue again. Even the smartest and best intentioned planning boards are not capable of figuring out what individuals want better than the individuals do when left to their own devices. That's a major reason why freer societies are more prosperous. Individual decision-making is like the using big data (billions of transactions) to planning boards' broad brush model.

You're clearly more involved in medicine than I am. Can you even address my basic question of why pharma reform and socializing medicine are necessarily related? If you take over healthcare and don't change patent law, aren't we in the exact same place regarding pharma prices? Conversely, if we reform patent law on it's own, we'd see the benefits of lower drug pieces unless I'm missing something.

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I can't speak to drugs / patent laws as it's not my wheelhouse. I'd have to think about it.

As for surgery centers? Sure, great lower cost option and a good business to be in....in high population density areas. Timely that you brought it up in a thread about VT. Know how many Ambulatory Surgery Centers exist in VT? 1! I helped open it last year. I don't anticipate seeing a major influx of them up there though. They simply lack the population density for it to make business sense for most docs to open a practice.

The other factor there is in rural areas, surgical services are literally the only reason hospitals can keep their doors open. They lose money in every other department. Do you think communities are going to want to give up a close ED and Extended Care option when Gramma gets the flu just so little Jimmy can get a cheaper fix for a broken arm?

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[Hawk]

Oh, lord, THIS.

People are completely clueless about how much it costs to bring a new medication to market. And clueless is the polite word. You also have the real morons of society out there who think cancer would be cured, but if pharma cured cancer then it couldn't profit from it. Those people are so stupid they shouldn't be allowed to slice a bagel unsupervised.

That said, I do think pharma as an industry should have a marketing campaign to educate the masses, and shame on pharma for not doing so. Given most people have "absolutely no idea" what it costs to bring a new therapy to market as you say, it makes it simple for lying politicians to demonize the entire pharma industry as "greedy", or to try to take one evil pharma example (opioid misuse, etc..) and make it seem like every company is doing this to tar-and-feather all pharma & biotech companies.



I still see it.

BG, Pharma certainly needs to recoup the monies spent for research and the approval process of new drugs. They also need to recoup moneys spent for drugs that do not get approved. The FDA is a total bitch I understand. But did you ever look at the earnings of these companies? Unless they totally F-up like Purdue Pharma they all do very well. Some of the most successful companies in america. They are inflation proof, recession proof and a very good investment in general. I guess what I am saying is how much is enough for those guys. Drugs are far less expensive in other country's so what is the difference here?

 

[mister moose]

I think the average person has absolutely no idea how much time, money, and effort goes into creating a single new drug. People are quick to say "well it only costs $1 to manufacture drug xyz so why do they charge $100 for it". Meanwhile they completely ignore the cost of the R&D and clinical trials and paperwork to get it discovered and approved in the first place. Who pays for that if we demand lower drug costs? Do we then rely on government grants to fund research? In which case we're now back to everyone paying for the R&D anyway (albeit indirectly so the cost is just part of that big black hole where taxes go).

Oh, lord, THIS.

People are completely clueless about how much it costs to bring a new medication to market.

Yes, but you left out risk. The cost of trying a new drug and it doesn't work as expected, the side effects are too risky, or it's just plain ineffective. The cost of lawsuits. The cost of attracting investment capital.

That said, it is an extremely complex web of worldwide markets and different regulatory rules that drug companies sell to. I have trouble holding out Canada's lower drug costs and thinking the very source, the producer nation's rules of those drugs cost/pricing system can be modeled on one or a few consumer nations. It's more complicated than that.

One of the many ways we vote is with our wallet. Socialized medicine takes that vote away, and places it in the hands of a committee. A committee can't possibly make the best decisions for all the unanticipated individual concerns and situations. Ideally that committee is benevolent, but we see all the time how government is affected by graft.

Individual choice is not perfect, but it is a better form of imperfection.

 

[machski]

Legacy costs - thats the killer Howie. Whats changed dramatically is the size and cost of government.

in the 60's and even the 70's if you had a government job it didn't pay well, but you were relatively secure. Still secure, more so now because nothing gets you fired. But now, you get paid well, and you get 70-80% of your last three years pay for life ( which is a lot longer than 30 years ago - despite our terrible healthcare) and paid healthcare for that time period as well. Of course these are generalizations, but if you're not buying in, the three or four wealthiest counties are no longer in metro NY - they are in and around DC. Thats where the $$ is.

I have a number of family and friends in various government positions, some are teachers, some are admin and some in IT.

Its a great gig. And those private companies that offered too-good-to-be-true retirement packages failed or their pensions went bust ( think Polaroid or GM) - not state or federal government - they have the power to tax.


I am not saying if I was a teacher at $75K a year that I wouldn't coach a couple teams, get on this project or that one in my last couple years to increase my income - I would. Who wouldn't? Its just that its a long term unaffordable legacy cost.


I wouldn't move to Texas either. Like our 4 seasons. Like our oceans and mountains and lakes. Like everything about it. And we pay more for it, thats all.

Wanted to retire in Portsmouth NH - can't afford it. Wifes likes beaches and I can get to hills in 2 hours or less. I keep telling her a double-wide allows us to travel anywhere anytime, and we can keep the heat as high as she wants in winter. . .she ain't buying it. It would be in NH though.

And that seems to be slipping into higher costs eventually too.

I have to tell you NH has a much different take on State pensions. Now public safety workers (firefighters/police) and teacher pensions are a bit different from each other in NH. I know the teacher side as that is what my wife does. NH pays pensions based on your last 5 years of BASE SALARY only. Any stipend pay for coaching, etc DOES NOT count towards pension. Accordingly, NH teacher pensions are some of the lowest in the country. Oh yeah, and bother teachers and safety workers have mandatory contributions they have to pay into the system as they work!

The flip side to this is, all pension systems are rated on a scale of how likely they are to meet their obligations to retirees. Guess what, NH's system rates tops in the Nation. Give and takes to everything. And don't try to tell me a government can just tax its way out. There have been some big cities that have gone bankrupt in this country due to pensions among other financial failures.

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[EPB]

I can't speak to drugs / patent laws as it's not my wheelhouse. I'd have to think about it.

As for surgery centers? Sure, great lower cost option and a good business to be in....in high population density areas. Timely that you brought it up in a thread about VT. Know how many Ambulatory Surgery Centers exist in VT? 1! I helped open it last year. I don't anticipate seeing a major influx of them up there though. They simply lack the population density for it to make business sense for most docs to open a practice.

The other factor there is in rural areas, surgical services are literally the only reason hospitals can keep their doors open. They lose money in every other department. Do you think communities are going to want to give up a close ED and Extended Care option when Gramma gets the flu just so little Jimmy can get a cheaper fix for a broken arm?

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I'm totally with you that rural areas create structural challenges to getting the cost of care down (vis-a-vis more dessert densely populated European countries). I highly doubt letting places close is a socially-viable solution, but would probably make sense from a dollars and cents perspective.

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[cdskier]

BG, Pharma certainly needs to recoup the monies spent for research and the approval process of new drugs. They also need to recoup moneys spent for drugs that do not get approved. The FDA is a total bitch I understand. But did you ever look at the earnings of these companies? Unless they totally F-up like Purdue Pharma they all do very well. Some of the most successful companies in america. They are inflation proof, recession proof and a very good investment in general. I guess what I am saying is how much is enough for those guys. Drugs are far less expensive in other country's so what is the difference here?

Only 5 of the top 100 most profitable companies in the world last year were Pharma companies (and the first wasn't until J&J at #25). Why is it ok for some companies to make profits but if a Pharma company does it, it is considered "greedy" and "evil"? Shouldn't their innovation and work be rewarded? Apple is the 2nd most profitable company in the world (with profits nearly 4x that of the highest ranking Pharma company). Yet I don't see anyone forcing or demanding that Apple lower their prices.

Don't get me wrong, there are certainly situations where I think some Pharmas get greedy and overprice things (raising prices on a drug that has been in the market for a while would be one example of a practice that I don't agree with). But overall I think Pharma companies get an undeserved bad reputation.

 

[EPB]

I have to tell you NH has a much different take on State pensions. Now public safety workers (firefighters/police) and teacher pensions are a bit different from each other in NH. I know the teacher side as that is what my wife does. NH pays pensions based on your last 5 years of BASE SALARY only. Any stipend pay for coaching, etc DOES NOT count towards pension. Accordingly, NH teacher pensions are some of the lowest in the country. Oh yeah, and bother teachers and safety workers have mandatory contributions they have to pay into the system as they work!

The flip side to this is, all pension systems are rated on a scale of how likely they are to meet their obligations to retirees. Guess what, NH's system rates tops in the Nation. Give and takes to everything. And don't try to tell me a government can just tax its way out. There have been some big cities that have gone bankrupt in this country due to pensions among other financial failures.

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We should really do away with public pensions for incoming employees. Just pay workers the approximate amount it costs to pay into the pension system today and stop guaranteeing retirement payment levels. It's an outrageous ask for public employees to just trust their retirements will be there for them as promised up to 50 years down the road. Who here would want to lend money to their state or local government for that long? The pensioners you mention lend their entire retirements to their state and or local governments.

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[deadheadskier]

I'm totally with you that rural areas create structural challenges to getting the cost of care down (vis-a-vis more dessert densely populated European countries). I highly doubt letting places close is a socially-viable solution, but would probably make sense from a dollars and cents perspective.

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Yes and no. In the spirit of this thread, I'm going to assume VT is getting very few takers on the 10k stipend to move there. Remove access to healthcare and that sell becomes even more challenging.

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[EPB]

Yes and no. In the spirit of this thread, I'm going to assume VT is getting very few takers on the 10k stipend to move there. Remove access to healthcare and that sell becomes even more challenging.

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Agreed

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[drjeff]

The reality is that modern medicine is being pushed into more of a data driven model than an actual individual model.

There are pro's and cons.

If your own personal data "fits" the essential algorithm that "big data medicine" has determined is the "best" way to manage things, then great, the system will work for you. If the data that the provider enters into the tablet for your medical record doesn't fully align with an exact diagnosis code, the code that determines your treatment course more often than not in today's medicine, then it becomes the role of the patient and the provider to try and work with the medical "system" to explain why a course of treatment that doesn't follow the one generated based on the diagnosis code is proper in your instance. That can, and is, a very frustrating things for all parties involved.

The more and more the push for "single payer" progresses, the less and less the actual diagnostic skills and treatment management skills that the medical provider spent years acquiring, mater anymore, and the autonomy that the provider has, which is often one of the appealing things that gets folks into the medical profession, decreases, and instead of being a clinician, the medical provider becomes more and more like a data entry person. If that's a good or a bad thing, I suppose has plenty to do with one's view and actual understanding of the medical system, something which not very many people actually have a grasp of what that entails, but have often been told by the media "costs too much" and/or "isn't as 'good' as such and such a different countries system" etc...

This thread may very well end up going on for 100's of pages, with lots of really good points

 

[Orca]

"Vermont is projected to exceed targets for health care spending in 2020, indicating the state’s reform efforts may not be working as planned.
...
According to Lindberg, much of the projected 2020 increase for care across the health system comes from Medicare, publicly funded insurance for disabled patients and people over age 65. That portion of the population, which is often the sickest and requires costly end of life care, is the most expensive."

-- VTDigger, 13 December 2019

This is problematic with the aging demographics of the state, and younger workers choosing elsewhere.