<p>LasMa – I hope you can have a good conversation with the PC doctor. My mom had some similar issues, and the guy I came to call Boy Surgeon recommended a very aggressive amputation that would have killed whatever quality of life she had (which wasn’t much anyway) and left her in a lot of pain. Very glad that mom’s internist talked with my dad and helped him understand that it would not have been a kindness to do that surgery even though Boy Surgeon thought it was technically feasible. </p>
<p>(I’ve put Boy Surgeon on my list of doctors never to use if I have a choice. There’s a big difference between knowing you CAN do something and understanding whether you SHOULD do something, and he was way too much about the CAN.)</p>
<p>Having personal examples helps a whole lot for people to understand the issues. I think it is hard for many of us to openly state our personal problems.</p>
<p>“For the age group a lot of us are in, 45-65 years, the average was about $5500, and for the age group of our parents, 65+, the average was almost $10,000.”</p>
<p>How does medicare work with lifetime caps? Have they had them or it is openended limit?</p>
<p>Medicare does not have lifetime caps and has never had them.</p>
<p>And I agree that personal examples help us all understand the current state of the US health care system, and how the ACA is supposed to change it.</p>
<p>Medicare has bizarre limits. You’re limited on hospital days…but then you get some back under certain conditions. They’ve imposed (in the past) caps on PT/OT, but sometimes just in certain settings. I think that got lifted. (The caps were awful-- and stupid – if you had, say, a knee replacement in January necessitating PT, and a stroke in August.) </p>
<p>I never saw limits on doctor visits on a lifetime basis. (They have some weird daily limits, however – like only one doctor can bill for a given diagnosis code for a patient in a day, which proves challenging when a patient is in intensive care.)</p>
<p>Let me rephrase that: Medicare does not have lifetime cost limits. </p>
<p>As arabrab says, they have other limits. And Medicare lately has been way better at negotiating costs down than private insurers. Medicare can’t negotiate drug prices, but they are good at squeezing hospitals and doctors.</p>
<p>One ACA program that I like a lot is fining hospitals that have a lot of readmissions for heart attacks, heart failure and pneumonia. Hospitals hate it, but we want to encourage hospitals to make sure patients don’t have expensive and painful complications after hospital stays. The program encourages hospitals to follow up on the care of their discharged patients, so they don’t get so sick they need to be readmitted. </p>
<p>Sending a nurse out to visit recently discharged hospital patients and make sure they are taking their meds and following their doctors’ instructions is way cheaper than sticking those patients back in the hospital for another ten days.</p>
<p>Another ACA pilot program explores paying hospitals by diagnosis rather than by service. If a hospital knows that doing the extra unnecessary MRI on that heart patient, or treating the hospital-acquired infection for the patient with the hip replacement, won’t make them any more money, it’s amazing how much that will concentrate their attention on working together to not do those things.</p>
<p>I wonder if anyone has looked at the degree to which Medicare’s lack of lifetime or annual cost caps, coupled with the existence of such caps in the private market, causes people to postpone expensive surgeries or other treatments or procedures until they get on Medicare, artificially driving up health care costs for the 65+ demographic while also inflating Medicare’s cost to the taxpayer. So, for example, if you’re in your early 60s and severely arthritic and your doctor says you need both hips and both knees replaced, but you know you’re already near your lifetime cap on your private insurance, wouldn’t you just delay the surgeries until you’re 65 and on Medicare?</p>
<p>If that’s the case, then ending lifetime caps in the private insurance market, as the ACA seeks to do, should produce some savings for Medicare.</p>
<p>Actually, I think it imposes costs in other ways. If it weren’t for Medicare’s limitations, people wouldn’t be buying Medicare supplement policies (huge $$$) and tremendous paperwork burdens on patients and doctors. </p>
<p>I do think that there are poorly insured people in their 60’s who wait until 65 to have surgical procedures because Medicare has very low out-of-pocket costs for most elective procedures.</p>
<p>I suspect if you looked at people who had hip replacements or similar procedures just after they turned 65, you’d discover that the effect of people suddenly getting any kind of insurance at all and being able to have the procedure was greater than the effect of people who had insurance, but a lifetime cap.</p>
<p>That is, suppose we have a bump in hip replacements at ages 65 and 66. Are the patients people who had bad insurance at age 64, or people who had no insurance at age 64? I suspect mostly the latter. This is just a guess, though.</p>
<p>By getting more people in the 60-65 age group on health insurance without lifetime or annual caps, the ACA should lower Medicare’s costs regardless of whether those postponing elective surgery until they get on Medicare are presently without any insurance, or with bad insurance. Still could be some of that effect if their private insurance has high deductibles or large co-pays, however.</p>
<p>To the extent that we lower Medicare costs by shifting some of the cost to subsidized insurance, we don’t save as much. Doesn’t mean we shouldn’t do it, though: people should get the medical care they need and not have to wait until they turn 65, even if that means they survive until they get to 65 and keep costing us money, instead of decreasing the surplus population at a lower age because their health needs weren’t met.</p>
<p>But it saves Medicare money. I know that’s only an accounting question, but it’s the kind of accounting question that can have policy implications. Medicare is set up to be a stand-alone program, paid for entirely out of dedicated payroll taxes. Big policy decisions will be made on the basis of projections about when Medicare will “run out of money.” To the extent we have created unintended incentives for people to defer needed medical care so it can be billed to Medicate once they reach 65, I think it’s a good thing to end or diminish those incentives, not only because more people may then get the care they need when they need it, but also because it will keep Medicare from picking up costs that it shouldn’t be picking up if people get timely care. And depending on the procedure or treatment that is deferred, it may sometimes become more costly or complicated to treat it after it’s festered untreated for a lengthy period–with Medicare getting socked with that bill.</p>
<p>It has simple videos that explain the basics. I haven’t delved deeper into it yet, but I think the “Obamacare in Under 3 Minutes” video should be a PSA.</p>
<p>Here’s another interesting slice of the pie. Foreign trained doctors have a very difficult time gaining the ability to practice here. Typically, they have to duplicate much of their training, particularly a residency, which have been frozen in number for decades. Canada is the only other country whose residencies are recognized here. Balanced against this is the brain drain issue. In India, one in ten MDs seeks to practice elsewhere. That aside, many foreign MDs are working as cab drivers, etc. I wonder if some of our primary care crunch could be alleviated if some of them could be allowed to practice at least as nurse practitioners. </p>
<p>Since foreign trained doctors need to duplicate their training here, do you think it means that the ones who are in practice here are more well trained? From a patient’s perspective, does it make them “better” doctors?</p>
<p>Well, I used to have a rule, which could by your reasoning apply to foreign doctors, that it’s preferable to choose a female professional because, as the saying goes, she had to work twice as hard to get half as far.</p>
<p>The residency requirements in most countries are not as stringent as in US. In India they do something called house surgency which lasts 1 year.</p>
<p>The education requirements in US to produce a doctor are onerous (4+4+ at least 3). There are practicing doctors in in India at age 22-23 which is almost impossible in US.</p>
<p>We are currently accumulating foreign trained American Citizens who spend two or three years just trying to make it to residency which means they are also spending 6-7 years before they become doctors.</p>
<p>When ACA was first announced, Business Week put out a story stating that the first order of business should be to increase funding for residencies. This funding mostly comes out of medicare and it has been fixed for a long time which means the number of qualified doctor output has not increased in over 15 or 20 years. So the pipeline putting out the doctors has been limited by the number of allowed residencies more than the fact that we are not allowing qualified foreign trained doctors to become doctors here.</p>