Senate Going Postal: The 2020 U.S. Presidential Election

In fairness, I don't think that's the take -- just yet another reason that Twitter is terrible, especially for policy discussion.

My guess is that he believes that fossil fuel executives who knowingly break the law (or regulations) should be put into jail, rather than excessively fining (or not) the corporation. Very similar to the take on banking executives, which -- during the Subprime Mortgage Crisis and subsequent recession were more commonly called for jail when they really weren't in most cases breaking the law -- for people like the Wells Fargo execs, or the LIBOR fixers 100% broke the law and did not go to jail.

 

They are few and far between. They simply tend to get a lot of press, like the idiot that killed Michael Jackson.

If you'd like to discuss quacks, I've encountered several 'naturopathic physicians' that are doing real harm. Treating metastatic breast cancer with herbal teas and chelation therapy certainly qualifies.

 

I thought he was referring to the falsification of the experimental results by research activities sponsored by the oil companies in order to portray climate change as less alarming than what it actually is. If this is the case, there might be some real illegal activity, in fact.

 

This discussion is getting a little busy and I don't quite have as much time to comment in-depth as I would like either. I'd be very interested to see the complete version of Vaderize's thoughts when he has a chance to post them.

I do think Even's take on concierge medicine is closer to the truth than dp4m's. There's no real evidence that the "best" doctors would or do go into concierge medicine. It's not even clear what "best" is. Do you mean the ability to perform the most complex or difficult procedures? If so, someone like Ben Carson might arguably qualify in his field. Or do you mean the ability to perform common procedures as quickly and safely as possible? That's probably someone different. Or do you mean the physician with the most diagnostic insight? The one whom can best encourage patient compliance and work together with them to successfully execute a plan of care? The person who is best at intuiting new treatments and research to advance the possibilities of healthcare? It's kind of an artificial question.

I've not seen any evidence to suggest that top graduates funnel that way, nor that those who make the "Top Doctors in Field X" rankings are predominantly concierge physicians. All you're really paying for is speed/access and a certain customer service experience. As physicians they may be entirely mediocre. I think there's some fair argument that the structure exposes them to greater pressure to comply with patient wishes, but I'd like to think this isn't the prevailing dynamic. Even if it is, I don't think that counts as benefit. If you want to be seen because you had a nasty viral cold, having a concierge physician won't change the fact that antibiotics are not advised. And even if you could convince your concierge physician to give you antibiotics, that still doesn't affect the course of your illness. Likewise, while a concierge physician might take you to surgery faster and bypass the common requirement to try some non-surgical treatment option, it's also the case that maybe one of those options would have worked, and that in the long run your health would have been better served by not having surgery at all.

Seeing concierge physicians is a "fetishization" of rich people and requires some false assumptions about how healthcare works at all.

 

This is a loaded topic, and will be difficult to summarize in one post. Nevertheless, I will try.

In order to avoid getting off on too many tangents, I’d like to focus on two things:

1) What constitutes a “good” doctor from say, an outstanding one or a poor one.

2) What drives physicians to a cash-only model, be it concierge or direct primary care (they are not the same thing).

#1–objectively speaking, a good doctor is one who displays the following qualities: diagnostic accuracy and precision at a consistently high level, superior technical skills (if applicable to one’s chosen field), a high degree of empathy, the ability to partner with patients and get them engaged in working together towards optimum health, and acts as a leader in the healthcare community through engagement and ‘giving back’. To other physicians, an ‘excellent’ doctor displays the same qualities but has also accomplished something groundbreaking such as inventing a new surgical technique or cancer-treatment protocol, or has attained a position of national prominence while simultaneously providing high-quality care to their patients.

In many ways, it’s a subjective measurement. One can look at patient outcomes, but it’s very difficult to gauge metrics such as patient compliance where relying on self-reported data (and a lot of outcomes research does; ie food journals for comparing different diets for weight loss in morbidly obese diabetics vs Bariatric surgery).

As an employed physician, I’m judged on three things: patient satisfaction, ie “Did I make them happy?”, preventing readmissions within a 30-day timeframe (specifically for pneumonia, congestive heart failure and stroke), and how quickly I can discharge patients to aid in emergency department throughput. Beyond that, my attendance at meetings and participation in committees (ie ‘citizenship’) is also objectively measured. Unofficially, how willing doctors in my group are to cover when we’re short-staffed is quietly kept track of as well.

Patient satisfaction is gauged by HCAPS scores, subjective questionnaires mailed to each patient after discharge with a series of standardized questions. Sadly, scores do not correlate with following evidence-based guidelines on treatment of common hospital-level ailments. In fact, I’ve received multiple negative reviews for refusing to inappropriately prescribe antibiotics or discharge patients on narcotics when they clearly haven’t needed it. All negative reviews are screened by the hospital’s “quality officer”, a non-clinical nurse who then ‘determines’ whether or not the complaint was warranted.

With that in mind, does my refusal to provide unnecessary care based on the evidence make me a ‘bad doctor’? We can argue about unnecessary surgery, but what about an unnecessary CT scan, and the radiation exposure it carries? What about the patient admitted with chest pain who files a compliant because I refused to order the MRI of her knee she was scheduled to have as an outpatient the following week, and she’d rather just ‘get it over with now’? According to how Medicare reimburses hospitals, satisfaction is paramount, yet so are outcomes. If I do what’s right, I risk alienating my patients. If I do what’s easy, I am at best wasting resources, at worse causing harm. Medicare penalizes the hospital for either, double for both. Add to that endless fights with insurance companies over denials, unrealistic expectations for treatment fueled by the internet, the portrayal of physicians as uncaring and greedy by the media, and it’s no wonder doctors are burning out in record numbers. We also have twice the suicide rate of the US population as a whole. Which leads me to....

#2 Why do physicians choose a cash-only model? In a nutshell, to escape the system. A concierge practice involves signing up a limited number of patients for a yearly subscription fee (usually 600 patients at $1500 each). Now, before you criticize this model, some data points to consider:

A) Medicare mandates that an initial office visit be given 30 minutes, with each follow-up thereafter capped at 12 minutes, no matter the reason for the visit. If you are an employed physician seeing outpatients, you are usually mandated to see at least 25 patients a day to make the organization’s payroll. Doctors are often double-or-triple booked, and may have upwards of 30 encounters per day. They often also have to spend an extra 2-3 hours a night completing their notes, leading to a 16-18 hour day most of the week.

B) Concierge physicians (as well as direct primary care) usually schedule a maximum of 10 patients a day for one hour each. Patients also are given the physician’s personal cell phone number and have 24/7 access to their doctor. By not accepting insurance, cash-only doctors are not bound by spending countless hours clicking boxes on their electronic health records or fighting denials of care by Aetna or IBX (to name two of my favorites). Direct Primary Care runs on a similar model, but employs a sliding-scale fee so that those with lower incomes can stay in the practice. DPC physicians also tend to have a larger panel of patients, but still far below the 4,000 that is the median in the insurance/Medicare world. Also, cash-only doctors usually contract directly with local labs and pharmaceutical clearance houses to obtain FAR lower prices for common tests and meds than dealing with pharmacy-benefit managers in the current system. Cutting out the middleman actually saves a lot of money for patients.

C) In regards to ‘who chooses’ cash-only—it’s a complex question. Most physicians who do this have been practicing for years or even decades, and simply want to get back to doing what they love: spending time with their patients. One cannot simply ‘hang a shingle’ as a cash-only doctor—you need to have a pre-existent panel willing to follow you. Some doctors who are ‘excellent’ by the criteria I listed choose this model for the above reason, some choose it for money (although it’s not all that much more lucrative than employment once you deduct overhead for yourself and whomever is in your employ, though overhead is far less when one is not dealing with insurers and their rules). Some merely ‘good’ doctors choose it, but it’s not an ‘easy’ lifestyle. You have to be constantly available, you must pay your own malpractice, and if you want to take a vacation, you must have a colleague willing to cover (and be willing to pay him or her back at some point).

***
I’m just scratching the surface here, but I hope I’ve provided at least some insight into this very complex issue. I look forward to further dialogue.

 

https://www.cnn.com/2019/08/24/politics/democrats-2020-debate-climate-dnc-summer-meeting/index.html

Up next, DNC will ban candidates from the "How to Stop the Asteroid that's going to collide with Earth and wipe out all life in 2021" Debate, citing that it's single issue and we need to have more 'comprehensive' debates.

 

Weird.
By the way, what's the reason behind the rule of not allowing candidates to meet outside the official debates scheduled by the DNC ?
Does it come from agreements made with the news networks organizing the debates?

 

Buh...buh...but...this is no time to argue over minutiae! We have to unite against Trump!

 

I actually don't see the point of outrage here. Yes, climate change is an important topic. So are many others. I don't see a compelling argument that it is hugely more exigent than every other possible. The reality, too, is that the single issue happens to cater to certain candidates strengths. I'm sure Bernie Sanders would love a healthcare themed debate, Joe Biden a "the importance of previous experience in federal government" one, Gilibrand a gender-equality centered debate, and Buttigieg "I have a mildly interesting life story for dinner parties but have yet to demonstrate anything that particularly qualifies me for this caliber of office" one. But the reality is that unless we're encouraging people to vote as single issue voters, they need to appreciate how candidates will juggle all priorities, not just a deep dive on one in particular.

 

This planet is literally going to be uninhabitable

 

So? How is that more important than His Latest Tweet?

 

GOP response: "Who cares? We'll be dead by then. Our children will have to deal with it, but at least they'll be born."

I am convinced at this point that if war doesn't wipe us out, an epidemic will. The Earth won't go down without a fight, and nature is older, smarter and faster than we are. Ultimately, she'll win.

 

I don’t think “we could die” is a strong form of argument.

Widespread nuclear weapons usage could also achieve this outcome. Is it therefore rational to have a debate solely about foreign policy? What about one even more hyper-focused on just the issue of nuclear proliferation?

The other reality is that in spite of you taking this rhetorical stance, both you in particular and the board in general spends most of their energy on other issues. We’ve just spent days debating the relative implications of different healthcare policies, for instance. So how is it sensible for climate change to get a dedicated debate when healthcare doesn’t?

 

Climate change is likely the biggest threat to our existence that the human species has ever faced. It's the most important issue. Yes, nuclear weapons can achieve the same result. Nuclear war is always a concern, but it isn't happening right now. Climate change is. Having a debate on the issue is not only about having a debate; as we have seen, the sanctioned debates haven't been particularly worthwhile in their content. It would signal the importance of the problem and how seriously the party and the candidates take it. It would also further expose the worthlessness of "centrists" like Joe Biden which is why Simone Sanders was adamantly against such a debate.

 

In the subverted world in which every debate must be approved by the DNC and there are all those ridiculous rules, yes, Jabba is right, it's unfair to make an issue-oriented debate, because it favors some candidates and damages others.

 

He's heavily skilled at the modern sound bite. He won't win the nomination. He won't win a state in the primaries. But, he might get a few eyeballs on some issues, and he might turn a few groups less enthusiastic about Trump.

Most important to him, though, he'll sell books and radio spots and the such.

 

Tom Perez is not a neutral arbiter, nor was Debbie Wasserman Schultz in 2016. They will try their damndest to protect Biden and if he goes down, anyone other than Bernie. They are terrified of losing their influence.

 

Warren might piss off some donors, but Bernie is the only one who can really destroy the system which keeps their career alive. I'm starting to agree with those who say that the democratic establishment would rather lose than win with Bernie.

 

Of course. The biggest threat always attracts the most attention, and gets the most pushback.

A Bernie victory would give me the same sense of smug satisfaction I felt when Bruce Willis's character Butch in Pulp Fiction decided not to throw the boxing match and burned Marcellus Wallace instead. If he wins, the collective diarrhea attack from the establishments of everything from the financial sector to the political class will be voluminous enough to rival the biblical flood.

 

To their network, Bernie is by far a bigger threat. If Trump wins, they will continue receiving donations and their political career will be mostly safe. But what if Bernie manages to change the campaign contributions laws, start putting them in the position of voting for M4A, decreases the amount of money sent to Israel, takes on the military industrial complex and the pharmaceutical industry and, most importantly, pushes for a change in the rules of DCCC and starts endorsing grassroots candidates for Congress? Bernie is their apocalypse. This is why he will probably lose. He is a menace to their way of doing politics.

 

I'm not saying "we could die." I'm saying we will die. And those of us who don't will be living a shell of a life. This is a case of the house burning down. Of course that's going to be the most important topic.

I'm perfectly fine with, in fact, I'd champion a healthcare debate.

The issue here is that a lot of dems are "yeah it's a big problem but we don't want to make any kind of structural changes to society to prepare for it."

 

And a Tea Bagger.

Anyone giving odds on him dropping out of the race after he's raised his profile (and money) just in time to jump into a congressional race?