Making the best of a bad situation

As I’ve read med blogs, a recurring theme is that Medicare and Medicaid vastly underpay doctors compared to private insurance, to the point where doctors lose money for each such patient they see, both as a straight cash loss and because of the time and money spent dealing with M/M paperwork.  Normally I’d be a bit skeptical of such collective kvetching, if only because doctors have a lot to gain by making a fuss and getting rate increases through Congress.  But if you look at the history, physician reimbursements have actually fallen over the past 20 years, even as improving technology has increased the costs of providing such care.  All this means that, basically, Medicare reimbursement schedules are unsustainable, perhaps not surprising when prices are set by fiat, by a government under pressure to both increase benefits (when Democratic) and cut expenditures (when Republican.)

From a policy perspective, well and good.  We need to either rethink our expectations of the level of care provided by Medicare, or raise a ton of money to pay for our current level of expenditure.  Anything else ends in doctors eventually leaving Medicare en masse, unless they are somehow coerced.  (That would be a pretty disturbing scenario, by the way, all the more so because there is easy demagoguery potential: “greedy docs refusing to help poor seniors.”)

But the question remains, for the individual (would-be) doctor, how do you respond to something like this?  Do you say that the loss – both in cash and in the outright waste of paperwork – is not worth it, and build up your practice, perhaps donating the profits to charity?  Or do you refuse to punish seniors for a system that’s really not their fault and accept Medicare?

I am sympathetic to the argument, made here by a real physician, that we have a duty to serve all patients regardless of their ability to pay, as long as we can make a decent income.  But I think there’s more to this issue than “how much will you sacrifice for the greater good?”  After all, revenue is not just money in the bank, it is also money that you can use to improve your patient care.  By accepting Medicare, the doctor loses the ability to upgrade his equipment, hire more support staff, and thus either treat more patients or improve his treatment of each patient.  It is plausible that the decision to be generous and see Medicare patients could actually reduce the amount of good he can do.  Perhaps more importantly, the decision to treat Medicare prolongs the existence of a system that everyone agrees needs reform.  In contrast, physicians who embrace innovative practice models such as cash-only practices, medical homes, or the unfortunately-named concierge care are public demonstrations of systems that may be superior to the insurance/Medicare zeitgeist.  In pointing the way to a healthcare system without the inefficiencies of public or private insurance, such risky experimentation is also a public service.

And so, I lean towards the idea of doctors not accepting Medicare if it is a losing proposition for them.  Instead, they should reinvest in their practices, improve their quality of care, and find a system that allows them to provide effective and equitable care to as many patients as possible.  But it’s a tough call to make, and there’s no obvious right answer.

You call THAT a silly walk? I’LL show you a silly walk!

Human social interaction has evolved to such a level of sophistication that it’s sometimes hard to see the status competition that goes on, until sites like SWPL helpfully point it out for us.  These border guards, though, make it pretty easy.  (h/t Marginal Revolution)

Compare:

Thought of the day

As you become more respected and climb the career ladder, do you get less feedback?  After all, more of your friends and underlings would be too intimidated to criticize you much, and most criticism would come from your enemies and hardly be constructive.  In that case, self-awareness would be a must.

Early risers rule the world

Robin Hanson:

larks [early risers] are older, more conformist, more dependable, and so more likely to set official rules.  Such rules seem to favor lark-preferred hours of work, school, etc., and to give larks higher school grades even though owls are smarter and eventually richer.  Seems some sort of “conspiracy” theory has decent support, though of course  conscious collusion isn’t needed here – self-serving biases and signaling distortions seem a sufficient explanation.

During this semester, I’ve been trying to shift my sleep schedule earlier, with only modest success (got up at 9:30 today).  Looks like I have additional incentive to do so now.  My intelligence and earning potential (at least in meritocratic medicine) is pretty much fixed, but if conscientious and agreeable early risers run the world, it behooves me to join their ranks!

Thought of the day

If “Eskimos have tons of words for snow,” why do we claim that “fish have no word for water,” besides the obvious?

Book review: The Big Sort

One of the problems with people getting new freedoms is that they’ll use it, and not always in the way you like.  Bill Bishop’s The Big Sort looks at what happens when people have the freedom to live wherever they like, thanks to greater job mobility and spreading prosperity.  The answer is, people like to live near people like them, and this means, among other things, that people will live next to those with similar cultural* and political beliefs.  This leads, organically and unintentionally, to communities where everyone marches in ideological lockstep.  Because of this sorting, he argues, political polarization gets worse, and, barring major changes, will only get worse in the future as people barricade themselves in politico-cultural echo-chambers.

Some choice quotes:

Regardless of demographic category – age, gender, religion, occupation – Pew found a difference in support for the war [remember, this was 2006] based on geography.  Labor union members were against the war in Democratic counties but for it in Republican counties [by 30%]; women were against the war in Democratic counties but for it in Republican counties [by 23%].  The partisanship of place overpowered the categories that researchers usually use to describe durable voting blocs.

There is a market demand now for “lifestyle” communities.  Developers built the Lareda Ranch subdivision in Orange County….into distinct groups.  There is “Covenant Hills” for the faithful (big family rooms and traditional suburban architecture) and “Terramor” for what the developers call the “cultural creatives” (bamboo floors and instead of a family room, a “culture room.”) [turns out marriage and family formation is a huge predictor of politics]….Responding to the demands of students, colleges offer “thematic housing.”  Two residence halls at Brandeis University are set aside for those interested in “Justice, Service & Change.”  Colgate has a foreign film dorm.  Union College has a residence based on recycling and the environment.  Wesleyan University has twenty-eight thematic dorms….Kids have grown up in neighborhoods of like-mindedness, so homogenous groups are considered normal.

My thoughts: To a large extent this sorting is a good thing!  People seem very willing to give up a certain amount of convenience (in location, price, or job opportunities) to cluster with those with whom they share a culture – therefore like-mindedness is a valuable thing to them, and their achievement of this like-mindedness should be celebrated.  Remember also Harvard professor Robert Putnam’s findings on the inverse relationship between neighborhood diversity and social cohesion.  While he rightly points out the benefits of immigration, his prescription for mitigation of this negative impact is by assimilation – that is, by decreasing cultural diversity.

And yet of course political polarization is a bad thing, leading to inability to pass good policy, let alone make compromises. But I think a major part of this problem is that these cultural enclaves are too small to have local political power – they can be as culturally echo chamber-y as they like, but they have little influence on their government.  Hence, a growing sense of disenfranchisement and resentment towards the fools on the other side of the fence.

Marginalized groups become more extreme – think of the birthers and the antiwar protesters.  The problem Bishop describes is a federalism of ideology in a country in which political power is increasingly centralized, with states and local government much less influential than they were at the founding of the republic.  The solution, it would seem, would be to devolve power to smaller polities whenever possible – not just “states’ rights,” states being too broad to enclose these cultural enclaves, but smaller units like cities and counties.  This serve as a release valve for frustration at being bundled into a country together with ideological enemies.  It would also act as a proving ground for what policies work and don’t work (part of the original motivation for federalism) and possibly modify political beliefs by forcing people to deal with the consequences of the policies they advocate.

*I use “cultural” in the sense of shared beliefs and lifestyles, rather than the folkways of a common homeland.  So, instead of kielbasa and lion dances, think SWPLs and rednecks, country-club professionals and media insiders.

Holidaze

Tomorrow is both Chinese New Year and Valentine’s Day, holidays with entirely different cultural origins and functions.  However, they do have this one thing in common: both are dating conventions.

(sorry)

Preliminaries on Facebook

I’ve been thinking about the sociology of facebook recently – how we developed certain norms about proper (“non-sketchy”) online behavior, and how much of these norms are novel and efficient, vs. inefficient carryovers from offline social instincts.  I’ll probably write up a longer post soon.  In the meantime, two incisive articles on the topic:

One:

In terms of things like Facebook—I’m a big fan of self-presentation theory, Erving Goffman’s idea that we have a private, backstage self, and a public, front-stage self, and of course Twitter and Facebook and blogs are all an extension of that front-stage presentation. And what I find funny is how many people are just so bad at hiding what they actually think of themselves. You know, on Facebook, some people can’t stop posting self-taken photos of themselves looking beautiful, as if that’s going to impress anyone.

Two:

People who talk about themselves a lot are generally disliked. A likable person will instead subtly direct conversation to where others request the information they want to reveal….This appears true of most human interaction, but apparently not of that on Facebook. On Facebook, when you are not posting photographs of yourself and updating people on your activities, you are writing notes listing twenty things nobody knows about you, linking people to analyses of your personality, or alerting them to your recent personal and group affiliations. Most of this is unasked for by others. I assume it is similar for other social networking sites.

If over lunch I decided, without your suggestion, to list to you twenty random facts about me, tell you the names of all my new acquintences, and show you my collection of photos of myself, our friendship would soon wane. Why is Facebook different?

Read the whole thing for some theories and rebuttals.

"…but I repeat myself."

The DoJ is looking for mentally retarded lawyers:

The U.S. Department of Justice, Civil Rights Division is seeking up to 10 experienced attorneys for the position of Trial Attorney in the Voting Section in Washington, D.C….The Civil Rights Division encourages qualified applicants with targeted disabilities to apply. Targeted disabilities are deafness, blindness, missing extremities, partial or complete paralysis, convulsive disorder, mental retardation, mental illness, severe distortion of limbs and/or spine.

H/T to The Volokh Conspiracy.

Irony of the day

I’ve always thought of high finance as being a pretty opaque profession to break into, without a clear trajectory and a lot of it’s-who-you-know.  Medicine, on the other hand, is a pretty predictable path: you put in your time, you take your tests, you’re a doctor.

That’s why I was so surprised to learn from Panda that prominent VC types routinely advertise job openings on their blogs (attracting of course a massively overwhelming response).  In contrast, all of the non-crappy doctoring jobs are advertised by word of mouth.