Archive for January, 2010

More on cash practice of medicine

Tuesday, January 19th, 2010

I have previously posted on the topic of doctors dropping out of Medicare and even private insurance and establishing cash-only medical practices. Here is another study of this phenomenon.

A few health insurers recognize the value of these services and reimburse enrollees for them, but concierge practices usually cater to cash-paying customers. Thus, they may be especially useful to patients who have a consumer-driven health account – such as a Health Savings Account (HSA), a Flexible Spending Account (FSA) or a Health Reimbursement Arrangement (HRA) – and to the uninsured.

A major consideration for the HSA patient is the fact that medical fees are grossly inflated by Medicare and insurance companies that draw up contracts with physicians including “discounts” from imaginary retail prices. When I retired from private practice, I had 176 contracts with various insurance companies and HMOs. Medicare will punish a physican who provides a cash discount to a patient. Balance billing is also prohibited.

The result has been reluctance on the part of physicians to see Medicare patents or HMO patients, both of which have poor reimbursement schedules.

* The proportion of people reporting problems seeing their primary care physician rose from less than one-quarter (23 percent) to one-third over the four-year period.
* Nearly one-quarter reported problems taking time from work to see a physician.

Here is one model.

Take DocTalker Family Medicine. This is the Virginia medical practice of Dr. Alan Dappen. Patients can schedule an in-office appointment or even request a house call, but about half of his consults are by e-mail or telephone.

Like an attorney, Dappen bases his consultation fees on the amount of time required. All patients must have an initial face-to-face consultation to establish care. There is no membership fee, but patients who prepay $300 annually receive a discount of about 25 percent. Each five-minute phone consultation or e-mail consultation costs $25. Nonmembers can buy services a la carte for $33.33 per five-minute block after a $150 initial check-up.

The office does not bill insurance companies for services, but most patients can easily file their own claim. Patient records are kept electronically for easy access.

The other common model is the “retainer practice” model.

Concierge medicine is normally associated with personalized services for the wealthy. These services can sometimes be expensive – in some cases more than $2,500 per year per person. However, in suburban Collin County north of Dallas, Texas, physician Nelson Simmons offers a version of concierge service for less than $500 per year. Aimed at small business employees who would otherwise likely be without employer-sponsored insurance, Simmons’ practice has attracted about 70 small business owners who pay $40 per employee per month. In return, employees get same-day primary care services and steep discounts on diagnostic tests and specialist care. Enrollees must pay out-of-pocket for specialist care, surgeries and diagnostic tests – but Simmons negotiates the rates, which are typically much lower than what others pay.

The $2500 usually includes all primary care services for the same annual fee. Doctors are starting to drop out of the old insurance model and this bodes ill for the corporate model of Obamacare.

The Romney role in Scott Brown’s campaign

Monday, January 18th, 2010

Scott Brown looks very good as the election goes into its last day in Massachusetts. He is a great retail politician and, I think, a coming star in the GOP. What has been behind his meteoric rise in Mass politics ?
Mitt Romney’s people.

Largely overlooked in assessing Brown’s prospects: the hidden hand of Mitt Romney. The former Massachusetts governor headlined at a fundraiser for Brown last October. And Romney has helped Brown raise money outside the state as well. “I know Scott and how determined he is to win. I’ve campaigned for him, raised money on his behalf, and we’re doing all we can to help him over the finish line,” Romney wrote supporters last Monday. Brown, 50, raised $1.3 million that day.

The Brown campaign is filled with Romney associates.

Ever since he entered the race to succeed the late Sen. Ted Kennedy, Brown has been counseled by members of the Shawmut Group, a Boston-based consulting firm that acts as the Romney political brain trust in exile. Among the many Romney disciples running Brown’s campaign are Beth Myers, the campaign manager of Romney’s presidential run; Eric Fehrnstrom, Romney’s chief spokesman; Peter Flaherty, Romney’s “go-to-guy for conservatives”; and Rob Cole, Romney’s 2008 deputy chairman manager. Beth Lindstrom, another player in Romney World, is working as Brown’s campaign manager. Lindstrom’s ties to Romney go back years; she started working with him in the Massachusetts State House as director of consumer affairs.

The next decade, if the Republicans are smart, is going to see a merger of the libertarian approach to domestic policy with traditional Republican national security policy. Bush’s failure was the spending and the inept handling of Iraq after the invasion. A lot of the latter was the fault of Bremer and the former of Dennis Hastert. Still, the president gets the credit when things go well and the blame when they don’t.

The Scott Brown story is a big plus for Romney.

More from a mom in Maine who drove to Boston for the rally.

My prediction: If Brown wins, it will be because the average person tuned out the liberal media and the negative ads and listened to Scott Brown himself. They liked what they heard — key messages on stopping health care, keeping us safe from terrorists, and not raising taxes. If this happens, it will be reminiscent of another politician who had the ability to talk directly to the people — Ronald Reagan. But Scott Brown, as good a guy as he seems to be, is no Ronald Reagan. He has some commonsense instincts, but if he wants to stay in power from super-blue MA, he will have to stick it to the Republican leadership more than once to “prove” himself. On what issues he will do this is anybody’s guess. Not unlike Obama, many people are making Scott Brown into what they want him to be, but he will be his own person no doubt.

I disagree. Reagan was told 100 times that he had to modify some of his positions to be a viable candidate. The times are different now. Brown is genuine and it would be a mistake for him to start to trim. His abortion amendment is enough. That established his with the social conservatives. His task now is all economic and populist.

UPDATE: John Kerry is now smearing the Brown campaign as “out of state” and dangerous. I’m sure they look dangerous to Kerry.

UPDATE #2: Eleanor Holmes Norton, elected by DC which does NOT qualify for a voting member of Congress, says the health care bill will be pushed through no matter what. And those pesky voters think they matter. Huh !

I can’t afford to be made to look ridiculous

Saturday, January 16th, 2010

One of the great moments in The Godfather.

She threw it all away just to make me look ridiculous. And a man in my position can’t afford to be made to look ridiculous. Now you get the hell out of here. And you tell that gumba that if he wants to try any rough stuff that I ain’t no band leader. Yeah, I heard that story.

Well, Martha Coakley has not only been made to look ridiculous, but she is a carrier of ridiculous.

Who has advised Obama to go up to Massachusetts and do this to himself?

Here is a new video that I like.

Big day Tuesday !

Haiti, anarchy and the collapse of societies.

Thursday, January 14th, 2010

The Haitian earthquake has been a disaster that any small country would have a difficult time dealing with. However, Haiti is almost unique in its disastrous social collapse. What happened ? Jared Diamond studied Haiti in his book, Collapse.

Here is a discussion of Diamond’s theory.

It’s very interesting: The Spaniards came to the island of Hispaniola first, settling mostly on the greener (rainier) side. Before long, the home country got too preoccupied with growing difficulties elsewhere in its empire to pay much attention to Hispaniola anymore. The French showed up later, took the dry end of the island, and then—because they were rich and their empire was on the rise—were able to convert it to intensive sugar cane cultivation, importing and brutally exploiting lots and lots of African slaves who eventually got fed up and revolted. Once independent, the Haitians understandably wanted to stop hacking at sugar cane. They also wanted to keep the Europeans out. So Haiti settled into an existence of isolation and subsistence farming. The Spanish side of the island, which eventually became the Dominican Republic, experienced no such sugar-cane boom, and was conquered by the Haitians a couple of times along the way, but welcomed immigrants from Europe and developed multiple cash crops.

OK, so climate had a role and slavery had a role.

Then, in the 20th century, both Haiti and Dominican Republic were ruled for decades by murderous tyrants, but the Dominican murderous tyrant (Rafael Trujillo) was at least interested in industrial development. He was also eventually succeeded by a former minion (Joaquín Balaguer) who, while not at all a nice guy, did turn out to be a patriot and a total tree hugger. Meanwhile, Haiti’s despicable “Papa Doc” Duvalier was succeeded by his only slightly less despicable son. The result: The Dominican Republic, while still poor, is much richer than Haiti—and it still has trees.

Neither of them made out well in the governance department. Typically, commenters on blogs that deal with these issues make a big deal of the fact that US Marines occupied Haiti from 1918 to 1934. I suspect that was a golden age for Haiti but that sort of thing doesn’t go over well in leftist academic circles.

Tyler Cowen has more ideas including a list of Haitian curses.

Voodoo religion ?

The comparison with Barbados is pretty interesting. Barbados exported manual laborers to the Panama Canal project. This resulted in an exodus of young men who might otherwise be unemployed or depress wages. They also sent home remittances that funded many social improvements.

Governor Carter refused to limit emigration because the remittances sent back to Barbados from the Panama workers had markedly improved the economy, especially for poorer tenant farmers. In a country that had recently been on the brink of collapse, he was not going to tinker with that.

Agents went out into the crowd to interview and select potential workers. A doctor then checked the potential workers, selecting those who would receive a contract. In 1907, Arthur Bullard described the scene as follows:

“Several policemen kept the crowd in order and sent them up into the recruiting station in batches of 100 at a time. As the men came up, they were formed in a line around the wall. First, all those who looked too old, or too young, or too weakly, were picked out and sent away. Then they were told that no man who had previously worked on the canal would be taken again. Then the doctor told them all to roll up their left sleeves and began a mysterious examination of their forearms. He saw that a few men had been vaccinated by him already, and these were sent away. One protested that a dog had bitten him there. Then, he went over the whole line gain for trachoma, rolling back their eyelids and looking for inflammation. Seven or eight fell at this test. Then he made them strip, and went over them round after round for tuberculosis, heart trouble, and rupture. About 20 of 100 were left at the end.”

The whole situation stirred up some resentment and anger.

The selected migrants reported back to the docks a few days later. After a second medical examination and a check to insure that every emigrant had a number that matched the one on their contract, they boarded the steamers, where they had to find deck space and food for themselves during the 12 day voyage to Colón. According to a report presented to the Barbados Legislative Council, the atmosphere on the docks was fairly hostile towards the ruling class. The crowds would “abuse whites and aggressively denounce them” before boarding.

The result, however, was interesting at home.

Ironically, the departure of so many angry young men gave plenty of leverage to those who stayed behind. One prospective emigrant was heard telling his co-workers, “Why you don’t hit the manager in the head and come along with we?” His co-workers refrained from assaulting the manager, but there was a wave of plantation labor disputes, and the following song became fairly common:

We want more wages, we want it now
And if we don’t get it, we’re going to Panama
Yankees say they want we down there
We want more wages, we want it now

And what do you know? Wages went up. By 1910, the American consul in Bridgetown reported that agricultural workers received 30¢ per day, a 25% rise in nominal wages over the 1900 level. More importantly, unpaid labor — remember the located labor laws? — basically disappeared. Planters reacted to the new environment. First, they started to employ tenant women in the fields. Second, they modernized production. In 1910 there were no modern sugar centrals on the island — intead, windmill-powered presses wasted upwards of 30% of the raw material. By 1921, in contrast, 19 modern sugar centrals had entered operation. Third, they mobilized politically to halt emigration.

Haiti was not so lucky. Today, The Dominican Republic, while quite poor, has five times the average annual income of Haiti and Barbados, with a similar post-slavery background, is prosperous and has a booming tourist economy.

Over time remittances grew, peaking at $2.39 per person in 1913 — a bit more than a week’s labor for a male worker at 1910 wage rates. Not nothing, but not the millenium, either.

But the indirect impact was huge. First, it bolstered the growth of smallholders. In 1897, an estimated 8,500 small proprietors held a bit less than 10,000 acres. By 1912, 13,152 smallholders owned plots. Assuming that the average size of holding remained constant, this represented an increase in smallholder ownership of 5500 acres, or over 22 square kilometers, five percent of the land area of Barbados. By 1929, the number of smallholding households had further increased to 17,731. Land ownership on the island remained astoundingly concentrated, but the percentage of Barbadians who owned property rose from 18% in 1897 to 40% by 1929.*

Second, it supercharged the Barbadian banking system. Barbadians opened 16,094 new accounts in government savings banks between 1906 and 1913, and deposits increased 88%. In 1920, deposits per person surpassed $11. That was a level of financial penetration about half of contemporary Spain and two-thirds of Italy; very high for a country as poor as Barbados. It prefigured the island’s emergence as a regional banking center a half-century later.

Very interesting comparisons. There seems to be little mention of the fact that what we are talking about here are property rights and capitalism.

I wonder if we could see another US occupation ? Not with this president.

The wisdom of Tom Freidman

Wednesday, January 13th, 2010

Tom Friedman has a column today about China. Interestingly, his theme is that he knows more about the economics of China than a very successful investor.

Reading The Herald Tribune over breakfast in Hong Kong harbor last week, my eye went to the front-page story about how James Chanos — reportedly one of America’s most successful short-sellers, the man who bet that Enron was a fraud and made a fortune when that proved true and its stock collapsed — is now warning that China is “Dubai times 1,000 — or worse” and looking for ways to short that country’s economy before its bubbles burst.

Friedman dismisses this fellow, who made a fortune shorting Enron, and thinks he knows better.

I am reluctant to sell China short, not because I think it has no problems or corruption or bubbles, but because I think it has all those problems in spades — and some will blow up along the way (the most dangerous being pollution). But it also has a political class focused on addressing its real problems, as well as a mountain of savings with which to do so (unlike us).

And here is the other thing to keep in mind. Think about all the hype, all the words, that have been written about China’s economic development since 1979. It’s a lot, right? What if I told you this: “It may be that we haven’t seen anything yet.”

Why do I say that? All the long-term investments that China has made over the last two decades are just blossoming and could really propel the Chinese economy into the 21st-century knowledge age, starting with its massive investment in infrastructure. Ten years ago, China had a lot bridges and roads to nowhere. Well, many of them are now connected. It is also on a crash program of building subways in major cities and high-speed trains to interconnect them. China also now has 400 million Internet users, and 200 million of them have broadband. Check into a motel in any major city and you’ll have broadband access. America has about 80 million broadband users.

He had previously expressed his enthusiasm for China’s political class.

One-party autocracy certainly has its drawbacks. But when it is led by a reasonably enlightened group of people, as China is today, it can also have great advantages. That one party can just impose the politically difficult but critically important policies needed to move a society forward in the 21st century. It is not an accident that China is committed to overtaking us in electric cars, solar power, energy efficiency, batteries, nuclear power and wind power.

Of course, that column was written before the CRU scandal so he is overly impressed with global warming, unlike the Chinese he so admires, but I doubt he has changed his mind. The religion of the left these days is global warming. If only Obama could just dispense with that clumsy democracy we have. Well, he is trying. Others have noticed a plethora of empty buildings and other signs of economic stress.

Some Chinese economists who argue for the merits of a Keynesian style market economy have openly defended the Chinese Government’s position. They claim that an over-priced property market is a small price to pay for preventing a sharp rise in unemployment.

I am not an economist. I cannot put forward a technical argument against this kind of fallacy. My friend Dfzh is not an economist either. However, he does represent a middle-class group in China. This group neither owns capital nor controls the State. Instead, they derive their income and status from service and management. Like many Chinese people in his socio-economic group, Dfzh has become increasingly disenchanted over the Chinese Government’s economic policy, as well as the CCP’s strong grip on power. He has regularly expressed to me his concern about a widening gap between the rich and the poor, and how this is creating social instability.

The problem with Friedman’s, and Obama’s, love affair with the corporate state is that it may not work as well as they think it will. Stratfor.com does not seem to agree with Friedman.

Security officials have warned that these out-of-work laborers could be a source of instability or, more ominously, a target for domestic or foreign instigators to exploit to undermine the Chinese government. The All-China Federation of Trade Unions has warned that China must be vigilant and prevent “hostile forces” from taking advantage of the new masses of unemployed migrants, while the Ministry of Public Security is sending work teams to the countryside and cities to assess social stability and stress factors. Chinese President Hu Jintao has led a chorus of Chinese officials calling on the People’s Liberation Army and the People’s Armed Police Force to be first and foremost loyal to the Party, and to be on alert for rising instability in China due to economic stresses and foreign and domestic hostile forces.

They are not that optimistic at all.

And with China’s economic problems (for which Beijing has assiduously sought to blame everyone but itself), cracks have begun to appear in the veneer of nationalism. They appear not only because of individual reactions to economic problems, but also as various provinces slip into local protectionism, seeking their own recovery over that of the nation.

I will take the advice of James Chanos, thank you. Friedman married money but Chanos made his own. Billions of it.

Well, SC has a new coach

Tuesday, January 12th, 2010

And I don’t like it at all.

Lane Kiffin seems to be the new SC coach and Norm Chow is supposedly coming back, as well. The Tennessee fans are not happy. He was there for one year in his “dream job.” Bullshit.

Tennessee’s Lane Kiffin has been named the next head coach at Southern California, athletic director Mike Garrett announced on Tuesday.

Kiffin replaces Pete Carroll, who jumped to the NFL as coach of the Seattle Seahawks.

“We are really excited to welcome Lane Kiffin back to USC,” Garrett said in a statement. “I was able to watch him closely when he was an assistant with us and what I saw was a bright, creative young coach who I thought would make an excellent head coach here if the opportunity ever arose. I’m confident he and his staff will keep USC football performing at the high level that we expect.”

The hiring was first reported by ESPN.com.

Kiffin, the former Oakland Raiders coach, led the Volunteers for only one season.

Kiffin has been on the move of late. He was 7-6 in his one season at Tennessee and 5-15 in one-plus seasons with the Raiders before being fired in September 2008.

Garrett seems to be assembling his own staff.

In another part of the blockbuster staff changes, a deal is being finalized for longtime offensive coordinator Norm Chow to return to the Trojans in the same capacity, sources close to the school told ESPN’s Shelley Smith.

It looks like Ed Orgeron, who left SC to coach MIssissippi, is also said to be coming back.
Kiffin will bring his father and defensive coordinator, Monte Kiffin, and assistant head coach and recruiting coordinator Ed Orgeron to Southern California with him.

What I see is the Carroll assistants assembling to take over again. What happened ? It looks to me that there is a story about why Carroll left and why these coaches all left while he was the head coach. Kiffin is not without some controversy.

Kiffin then became Al Davis’ unusual choice to take over the Raiders as a 31-year-old coach with almost no NFL experience. He made it through just 20 games before an ugly public firing in which Davis called Kiffin a liar who brought “disgrace” on the Raiders.

Kiffin was the youngest head coach in the Football Bowl Subdivision last season, but he also brought an unwelcome spotlight on the Vols with several minor NCAA violations.

He returns to USC with the school facing a yearslong NCAA investigation over events during his tenure as an assistant, including Reggie Bush’s final years at the school.

It still looks to me that Garrett is running things and Kiffin may not have much control. There is a story about Carroll leaving that I don’t know yet.

UPDATE: Norm Chow is not leaving UCLA. So much for that rumor.

Health care costs and payments

Tuesday, January 12th, 2010

Here is a chart that illustrates what I have been saying for a while now.

In 1965, most people paid a large part of their health care costs out of pocket. Over the past 45 years, the system we have has assumed more and more of the cost and consumption has climbed accordingly. This is the essence of the health care cost problem and why the Obama-Pelosi approach will not work. They will have to ration and there is no evidence that government is any better at making these choices than the average citizen who knows what is important to him or her.

More analysis is here.

An analysis of the CIA disaster in Afghanistan.

Monday, January 11th, 2010

Stratfor analyzes the successful Taliban suicide attack against the the CIA in Khost last month.

As Khalil Abu-Mulal al-Balawi exited the vehicle that brought him onto Forward Operating Base (FOB) Chapman in Khost, Afghanistan, on Dec. 30, 2009, security guards noticed he was behaving strangely. They moved toward al-Balawi and screamed demands that he take his hand out of his pocket, but instead of complying with the officers’ commands, al-Balawi detonated the suicide device he was wearing. The explosion killed al-Balawi, three security contractors, four CIA officers and the Jordanian General Intelligence Department (GID) officer who was al-Balawi’s handler. The vehicle shielded several other CIA officers at the scene from the blast. The CIA officers killed included the chief of the base at Khost and an analyst from headquarters who reportedly was the agency’s foremost expert on al Qaeda. The agency’s second-ranking officer in Afghanistan was allegedly among the officers who survived.

The CIA officers clearly violated tradecraft in this incident, which makes me wonder what else they were weak in. I am just not impressed with the CIA, especially in analysis. They attacked George Bush more successfully than they did the Islamists. I reviewed Timmerman’s book a couple of years ago. I wish I had more confidence in this institution.

The Ice Age cometh

Monday, January 11th, 2010

The world is experiencing a severe cold spell. This is what Britain looks like now from the weather satellite. Florida is seeing temperatures that haven’t been seen in decades. What is going on ?

This is not a welcome answer.

The bitter winter afflicting much of the Northern Hemisphere is only the start of a global trend towards cooler weather that is likely to last for 20 or 30 years, say some of the world’s most eminent climate scientists.

Their predictions – based on an analysis of natural cycles in water temperatures in the Pacific and Atlantic oceans – challenge some of the global warming orthodoxy’s most deeply cherished beliefs, such as the claim that the North Pole will be free of ice in summer by 2013.

According to the US National Snow and Ice Data Centre in Colorado, Arctic summer sea ice has increased by 409,000 square miles, or 26 per cent, since 2007– and even the most committed global warming activists do not dispute this.

Whoa ! I thought “the world’s most eminent climate scientists” were all telling us we were about to fry. What happened to those swimming polar bears with no ice to rest upon ?

It really is ironic that the year the CRU scam collapsed, we start a severe cold trend. This sort of thing only happens in fiction, right ? This may be more than a cold snap.

Fossil evidence clearly demonstrates that Earth’s climate can shift gears within a decade, establishing new and different patterns that can persist for decades to centuries. In addition, these climate shifts do not necessarily have universal, global effects. They can generate a counterintuitive scenario: Even as the earth as a whole continues to warm gradually, large regions may experience a precipitous and disruptive shift into colder climates.

I think this statement is a bit of ass covering in 2003 when the warmists still held sway and were perfectly capable, as we have seen, of spiking any “skeptic” piece submitted to a journal. The “regional” theory might be a sop to the warming fraternity who might otherwise have had a word with the editors at Wood’s Hole to spike this paper.

This new paradigm of abrupt climate change has been well established over the last decade by research of ocean, earth and atmosphere scientists at many institutions worldwide. But the concept remains little known and scarcely appreciated in the wider community of scientists, economists, policy makers, and world political and business leaders. Thus, world leaders may be planning for climate scenarios of global warming that are opposite to what might actually occur.

So maybe this is the first year of a new ice age. A 100 year “Gore effect.” Of course, the “Little Ice Age” lasted 1000 years.

Al Gore Poetry Prize

Sunday, January 10th, 2010

By Bradley J. Fikes

Courtesy of James Delingpole at the Telegraph.

This is my favorite:

Hark the Al Gore warming sting
“Glory to the carbon king”
Cap and trade and tax the air
Help the drowning polar bear.
Plant the wind farms curb and sanction
He needs the bunce to fund his mansion
The science settled graphs are in
Computer models tweaked and spinned
Give him money for your sins
“Glory to the carbon king ”

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DISCLAIMER: This post represents my opinion, and not necessarily that of my employer, the North County Times.