Gyroscopic Investing

MachineGhost wrote: I'll make another prediction that Medicare-For-All basic sickcare is going to be robot driven.  Like in Star Wars.

What do you think ICD10 is for?? 

Seriously, I've thought exactly the same thing.  I can't imagine that no one else has thought of the advantages:  robots only need maintenance/repair, not salaries and benefits and still less medical school tuition and residency; they will unblinkingly follow guidelines and not do anything deemed unnecessary; they won't complain when patients call about stupid stuff in the middle of the night; and they won't need malpractice insurance.

I suppose patients will miss having personal relationships with their doctors, but they don't exactly have a say in health care policy either.

WiseOne wrote: I suppose patients will miss having personal relationships with their doctors, but they don't exactly have a say in health care policy either.

Quantitative quantification is killing sickcare!  It started to become a problem in the early 70's when the physician switched to treating the lab values instead of the patient.  So you have hundreds of thousands of women going around for 20 years or more  with hypothyroid symptoms because the "lab range is normal" despite persistent clinical or subclinical symptoms.  That is pathetic when a old time, country doctor would have figured it out just by using his eyes and ears.

Try arguing with a robot!!!  The only way this concept is going to work is if robots are true Expert Intelligences like IBM's Watson and not just merely programmed to follow "standard of care" dogma that insurance companies or government authorities declare appropriate and legally binding.  We know their vested interest isn't in the optimal outcome for the patient, but a procedure with enough shoddy, manufactured, and/or fraudulent evidence to keep costs down and profits up, or to make political numbers look good.

MachineGhost wrote: So you have hundreds of thousands of women going around for 20 years or more  with hypothyroid symptoms because the "lab range is normal" despite persistent clinical or subclinical symptoms.  That is pathetic when a old time, country doctor would have figured it out just by using his eyes and ears.

Try arguing with a robot!!!

That's the whole point:  you can't argue with a robot, or wheedle them into providing pain meds, whole body CT scans, or an extra month for Grandma to be in the ICU on a ventilator with a hopeless prognosis.  This is part of what drives up health care costs, unfortunately:  the "Burger King" health system ("Have it your way").

Incidentally...beware of what's being called "hypothyroidism" in the popular literature, which is a constellation of symptoms that could be diagnosed as lots of other things:  (pre)menopause, chronic fatigue, etc.  I don't think it's the same as the thyroid gland dysfunction due to autoimmune conditions, endocrine neoplasias etc that the lab tests are designed to pick up.  I don't doubt that the recommended supplements could help with the symptoms and that it's likely that they're caused by some environmental or dietary factors, but that's not to say you know for certain that the cause is reduced thyroid function.

WiseOne wrote: Incidentally...beware of what's being called "hypothyroidism" in the popular literature, which is a constellation of symptoms that could be diagnosed as lots of other things:  (pre)menopause, chronic fatigue, etc.  I don't think it's the same as the thyroid gland dysfunction due to autoimmune conditions, endocrine neoplasias etc that the lab tests are designed to pick up.  I don't doubt that the recommended supplements could help with the symptoms and that it's likely that they're caused by some environmental or dietary factors, but that's not to say you know for certain that the cause is reduced thyroid function.

That's a good point.  I think you're referring to "sub-clinical hypothyroidism" where you have some of the classic symptoms, but workups and imaging don't flag anything overtly abnormal (though the TSH range is rather wide being derived from an outlier, sickly population). 

My Gma has a relatively recent neoplasma on her thyroid gland and so she had trouble regulating her body temperature and her T4 dose is now somewhat lower than normal at 86mcg.  I do wonder if that neoplasma wasn't instigated by a chronically too high T4 replacement dose.  She's been on T4 for at least 30 years, so that's pretty good for her PCP, even if he doesn't really know all the ins and outs of the whole hormone enchilada.  He's definitely a treat the lab results rather than the patient type and its been challenging at times to get him to acknowledge reality even as she was burning up.

There's also the unacknowledged issue of a minority of women that don't respond to T4 alone and need T0, T1, T2, T3, T4 and calcitronin that are in natural thyroid extracts (I would not call those a supplement since regular thyroid glandular extracts have the active hormones removed).  It is very challenging (to say the least) for mainstream PCP's and/or endocrinologists to grok.  Maybe that's not the best way to fix an elevated rT3, but it certainly fits in with a drug for every ailment model.  Interestingly, synthetic T4 in this mainstream context is actually bioidentical unlike the other pharmaceutical hormones.  It must have been a fluke of how it was first discovered because I think Big Pharma was not funding the discovery, so no need to tweak it, make it toxic and patentable.  Hence why T4 replacement is such a "widespread success".  Doh!

Anyway, why do you think hypothyroidism (sub-clinical or overt) overwhelmingly strikes women rather than men?

Looks like my United Healthcare plan is going up 14%.  Healthcare is included in CPI, right? 

There are a few cheaper options, but I don't really care for the doctor networks and I like that my plan is HSA eligible so I'll probably stay put.  BTW, I think my biggest complaint about the new system isn't even the costs but the hassle involved with the subsidies.  Many people on the individual market are there precisely because they don't have full time jobs with consistent income, but the hurdles you have to jump through to "prove" your future income to qualify for "correct" pre-paid subsidies are a real pain.  They really incentivize you just to pay the full rate yourself and wait 18 months for the eventual tax return. 

Tyler wrote: There are a few cheaper options, but I don't really care for the doctor networks and I like that my plan is HSA eligible so I'll probably stay put.  BTW, I think my biggest complaint about the new system isn't even the costs but the hassle involved with the subsidies.  Many people on the individual market are there precisely because they don't have full time jobs with consistent income, but the hurdles you have to jump through to "prove" your future income to qualify for "correct" pre-paid subsidies are a real pain.  They really incentivize you just to pay the full rate yourself and wait 18 months for the eventual tax return.

My state allows you the option of them pulling your previous year's tax record to determine your qualification and subsidy.  Simple.

MachineGhost wrote:

Tyler wrote: There are a few cheaper options, but I don't really care for the doctor networks and I like that my plan is HSA eligible so I'll probably stay put.  BTW, I think my biggest complaint about the new system isn't even the costs but the hassle involved with the subsidies.  Many people on the individual market are there precisely because they don't have full time jobs with consistent income, but the hurdles you have to jump through to "prove" your future income to qualify for "correct" pre-paid subsidies are a real pain.  They really incentivize you just to pay the full rate yourself and wait 18 months for the eventual tax return.

My state allows you the option of them pulling your previous year's tax record to determine your qualification and subsidy.  Simple.

Mine too. The problem is when the income from your previous tax record is nowhere close to your expected future one. Using your 2014 tax return to determine your 2016 subsidy eligibility doesn't work well for people with a large income drop in between.  They demand lots of documentation to "prove" the income discrepancy, with the threat of penalties if you're too far off in your estimate.  Give it another year or two and maybe it'll catch up for me and be easier. 

Benko wrote:

WiseOne wrote: Doctors are basically the janitors of the health care world.

Agree.  I usually put it, docs are 3rd class citizens way way behind administrators.

They are the mechanics in the health care auto shop.

MediumTex wrote:

Benko wrote:

WiseOne wrote: Doctors are basically the janitors of the health care world.

Agree.  I usually put it, docs are 3rd class citizens way way behind administrators.

They are the mechanics in the health care auto shop.

Highly relevant sign on the wall of the auto shop:  "Squeaks and rattles are not covered by the warranty."

And as a physician friend of mine is fond of saying:  "No user serviceable parts inside."

MG:  in response to your question - no idea although if I had to guess I'd think about genetics and hormones.  I do know that endocrinologists worth their salt generally know that the world doesn't begin and end the T3 and T4RU tests, but there's a world of difference between someone with some vague symptoms and no known thyroid disease, and someone with known thyroid disease, relevant complaints, and normal or borderline test results.

Tyler wrote:

MachineGhost wrote:

Tyler wrote: There are a few cheaper options, but I don't really care for the doctor networks and I like that my plan is HSA eligible so I'll probably stay put.  BTW, I think my biggest complaint about the new system isn't even the costs but the hassle involved with the subsidies.  Many people on the individual market are there precisely because they don't have full time jobs with consistent income, but the hurdles you have to jump through to "prove" your future income to qualify for "correct" pre-paid subsidies are a real pain.  They really incentivize you just to pay the full rate yourself and wait 18 months for the eventual tax return.

My state allows you the option of them pulling your previous year's tax record to determine your qualification and subsidy.  Simple.

Mine too. The problem is when the income from your previous tax record is nowhere close to your expected future one. Using your 2014 tax return to determine your 2016 subsidy eligibility doesn't work well for people with a large income drop in between.  They demand lots of documentation to "prove" the income discrepancy, with the threat of penalties if you're too far off in your estimate.  Give it another year or two and maybe it'll catch up for me and be easier.

we are one of those you speak of where we had a huge income drop from 2014 compared  to 2015 and 2016 .

because they use tax returns so far back getting the subsidy is very hard .  income wise because we are living on cash and the little i worked in 2015 and filled my 401k i  might have gotten something as a subsidy hypothetically based on 2015 earnings in 2016 but that is not how it works .

2016 looks at 2014 taxes . in 2014 we sold our commercial lease rights and had a 420k taxable  income .

so even though  in  2015  we had a very low taxable  income since i worked part time and retired 1/2 way through  2015 , this tax year will not come in to play until 2017 medical .

i still will be a bit to high for a subsidy in 2017  which really leaves only 1 year 2018  where i stand a pretty good chance of seeing anything .

then it is right on to medicare .

so at best 1 year out of 3 may see a subsidy ..

tax planning for these subsidy's has to be done pretty far in advance .