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Iāve talked about end of life before. I worked oncology for 8 or so years, we are now pursuing things with PCPs. The data is clear, if you center pts at date of death and look back, adjusting for age and sex and whatever, it is very clear that hospice saves $15k per decedent.
And itās clear that dying people much prefer dying at home, as comfortable as possibly, vs living an extra 2-4 days in the hospital. For pts not enrolled in hospice, the most likely outcome is death in the ICU. Likely on a vent in an induced coma. Itās the poster child for low value care.
So, why do we see so many people going down the wrong path? Physicians donāt like having difficult conversations and, compounding it, they donāt get paid much for the trouble. I hate to say that but itās a complaint Iāve heard from doctors.
Value Based Care is helping, providers get to keep part of that $15k savings. We need more of this, imo.
Why isnāt MA doing much? I think itās a lot of squeeze for the juice. Much easier to pump risk scores, give out dental and vision and gym benefits. Then cram as much risk down on providers as they can to get closer to the goal of a guaranteed 15% margin.
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Is āValue Based Careā related to āAccountable Care Organizationsā?
Probably more nuanced than that.
How did they normalize for the difference in healthcare funding?
Ditto for retirement income?
My intuition says a lot of people in the US, who pay no FIT at all, might be o,ay with paying another 8% of gross for health insurance and a government backed pension. Just a hunch. Thatās hard to back out of a graph of tax rates by income decile, if that was the evidence.
ACOs are a form of VBC, yes! There are all kinds of models, starting with pay for performance type models, maybe just a few metrics you work on. Then you move up to taking risk on a subset of costs, on the far end you are fully responsible for total cost.
As you can imagine, taking full risk for cost could lead you to just being cheap. Cheap does not equal value (imo), so the hard part is defining value and increasing that.
Iām on Medicare. I got a letter today reminding me that I am in an ACO.
Is there a single model, or a typical model, for Medicare beneficiaries?
Like the US, Canadaās tax regime is favourable for low and middle income earners. A Canadian earning about $100K pays less income and payroll taxes than his/her American counterpart and his/her marginal tax rate is lower depending upon the province/state being compared.
Are you in traditional Medicare that the government oversees, aka FFS Medicare? Or are you on an Advantage plan with Humana, Aetna, CIGNA, etc?
Fee For Service
So you are in some flavor of the Medicare Shared Savings Program. Could be the regular one, or Flex, or REACH. They share some things in common, with different things bolted on. I work a LOT in MSSP. Itās not perfect but itās a good program, I wouldnāt mind being en enrolled beneficiary.
ETA: I think FFS is the right call, fwiw. MA plans look shiny on the surface but they pull some shenanigans and Iād skip the hassle.
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They are already paying 6.2% (12.4% by some estimations) for a government backed pension. And may be paying negative FIT when EITC is considered.
this matches my understanding of the ACOs and the ranges. I work ~10% in the VBC space.
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Kinda. SS is not really a pension. It was a way to avoid destitution. The average Social Security retirement benefit in January 2025 was $1,976 per month. That will not cover housing let alone any āgolden yearsā. People are justifiably worried about how they will eat. It needs both personal savings and a pension (now a 401k) to avoid destitution. I defy you to try and live on $2000 CA per month.
And the rise in consumer credit, especially among the bottom 50% of incomes tells you that they have no ability to generate retirement wealth as it stands today.
So the psychological impact is devasting. Without a paid off home, most Americans are facing a pretty bleak old age. Toss in long term care, and itās truly frightening. Millennials and Genx are in awful straits.
I have a brother retiring Spain next year as a Spanish citizen. He will enjoy a satisfying retirement even with less than $100,000 in savings. My daughter is an Aussie, living in Melbourne. Her government pension is considerably more than the US SS benefit.
And both are best described as independent contractors.Their old age benefits are portable, not tied to any single employer. Same with their HC. Not tied to any employer. This allows a degree of freedom unimaginable in the US.
Plus sheād have superannuation on top of that Aussie pensionā¦
While it isnāt designed to be the sole source of retirement income, it most definitely is a pension. It is portable, not tied to any one employer. It is also inflation indexed, which exceedingly few US private pensions are (correct me if I am wrong pension folks). Medicare is also not tied to any one employer. Granted, pre-retirement HC in the US is a costly mess, but we are focusing on retirement.
I canāt really speak to your anecdotes about your familyās experience. I will note that OASDI has been very successful at reducing elderly poverty rates. How it compares to other nations public plans replacement ratios would be a better way to say which is more generous. Note that 2000/mo is 153% of 2025 FPL for a single person, and 4000/mo is 226% of 2025 FPL for a couple.
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That is the main advantage really. You canāt buy an annuity like that in any market that I know of (usually an annuity that is index-linked would have something like a 5-year guarantee).
Personal note: The company I worked for 25 years ago had a CPI linked annuity. It made sense because the early 30-year TIPS had coupons over 3.5%. TIPS yields fell and annuity payouts fell and they pulled the product.
We sell annuities with a fixed escalation of payments (up to 5% annual increase), but not true CPI linked payouts.
Some pre-need focused contracts have CPI linked benefits. These are small face amount, permanent contracts normally sold for funeral costs. Thatās about the only thing i am aware of with cpi links.
Youāre suggesting that they should pay another 8% in taxes to fund a bigger retirement income. Do they have the ability to pay that additional tax?