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Old 26-04-2012, 06:55 PM   #51
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That's the thing with buisness and capitalism, the system works in such a way that you have to play a certain game to truly profit financially.
That's not pure capitalism. That's crony capitalism where the lobbyist with the most cash and whose values are most in line with the current administration influences policy decisions that increase central regulation on business, thereby favoring the business model of the crony.

This is what we're facing in health care- as Jason has already stated: the problem is excessive centralized authority over the industry.
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Old 26-04-2012, 06:58 PM   #52
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Hi Frederic,
You hit the nail on the head. What other business model works by attracting customers and then trying to limit the cash that the business extracts from them. Hoping just that the marketing of word of mouth will generate more footfall.
In my experience a lot of professionals who should have this approach have long since switched to the 'screw the customer' approach; estate agents, lawyers, motor mechanics, builders, plumbers - yes, not surprising, but dentists and vets are increasingly over-treating. Vets are the worst IMO. They have you over an emotional barrel. I mentioned this in passing to a patient the other day and they had initially been charged £120 for their dogs care, the receptionist asked whether the dog was insured and it was - the bill he got back from the insurer was £430.
So many chisellers - but I am glad that we are not amongst them.
Not so kind thoughts,
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Old 26-04-2012, 09:56 PM   #53
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the lure of over-treating for financial gain would be sweetly self-justified and I would not notice myself saying 'One more session' to the dependent, fear and anxiety driven individual. The little Macchiavelli in me would even make me feel good about it.
cognitive dissonance?

Andy
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Old 26-04-2012, 10:05 PM   #54
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Hi Frederic,
You hit the nail on the head. What other business model works by attracting customers and then trying to limit the cash that the business extracts from them. Hoping just that the marketing of word of mouth will generate more footfall.
In my experience a lot of professionals who should have this approach have long since switched to the 'screw the customer' approach; estate agents, lawyers, motor mechanics, builders, plumbers - yes, not surprising, but dentists and vets are increasingly over-treating. Vets are the worst IMO. They have you over an emotional barrel. I mentioned this in passing to a patient the other day and they had initially been charged £120 for their dogs care, the receptionist asked whether the dog was insured and it was - the bill he got back from the insurer was £430.
So many chisellers - but I am glad that we are not amongst them.
Not so kind thoughts,
Steve
Hi Steve,

Dentists are an interesting example here in the UK (my wife is a dentist). When the NHS changed the way that dentist were paid then is vastly changed clinical practice. The stopped paying for one certain procedure and the numbers done went down 80%. They also only get paid the same for one filling as for 3, so they now under treat as they don't get paid for it. It shows that clinical need has very little to do with it.
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Old 26-04-2012, 11:50 PM   #55
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I'd just like to say that I've experienced firsthand the consequences of central planning of plumbing in Europe as well as on the mouths of Europeans (by the regulation of dentistry), and neither, generally speaking, is particularly pretty.

The Danes, in fact, have a funny little term for certain Americans, which, now that I think about it, may be a reference to our relatively pearly, white and intact teeth. They call us "rubber faces" (am I right, Adam, or what?).

I can't tell you how many public restrooms I entered in Paris and southern France (around Lyon) where the toilet pressure was wholly inadequate. And I had just returned from 2 years of eating partially tainted bush meat, greens laden with palm oil and hot pepper soup with partially dried saltwater fish.

Needless to say, I sampled quite a few toilets in France... And you practically have to jump around in the shower to get wet.
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Old 27-04-2012, 01:32 AM   #56
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That's not pure capitalism. That's crony capitalism where the lobbyist with the most cash and whose values are most in line with the current administration influences policy decisions that increase central regulation on business, thereby favoring the business model of the crony.

This is what we're facing in health care- as Jason has already stated: the problem is excessive centralized authority over the industry
I think the difficulty John though is that ideal capitalism doesn't exist as inevitably greed and ego get in the way and there will always be a drive to dominate by those who can. The marketplace is not rational however we might wish it so. A completely deregulated marketplace would simply be to let the wolves among the sheep - slaughter would ensue and those at the bottom would be left ever further behind. I don't want to live like that.

As for the inadequacies of social medicine - well lets not go there, after all we live longer bad teeth or not ...

regards

ANdy

(sorry just couldn't resist)
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Old 27-04-2012, 02:26 AM   #57
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Did I mention that our healthcare delivery system is far from free market capitalism?

Dentistry approximates a free market.
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Old 27-04-2012, 05:45 AM   #58
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John,

Here in Quebec, physical therapy is only regulated (on billing only, it's total freedom when it gets to choice of treatment) when it gets to workers comp and to a lesser extent, MVA. I don't think the overtreating issue is brought up because there is a central control over the billing of WC and MVA per se. Rather, there is perhaps part of the reason stemming from the amount currently paid by the WC and MVA. This amount is much lower than what I charge private clients. Overtreating allows making revenues off volume rather than per treatment. The gouv. doesn't want to increase the amount paid as there is no garanty clinics will stop overbilling/overtreating once the amount is raised unless you put a cap of some sort which clinics won't accept.

From the moment the money used to pay the treatment entirely comes from a third party and the client doesn't have anything to pay, there is a big potential for overtreating, almost endlessly. The fact these aspects seem to even play a role in the road to chronicity makes the issue even greater.
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Old 27-04-2012, 06:05 AM   #59
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From the moment the money used to pay the treatment entirely comes from a third party and the client doesn't have anything to pay, there is a big potential for overtreating, almost endlessly. The fact these aspects seem to even play a role in the road to chronicity makes the issue even greater.
Precisely the situation here. When I worked part-time in private clinics there were patients who rocked up every week or two for "physio" and had been doing so for years. The PTs concerned were of the opinion that if they told patients there was no more they could do, the pts would simply go off to another clinic, so nothing was gained for anyone.

Which is why I like our Medicare system - open and free to all and sundry, but the PTs call the tune; no change after 3-4 treatments with or without poor compliance, the pt was discharged with homework. This did not apply to acute conditions. Each patient could return after a few weeks if they wished to, and sometimes this strategy worked well - they started to improve.

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Old 27-04-2012, 10:37 AM   #60
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Hi All,
As ever SBM have some great stuff and on over billing and what happens when the control of the cookie jar is loose - check out what happens in Florida where every driver needs personal injury insurance and claims of up to $10,000 are poorly regulated.
http://www.sciencebasedmedicine.org/...ins-and-pains/
Needless to say the chiros are a lot more guilty of exploitation than the PTs but hey thats not a standard we like to measure ourselves against. A good one to get your blood boiling on a friday morning.

Hi ANdy,
Re Cognitive dissonance (one of my favourite couplets). I am fundementally a nice guy who dreams of being nasty and so does not let temptation (in its many guises) get too close. I suspect I am not alone. It is the age old interplay of excitement versus security. Leave security for excitement. Feel insecure. Develop security - went excitement. Too much excitement want security back. Get security back, miss excitement. Rinse and repeat for about 40 years and gain self-awareness and laugh!
Kind thoughts,
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Old 27-04-2012, 01:40 PM   #61
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Did I mention that our healthcare delivery system is far from free market capitalism?

Dentistry approximates a free market.
I wasn't referring to anyone's system John, I was arguing that free markets only stay free as long as no-one achieves dominance. Once dominance is achieved the market becomes distorted or is distorted in their favour. Great for them not for the others. Remember historically we all were part of free market economies in the distant past, some always came out on top and in doing so skewed all they could in their favour. It was always thus - it is in our nature. The problem is not the market, it is indifferent rather the problem is us - people.


Regards ANdy
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Old 27-04-2012, 04:14 PM   #62
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ANdy, couldn't agree more. If it weren't for people agitating continuously...
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Old 27-04-2012, 04:23 PM   #63
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Remember historically we all were part of free market economies in the distant past some always came out on top and in doing so skewed all they could in their favour.
Are you talking about when peasants bartered eggs for goat feed? Surely our democratic republics and rule of law have advanced since the days of monarchs and feudal lords?

How else would you explain the unprecedented rise of America in such a short period of time?

As in everything, the context (in this case one of individual freedom and responsibility) is critical.
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Old 27-04-2012, 04:38 PM   #64
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Are you talking about when peasants bartered eggs for goat feed? Surely our democratic republics and rule of law have advanced since the days of monarchs and feudal lords?

How else would you explain the unprecedented rise of America in such a short period of time?

As in everything, the context (in this case one of individual freedom and responsibility) is critical.
Um, a chance to grab everything in sight on a brand new continent with no holds barred, no upper crust to feed and maintain (until a new one formed of course..) ?
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Old 27-04-2012, 05:17 PM   #65
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Um, a chance to grab everything in sight on a brand new continent with no holds barred, no upper crust to feed and maintain (until a new one formed of course..)
Brand new? What, North America suddenly emerged from the ocean floor?

These discussion invariably turn to America (as in U.S.)- bashing. So, I'll bow out now while the Western European socialized economies continue to move inexorably towards bankruptcy...
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Old 27-04-2012, 05:25 PM   #66
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I certainly tend to agree with ANdy. I do not idealise capitalism. Yet it seems probably the lesser of two evils. Then again there are countless variation on the same theme that it is a bit dichotomous to speak of capitalism vs socialism vs communism. It is often really grey and blends with the other comparison of democratic vs totalitarian. Left vs right, ...

These schools of though are trying determine how to share wealth, attribute value (importance) to the individuals and their role through money and arbitrarily decide what job and what knowledge and what idea is worth what based on concepts that are by and large really abstract and subject to cultural values that vary greatly.
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Old 27-04-2012, 05:26 PM   #67
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Whats the national debt of America? Sounds solvent to me
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Old 27-04-2012, 05:33 PM   #68
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Hey John,

No one is bashing the US here right now (and generally we are hard on the one we love anyway). This discussion simply reflects the fact that trying to control societies is meant to be awfully hard and an ideal model is utopic.
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Old 27-04-2012, 05:41 PM   #69
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"Difficulty" (of fairly, equitably, holding the human primate social troop/social commonwealth/society together) rises geometrically, or seems to, whereas "increase in population" rises merely arithmetically. Result: Exponential problema
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Old 27-04-2012, 09:49 PM   #70
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Are you talking about when peasants bartered eggs for goat feed? Surely our democratic republics and rule of law have advanced since the days of monarchs and feudal lords?

How else would you explain the unprecedented rise of America in such a short period of time?

As in everything, the context (in this case one of individual freedom and responsibility) is critical.

I wasn't having a go at the US of A in fact I was trying to avoid it, I was trying to have a go at the concept of the free market as some utopian ideal of trade and social development.

I don't think that resorting to monarchy or feudal lordship demonstrates any sort of free market. If anything they are the polar opposite where one or a group has ascended to a position of power and "lord" it over the rest.

Against that, while I live in a democracy and would not choose otherwise I think we are being self deceptive to think it is quite what it seems or that it came about as some sort of social uprising in pursuit of higher goals. In its nascent form it was intrinsically tied to trade and the drive to wrest power from the aristocracy and their cronies in order to "democratise" trade democracy as a social construct was a by product. However I am unconvinced to date that that amounts to quite the freedom supposed. After all we did not emancipate women until well after the turn of the twentieth century - why not? Blacks were not emancipated electorally until 1865 and arguably not universally until 1965 - again why not?

My point about past history is that we can find times in most social histories were no-one had the economic upper hand but once someone does it seems to me that the less favourable side of human nature does out and the desire to dominate your fellow man emerges or that rise to the position of having leverage demonstrates that desire. Any legitimate tool and sometimes not so legitimate can be used after all its "not personal" its "just business" how many destructive acts has that phrase justified?.

I wish I had your faith John in how things would pan out if all was de-regulated. I think the result would be less than favourable and inevitably the few who are quite willing to screw their fellow man and subordinate moral value to achieve dominance will out and dominate. My view of the world is bleaker than yours.

I am bothered that healthcare now exists in this arena, has become a commodity to be consumed a product to be packaged marketed and sold. The patient is less and less a person they have lost their democratic health right and now must subordinate themselves to those who hold power over health.

Professionally I am not convinced we should have no part in this process. Professionally I am not sure I want to be part of that process at all.

(rant over for now before I do get cross) and no I am not a raving pinko subversive

ANdy
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Old 28-04-2012, 04:13 AM   #71
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The only way anyone "dominates" an open market is through force or fraud. One is usually perpetuated by the central authority to favor one group over another (eg scope of practice legislation) and another by individuals to defraud others (the Florida example). One is a problem with centralizing authority the other with failure to maintain the rule of law. We need a central authority to set ground rules and an even playing field, but not to tilt the table toward any one group. None of our respective governments has managed this.

I'm lucky to work, like Steve, in a socialized medical system where all decisions are totally in the patients best interest, there's never any over-utilization and we have plenty of money to take care of all our patients needs. Because magically when the government does it, human nature changes and we all skip merrily toward our defined-benefit pensions knowing we are the good altruistic people not the evil corporate stooges in the private sector just out to make a buck. Yay government altruism! [/sarcasm]


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Old 28-04-2012, 05:30 PM   #72
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Good Post. Our founders feared a authoritarian government more then anything. Including a little fraud. The first 15 amendments are to control a democratic/totalitarian tyrannical government.
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Old 28-04-2012, 05:54 PM   #73
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I appreciate what you're saying, Smith, but actually the whole damn Constitution checks the power of the federal government. The first 15 Amendments were added because they didn't think the original document was restrictive enough.
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Old 28-04-2012, 08:18 PM   #74
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in a socialized medical system where all decisions are totally in the patients best interest, there's never any over-utilization and we have plenty of money to take care of all our patients needs.
I do not think that socialised systems end up serving the patient any better, too often they become unwieldy and the only people they serve are those who are employed by the system.

I don't think a degregulated market works either for the reasons above. I don't see how it will stay in balance because in the end it is a system and like socialised medicine can be perverted to serve the provider.

I don't think either scenario can be described as altruistic. I think by definition if we choose to make a living from providing healthcare we are not altruistic.

Setting that aside I cannot stomach the advertising, the marketing, the overtreating, the conflicts of interest, the focus on disease rather than health, the almost prostitution of healthcare for personal profit. I find it abhorrent when costs reach such proportions that they are unaffordable or inaccessible to large sections of the population because for them it becomes a luxury beyond what they can afford. Socialised medicine seems to fail to provide an answer becoming no less perverse in its form and maybe there isn't an answer but I would like to explore if there is some other way that healthcare was or could be delivered.

regards

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Old 28-04-2012, 08:25 PM   #75
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The biggest gains (served the most people for the least amount of money, ongoingly) have been nation-wide (no matter the nation) public health campaigns, like sanitation and vaccination.
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Old 28-04-2012, 09:04 PM   #76
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I do not think that socialised systems end up serving the patient any better, too often they become unwieldy and the only people they serve are those who are employed by the system.
ANdy nails it. Three words: public sector unions.

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I don't think a degregulated market works either for the reasons above. I don't see how it will stay in balance because in the end it is a system and like socialised medicine can be perverted to serve the provider.
I think we need enough deregulation to allow competition and market forces to do what they do: increase quality and access while reducing cost. We need enough regulation to establish basic ground rules and control fraud. I among others would like some kind of basic safety net for the truly poor and disadvantaged as well for basic health services.

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Setting that aside I cannot stomach the advertising, the marketing, the overtreating, the conflicts of interest, the focus on disease rather than health, the almost prostitution of healthcare for personal profit. I find it abhorrent when costs reach such proportions that they are unaffordable or inaccessible to large sections of the population because for them it becomes a luxury beyond what they can afford. Socialised medicine seems to fail to provide an answer becoming no less perverse in its form and maybe there isn't an answer but I would like to explore if there is some other way that healthcare was or could be delivered.
I totally agree with these criticisms but find its probably the same in every other industry. There's the tension between quality products and marketing of less quality products more for profit and the exploitation of the system overall by big players who can afford to influence the central authority's rules ostensibly for the greater good, but in reality to favor organized interests. Same thing in the computer industry linux vs windows vs mac vs DIY vs etc, etc.

Ironically the thing most holding back medicine from being cheaper and more accessible is the set of rules put in place by the government. If we had an even playing field versus other providers of services in terms of access and reimbursement we could see huge changes in how musculoskeletal heath care is delivered - while we have these rules, we are stuck where we are now.
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Old 29-04-2012, 12:48 AM   #77
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The problem is that recognition of quality requires a certain maturity of discernment.
Too many individuals are taken by sales-jobs, in ANY field of society.
This includes the health care industry.

The system does not matter, really. In some of the socialized European countries for instance, homeopathic treatments are partially funded - based on popular demands. Which often is driven by celebrity marketing.

I am not overly hopeful regarding any system - but tend to lean towards less top-down regulation in health care AND more regulation regarding marketing.
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Old 30-04-2012, 03:32 AM   #78
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I am not overly hopeful regarding any system - but tend to lean towards less top-down regulation in health care AND more regulation regarding marketing.[/QUOTE]

The problem with regulating marketing, minus the moral and political arguments of free speech and coerced participation in funding, is that the ones doing the regulating then decide what is acceptable or not. Do you really want to compete for regulations regarding the marketing of the type of care that is proposed here and the type of care that is complained about here? I think we know who will win that one.
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Old 30-04-2012, 04:10 AM   #79
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In the private sector here in Quebec, a GP will charge around 80 to 90$ for a regular visits for which he will reserve 20 minutes in his schedule. Whereas for the same consultation he would be given around 36$ in the public sector if he is working in an outpatient privatly operated but affiliated clinic. this latter appointment will last more 10-15 minutes. Even if you ajust for time of consultation, it is still less affordable in the private sector. The clinics are nicer, the equipment is newer, they answer the phone more quickly, you don't have to show up at 6 in the morning to have a spot on the day's minor emergency no appointment list. But in the end, the patients get the same medication for the same problems for a more expansive fee.

In the end, the way I look at things, I prefer the public sector because it does not limit the access to any social class. It limits the access to everyone! But, the gouvernement decides for us what is included/covered which is pretty much every medical (by a medical dr) act with some exceptions when it gets to esthetics. I would prefer they include a lot less to demedicalize people but that won't happen. They control that some other way, by limiting access to non urgent surgeries with long waiting lists and by having you wait something like 12-17 hours at the hospitals emergency if you don't need really urgent medical attention. They won't admit it, but it's their way of controling cost, I'm sure.

If it where all private, who would pay for people on wellfare, for families with low income that can't afford an issurance, for the guy who just lost his job along with his insurance plan? And then you'd have star doctors charging more with no waiting lists that only rich people could afford and skip the waiting lists. They certainly would not encourage demedicalization as the main goal would be profit. Hell, the radiologists around here where complaining about their salary because it was only 500 000$ on average! Talk about being altruistic. But then, in this private system, you could always choose an insurance coverage that suits your views and only pay for the care you deem really needed. You could choose not to pay for the medicalized society. Oh wait, I'm sure the insurance companies and the gouvernement would regulate this too so that you can't really choose...

I'd change a whole lot of things in our healthcare system, starting with a minimal consultation fee of a few bucks but I prefer that it's a public one. For me, the main issue is medicalization, and regardless of the system it is present.
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Old 30-04-2012, 02:21 PM   #80
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Randy, it is pretty simple. ANY regulation or law is decided upon in a democratic way. Goodness, our societies constantly engage in moral and political issues - any law or regulation or change involves that. Which is good: we need to re-examine and debate our assumed rights and responsibilities on a regular basis, and that can only happen in healthy and difficult debates.

Good stuff is never easy.
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Old 30-04-2012, 11:34 PM   #81
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Newer amendments have grossly empowered the Fed government. One of the amendments was the income tax. The sales tax is better way to go. Other amendments empowering one group over another also, think quotas. Or wars without consent of congress. Just wholesale neglict of the constitution.

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Old 01-05-2012, 12:20 AM   #82
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Newer amendments have grossly empowered the Fed government. One of the amendments was the income tax. The sales tax is better way to go. Other amendments empowering one group over another also, think quotas. Or wars without consent of congress. Just wholesale neglict of the constitution.
Taxes are a good idea, but what about when rich people decide not to spend but rather save their money, or when they decide to spend abroad?
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Old 01-05-2012, 02:22 AM   #83
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Randy, it is pretty simple. ANY regulation or law is decided upon in a democratic way. Goodness, our societies constantly engage in moral and political issues - any law or regulation or change involves that. Which is good: we need to re-examine and debate our assumed rights and responsibilities on a regular basis, and that can only happen in healthy and difficult debates.

Good stuff is never easy.
Yes, any law or regulation is decided in a democratic way, as a best case scenario, which means that the majority often gets to decide the rules. This is my point, do you want the majority of therapists to be able to dictate what you can do or say or how you "market" your services? Do you think you or anyone here is in the majority regarding PT and the provision of care?

That is putting aside the other questions, but I myself would say that as few regulations and laws as possible are a better solution and that rights aren't something that are up for review by the majority. If they are dictated by other people or by government fiat then they aren't really rights, they are privileges which can be taken away or ignored.
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Old 01-05-2012, 02:28 AM   #84
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Taxes are a good idea, but what about when rich people decide not to spend but rather save their money, or when they decide to spend abroad?
Frederic,

I think this statement shows the depth of a cultural divide that we aren't usually even aware of. I couldn't disagree with you more regarding taxes being a good idea nor can I think of any reason that "we" should have any control of what people, rich or otherwise, do with their money and I certainly don't think we have the right to force people do to with it as "we" wish them to.

I've read many of your posts so I'm reasonably sure that you don't mean to advocate forcing anyone to do anything, but that is exactly what your question suggests.
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Old 01-05-2012, 02:36 AM   #85
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It's pretty hard to have a society that can hang together in any kind of coherent way with out taxation.
Unless you are of anarchist persuasion, leftORright, in which case, it's a political position, not a workable alternative.
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Old 01-05-2012, 04:35 AM   #86
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Without taxation it would be a very vulnerable society.

Feudalism worked OK as the serfs were looked after in a way although abused; but society could not survive without a fair tax system, ie tax everyone over a certain income, and ensure billionaires contribute equably.

Sounds dire for the anarchists and libertarians, but society slowly collapses if the inequity between rich and poor increases exponentially.

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Old 01-05-2012, 04:52 AM   #87
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I agree that taxation of some sort is necessary, because government is necessary. This does not make it a good thing, it only makes it a necessary thing. The manner and type of taxes are a big issue and those that use the least amount of force in order to gain compliance are the most preferred while those requiring the most amount of force and coercion are the least preferred. Things like usage fees therefore are preferable to imposed taxes such as property and income taxes.

I'll stop now, because I tend to go on and on about this and this is not a politics forum. I guess it is clear that I am a libertarian, most of my views are already out there, written by someone else anyway. My political philosophy can best be summed up as

The initiation of force is always immoral.

Pretty much everything else flows from that. It should resonate with you, it certainly does with most of the clinical philosophies here.
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Old 01-05-2012, 02:28 PM   #88
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This is my point, do you want the majority of therapists to be able to dictate what you can do or say or how you "market" your services? Do you think you or anyone here is in the majority regarding PT and the provision of care?
Guess what? In our world here, the advertising rules HAVE already been tightened up quite a while ago. And these things have been decided by our regulating body (College of physiotherapists) in communication and with feedback from the members (all working PTs in Ontario).
My point was about ALL medical marketing. Decided upon by all involved parties - through their elected governments.

Does it work all the time? No, but I do not like the alternative.
I am not a libertarian, socialist or conservative. I have opinions and ideas about many things, and realize that there will never be a perfect system.

The "initiation of force" being immoral sounds bright and clear, but it is subject to interpretation of what "force" means and entails. too many attacks in the world - political, armed or legal - have been intitiated in "defense" or as "response" to a perceived threat/action. Just saying that lofty ideas WILL be corrupted by people - all the time, in any society.
Sorry, rant over (had a very late night last night....)
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Old 03-05-2012, 05:01 PM   #89
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I think at the end of the day we will never settle the issue of what is high quality and worthwhile paying more for vs what is low quality mass marketing stuff. That is really for the consumer to decide and decision about altruism as the primary motivator vs profit as the primary motivator is probably the only thing we can settle on.

I'm for clarity of motivation and principle, and how that ends up working itself out in a bottom-up self regulating emergent system will be messy and unclear but that's the way emergent systems work.
Ironically less centralized authority would free up far more medical providers to do pro bono work part of the time - so all these rules in medicine really force providers of medical services to be more "profit-focused" rather than "service-focused" to survive. Such is sad but wholly predictable outcome of increasing layers of well-intentioned laws and rules - they end up providing perverse incentives. We imagine that with the right rules we can create a better system but the rules just seem to perpetuate these perverse incentives that make our actual goals harder to achieve.

"The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design." FA Hayek
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