UNDfaninMICH

I don't know much about Portland State. So far my biggest reason to dislike them is the way they shorten the name Vikings to "VIKS".

Where is the place to be in the Twin Cities?

Or as I prefer to call it, Meet the North Dakota.

I wanted to refresh my memory about the Philip Nelson story, so I looked around a little bit. Looks like he never really got a shot with South Alabama, but he's now a walk-on at East Carolina. http://www.cbssports.com/collegefootball/eye-on-college-football/25262618/ex-minnesota-rutgers-qb-philip-nelson-walks-on-at-east-carolina

I would guess you've either never been to the Big Boy in Bismarck, or you didn't visit a Michigan Big Boy. More than one North Dakota native has become excited upon seeing the Big Boy sign in Michigan, only to find it's not at all the same awesomeness found in Bismarck. Same name and logo, different food altogether.

I'm flooding all the polls for Pride, so we can have an awesome new fight song.

I can't get on board with Boondockers. People will put me down 'cause that's the side of town I was born in.

Ronnie Bass! I thought all of his eligibility was used up.

You're still working under a premise that you have not yet proven to be true.

1) Would you do the same for athletes who are admitted to universities despite having academic qualifications lower than the vast majority of the rest of the student body? Put an asterisk on their diploma if they graduate? 2) Medical school is where students learn the framework to then go on to residency, which is where they actually learn to practice medicine. Every medical student must take national licensure exams and pass them before they can move through residency. 3) Do you think that there are not white people who get into medical school despite having lower GPA's and MCAT scores than some of the other applicants?

When did he attend? I don't believe this was the case during my time there, and I have a hard time believing that the AAMC would allow this to happen.

In my mind it's a matter of who is controlling the message. The Seminole tribe in Florida has given approval of the school's use of their name. They have control of the message.

Here's what happened in Cleveland for the home baseball opener: http://sports.yahoo.com/blogs/mlb-big-league-stew/cartoon-predicted-encounter-between-indians-fan-and-chief-wahoo-protester-221403256.html I think even most supporters of the Sioux name have understood why caricatures of Native Americans and dressing in "redface" is offensive to some people.

Yeah, I'm a hospitalist. And I was giving more thought to the question about the x-rays. When I was in training, the x-rays were on film, and if I wanted to see them personally I needed to go down to radiology, have someone pull the file, and put the film up on the box. All of this took time and the location was usually far-flung from where the patients were. So we waited for the radiologist to read the film and tell us what he saw. Now, the x-rays are digital and I can look at them from virtually any computer. Perhaps we should shift towards using our own interpretation when we see fit, and asking the radiologists to perform a "consult" and read the film if things are not going as we think they should go. I'm talking about basic films (whatever is considered "basic" to that given specialty). Would patients go for that? In a setting where patients more directly saw their bills, they might. I could say, "I think this x-ray and everything else about you is consistent with viral pneumonia, and we'll treat it as such. If you want a radiologist to look at your x-ray it will cost you $x more." I can tell you that the radiologist would NOT go for this, but I can also tell you that the radiologist read of certain films often adds nothing to the care of the patient. Their readings might pick up unusual things that wouldn't have otherwise been seen, but that happens fairly uncommonly, again when we're speaking of films that the doc in question deals with on a frequent basis. Arm x-rays for orthopedist, abdominal x-ray for surgeons, chest x-rays for hospitalist, etc. This is another one of those things, where if the consumer was not so far removed from the things that made up their hospital bill, there might be more movement to change. I have no idea what the historical things were that lead to all films being read by radiologists in all hospitals, but I suspect that the "healthcare as a business" mentality had something to do with it, both from the standpoint of radiologists wanting to earn their income, and from non-radiologist being worried about lawsuits over things that they didn't see on x-rays, but someone else with more training may have.

As far as I know, only one doc is going to get reimbursed for the specific billing code that applies to reading the diagnostic test. That is typically the radiologist. If I'm in the hospital seeing a patient and order for example, a chest x-ray, I might be able to look at it right after it is done, whereas there may not be a radiologist reading until after the point that the information is crucially important. My own reading of the chest x-ray gets wrapped into the billing I submit for the day (to put it simply, low, medium, or high complexity of service for that day). My own interpretation of the chest x-ray is just one of the potential components that might bump my level of care from medium or high complexity for that day. I don't bill directly for the chest x-ray, but I looked at it, I took action based upon it, and my actions (hopefully) benefited the patient. I think that's most of the rationale for why I can add that to my level of complexity, but there's also the fact that the ordering of and interpretation of a radiology study is another thing that increases the risk of harm to the patient and increases my risk of exposure to malpractice claims. Consultants like surgeons may be asked to also see the patient and they will also want to look at the radiology studies that have been done, but just like me, they aren't billing directly for viewing those studies. Yes, you want the oversight of the radiologist reading the test. But you also want the docs that have all of the clinical data about you and are seeing you in person to be seeing those x-rays for themselves. A common thing I deal with is radiologist reading of "pneumonia". Now I look at the x-ray, take into account the pattern on the x-ray along with the patient's history related to their illness, their exam, and perhaps some labs, and I figure whether it's most likely to be viral, bacterial, or fungal pneumonia.

This is an issue that irks me every year about this time. It has bothered me less since I've started just discarding the annual student loan interest statement. Just put my head down and keep on paying. It essentially is a way to bump up the rate of taxation on certain higher paid individuals, and that's the part that doesn't feel equitable. I would propose a system by which student loan interest paid is compared to income earned, to account for what you said: my higher income required higher dollars of student loans. The deduction starts to get phased out for single people at modified adjusted gross income of $60,000 and goes to zero at $75,000. $125,000 and $155,000 are the numbers for married filing jointly. So you and your buddy go to get MBA's together. You both get federal loans, because the government feels that you advancing your education is worthy of their investment. You both graduate. You are the one who chooses to work hard and gets promoted, making a handsome salary. You're doing the work your loans and your education gave you the means to do. Your buddy says to hell with it, he wants to go do something else that he finds personally fulfilling, but it also happens to be something that doesn't require an MBA, and his income is below the phase-out threshold. So now the government lets him effectively pay back less of his student loans. Fair? See what you guys made me do? I was starting to live in blissful neglect of this little thing that pops up every year, and I truly haven't opened my interest statement this year. Next you'll have me starting my rant on how Medicaid is a form of a tax on people who accept it as payment, because it is government paying about 2/3 of what the going rate is for a service. Can a person go to the grocery store and buy commodities that are a basic need (like healthcare is) and pick up $100 worth of groceries for $65 in food stamps? No? Shocking. I used to be very judgmental towards docs who refused to see any Medicaid patients. Now I realize that they are more comfortable with "medicine as a business" than I am.

Trust me, reasonable and fair pay for physicians is near and dear to me. When I make the statement that I'm uncomfortable with healthcare as a business, I'm referencing things like: -a system of medication development which is based on "what makes money?" rather than "what is needed to solve medical problems?". This gets us things like isomers of already existing medications that work well but are about to come off patent. This also gets us direct to consumer advertising. We also get pharma reps who are paid to try to convince docs that their new product is the way to go, when it should be peer-reviewed literature that drives practice. That point is an issue that docs need to clean up, too. Those reps also have (at least I think they still have) access to prescribing patterns, so they can learn who is and who isn't prescribing their meds, so they know who to target. Absolutely, new treatments are needed all the time, but do we really need eight different brands of PPI's, several of them again just tweaks of existing ones so that a new patent can be obtained as others are coming off patent? -a system that results in competition for resources (patients and the procedures that come with them). While reasonable people bemoan the use of ER's for non-emergency conditions because of the cost of care provided there, hospitals continue to advertise their ER wait times. Effectively, they're inviting people to come in with their non-emergent maladies, because the wait won't be too long and it will be convenient. In most communities, "wait times" are not applicable to people who have true emergencies, like MI's and traumas, because they get triaged to the front. Hospitals and medical groups are positioning themselves to perform various high dollar procedures, despite the fact that there may be a recognized center of excellence within reasonable driving distance. This is billed as service to the community, but I'm skeptical. Not every community needs a heart transplant program (an extreme example, but you get the idea). -the fact that MD's can transition into administrative roles, work better hours, generate zero RVU's, and greatly increase their salaries. Does it truly take one million dollars in compensation annually to find good talent to be the CEO of a hospital, or VP of Medical Affairs? -if execs at relatively small-time BCBS of ND are being compensated near the $500,000 range, one would imagine that is happening in much bigger numbers all over the country. Why is that necessary? Again, the care management/cost-lowering measures that insurance companies bring to the table are things that are quite generalizable across the country. There is no reason to have a different formulary for one plan in one state than for places elsewhere, other than the deals that insurers cut with pharma companies. Criteria for approval for procedures ought not to vary across the country. Centralize this process and employ more of the clerical types, less of the executive types. As for the physician workforce, I agree with much of what you're saying, but I also agree with what mg says. I want young people to go into medicine because they're interested in it and have talent for it, and by and large that's what I see happening. Absolutely there should be some financial incentive for some of those people to get extra training, and to work within high-risk areas of medicine. There are some areas where this works, others in which it doesn't. Take a look at these slides on dermatology, for example: http://www.medscape.com/features/slideshow/compensation/2013/dermatology Eighth highest compensated specialty, with median comp about $300,000. A full 80% reported 40 hours per week seeing patients, or less. 67% reported less than one hour per week seeing patients in the hospital. Let me tell you, that less than one hour equals "zero" for most of them. No calls from the hospital in the middle of the night asking for them to come in and see patients. Dermatology is one of the most competitive specialties for students to get a residency spot in, so that only the ones who are considered the best and brightest of their class have a shot. Is it because learning the content requires that they be more brilliant than their classmates? Nope. It's because the residency spots are few, and the reward for that training is great pay with great hours. The big compensation comes from the fact that RVU systems value procedures over thinking, technical skills over problem solving, and dermatologists perform tons of quick office procedures. Medical student debt is another major problem, as you mentioned. Medical students are told that their tuition pays for only a fraction of the cost of educating them. Here in Michigan, Wayne State U gets $32,000 in tuition and fees for residents ($64,000 for non-residents!). They have about 300 students. $9,000,000 per class per year. The last two years of their education are in hospitals, with largely faculty who are paid a relative pittance for having teaching med students, and the costs of the last two years to the school are mainly administrative costs. I have a hard time that believing that the $36 million annually collected in tuition goes to direct expenses of educating medical students. The total cost of attendance they list is about $55,000 per year. Given that many of these students have undergraduate debt that they need to defer so that it accumulates interest during their years of med school and residency, your estimate of debt at $200,000 is unfortunately low. From what residents tell me, gone also are the days of low-interest loan consolidation. This again drives people away from the primary care fields, as you noted. This is not a complaint about my own state of being, I think I'm compensated well, I enjoy my work (mostly), and my debt from UND comes nowhere close to the debt that students these days are facing. Some residents, through what I would say were less than ideal personal choices (private undergraduate school, non-resident medical school) are projecting to finish residency with $500,000 in debt. I'm worried about the future.

I think the above gets me back to my discomfort with healthcare as a business to be invested in. It's a commodity that pretty much everybody needs, like public education, or police and fire protection. Maybe that makes me the ultimate socialist, but as I said before, socialism in medicine has been around for a long time, it's just disguised in that the money shunts through insurance companies rather than the government. Or in the case of Medicare and Medicaid, it shunts through government, then to insurers, and then to providers of healthcare.

I appreciate your understanding of this topic, because it's better than mine. The last part of your statement is the part that I still don't grasp. I understand that investors think about percentages, that's a simple concept. We all want to invest our money in areas that yield the best return. In the example where you said that by law the payments out have to be at least 85% of the premiums paid, the premiums aren't an investment, it's other people's money. The insurance companies keep a percentage of it to cover their cost of doing business. This is why I think that the "absolute" margin matters. As the insurers add more insured individuals to their plan, their cost of doing business per insured individual should go down. They need to employ people to make a formulary, for example, but once they have a formulary, it is applied to each patient. Sure, they have to employ more people to manage all the payments, denials, questions, etc., as they add more insured individuals, but they also have many costs which are fixed, so that each new patient should increase their revenue. Wouldn't this explain how the CEO of a huge insurer like United Healthcare can be paid $5 million? Did he personally invest $30 million and his return on investment is 15%?

I'm not trying to be obtuse, I truly know little of the finance world. Comparing a health plan to retail seems like apples and oranges to me. At some point doesn't the absolute margin (if that's a thing) matter more than the percentage? For example, car dealers apparently sell their vehicles for a relatively smaller margin by percentage, but since it's a $40,000 vehicle, those small percentages add up and may easily exceed the profit made by the Mom and Pop grocery store on the corner (acknowledging here that those don't exist). A retail store also has to stock inventory, and they are responsible for acquiring it and paying for it. If, for example, the car dealership wants to sell more cars, they have to buy some wholesale to then sell to the public. Some of those cars may go unsold, and the dealership eats the cost. In healthcare, the insurer is serving more as a broker... they have the access to the commodity (contracts with physicians, hospitals, etc. to accept their payment), but they don't pay for it until there is a buyer for it. This would be like a Chevy dealer who has relationships with the manufacturer, and only acquires a car when there is a customer for it. In the retail setting, when the dealer has success, the manufacturer has success. In healthcare, when the insurer has financial success, the manufacturer of the commodity (the physicians, hospitals, etc.) does not have financial success. It seems to me that although many people rail against socialized medicine, we have it. Healthier people (and their employers) are paying for healthcare at a rate beyond which they are consuming it, because sicker people (and poorer people) are using healthcare at a rate beyond which they are paying for it. Unfortunately, if we allowed people to pay as they go, we would find that people don't save for the healthcare they're going to demand in their later years. We have the insurance companies in the middle which makes many people feel that there is not socialism in health care. I'm not saying this socialism is bad, because I don't know of any other good means to fund it. Count me as a "provider" who would skeptically welcome pooling of resources (single payer). Medicare is already a huge single payer, and last I knew, most docs who care for adults still accept it. Allow people to get a rough idea of how much they'll get paid based on how much work they do, and let them decide if incurring the debt of medical school and stress of medical school is worth it. It works for the military, right? I like the fact that I have a reasonable income and can comfortably repay my student loans, but healthcare as a business makes me a little bit uncomfortable. It makes me beyond a little bit uncomfortable to know how much the brokers of that healthcare (and medical executives, for that matter) are lining their pockets from it.

So maybe that statement was unfair. What I should say is they are doing a job which is duplicated all over our country by various organizations who are making quite a living from doing it. And I get the point that insurance companies might help keep costs down by such things as formularies and pre-approval of tests and procedures, but is there a reason that say, for example, BCBS of ND and BCBS of MN couldn't pool resources? I stand behind my belief that the "15% to cover costs" is still one heck of a lot of money.

Where do I sign up for some of this "no money in health insurance" that reimburses relative small-timers like CEO's of BCBS of ND nearly half a million? Sure, they only get to "keep" 15% of what they collect, but they're not manufacturing a product with that other 85%, they are doing clerical work.

In 2011, the Fargo Forum reported that the top three highest paid executives at BCBS of ND were compensated roughly $400,000 each. Reasonable, or no?

If you are feeling like big timing it, there are some great places to stay within an easy walk of the arena, including the Amway Grand and the JW Marriott. If you don't stay downtown, parking for the arena is easy and usually costs $8 for the night. As I mentioned in another thread, Grand Rapids recently won the title of Beer City, USA. Lots of great microbrew here. Founders is a must-see, a brewery not far from the arena. Hopcat is a taproom within two blocks of the arena if you want to experience a wider variety of breweries. The Grand Rapids Brewing Company recently re-opened right across the street from the arena. The food is good, the beer is OK but nothing special. If you appreciate good beer, don't waste a minute going to the BW-3 right by the arena, you can find that anywhere. The B.O.B (Big Old Building) is also right across the street from the arena and gets a lot of business. It has a few different restaurants which are pretty good, as well. Friday starts spring break week for Michigan public schools, so things might be a little slow around town, which I take as a good thing. Feel free to hit me up with any questions about visiting GR. There are too many great restaurants to list them all, but I'm more than happy to make some suggestions if you let me know what you are looking for. There are lots of things to do in the down time between games, too. Just let me know.

I'll be making the 20 minute trip. SO pumped for the games to be here.