Are the problems the same for all branches of healthcare? The conditions of hospital emergency rooms have been a topic of concern for many years. But there is also the matter of worsening conditions at small clinics, especially since the implementation of the ACA. Would it be more informative to distinguish between hospitals and small clinics when discussing problems and causes?
The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
21–30 of 228 posts
Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
#22Seems like we need to lift the residency limits and allow for more doctors to be added to the work force.
There is no limit by rule -- just by funding. We've had really nice increases in medical school graduates since the ACA, but predictably, one of the two major parties is staunchly against spending more dollars on residency slots so they torpedo the legislation every time when it's proposed (the vast majority of residency funding is provided via Medicare). The most recent bill: https://www.congress.gov/bill/117th-cong…
The issue isn't a shortage of residency slots, it's that we don't allow doctors with foreign residencies to practice in the United States.
The physicians in Spain and South Korea and Costa Rica are really good. Arguably better than American doctors based on health outcomes. Many would jump at the chance to earn high American wages. There's no reason a South Korean doctor with ten years of experience in the world leading hospitals of Seoul shouldn't be allowed to practice medicine in the US just because he didn't do a residency in rural Alabama
Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
#23Continued: Why did you end up in the ER in the first place? If you’re lucky enough to have a primary care doctor, they probably couldn’t see you for at least a week or two because they’re too busy. By busy, I mean filling out prior authorization forms - the bureaucratic stranglehold of the health insurance companies is immense. If you had abdominal pain the primary care doctor could easily order labwork and a CT scan…
Many, many people are still rushing to enter med schools, despite numerous comments like yours and essays like mine: https://jakeseliger.com/2012/10/20/why-you-should-become-a-n...
It still pays well, and the system is setup to be very generous to physicians. Student loan forgiveness is available to physicians[0] and its not super hard to meet at least one of the qualifications, as physician demand has been intense for decades, so the debt load can be decreased significantly (and often outright forgiven after a set number of years) by just working the job.
The pay is also still super good. Even a primary care physician will most likely make 200K or more. Specialty physicians typically make even more than that, I've seen quoted anywhere between 300-700K, sometimes more.
And don't discount prestige. While jury is out if lawyers still garner prestige with the average person, being a board certified medical doctor certainly does, and I don't think this privilege in society should be discounted (and arguably, might even be deserved at times). This inevitably will drive at least some of it.
While physician assistants, nurse practitioners and other forms of care are eating at the very low end of a physicians duty, we're a long, long way from anything really upending them.
Taken all together, I'm not surprised. Though residency is grueling and the work is hard, it does seem to pay off in the long run, unlike alot of other things in society.
That said, nurses and PA's are also in super high demand, and I've seen some nursing salaries even edge out doctors in some cases when they do travel stuff, and of course you aren't married to your student debt the same way (all that fancy forgiveness is tied to actually being a doctor, after all) so if you get stressed, hate it, or otherwise give up the ghost on that career, its easier to move on
EDIT: I'm not saying these are good reasons, per se, but they certainly are, from all available evidence, reasons people become an M.D.
[0]: https://www.nerdwallet.com/article/loans/student-loans/medic...
Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
#24Continued: Why did you end up in the ER in the first place? If you’re lucky enough to have a primary care doctor, they probably couldn’t see you for at least a week or two because they’re too busy. By busy, I mean filling out prior authorization forms - the bureaucratic stranglehold of the health insurance companies is immense. If you had abdominal pain the primary care doctor could easily order labwork and a CT scan…
> Can we fix the U.S. Healthcare system? My opinion is no. I am going to say that every large 'super' institution will end up in this problem ... Unfixable. Whether it is military, judiciary or educational system -- they have the same issues as the healthcare system -- when they grow 'super-large' and become managed centrally (either directly or via near-centralized money flows). It is the nature of end-days of human…
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Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
#25I’ve been working in the health tech space for awhile now and it’s sad how you’re not alone in noticing this. It’s the dirty secret of the entire industry, and there’s too many things disincentivizing any fixes. The more I witness this the more I realize that having a single payer is necessary to actually break up enough of the monopoly to get some traction on this problem. Until then there are too many middle men an…
I've read that a single-payer system is very unlikely in the USA, due to political forces. The tremendous inefficiency of the American medical system increases costs, but also provides more jobs, and those job-holders vote.
Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
#26Everyone knew Obamacare would cause this (or make it worse), but no one could do anything about it because there was no alternative plan acceptable to a large enough majority.
Obamacare dramatically increased deductibles, in the name of providing "coverage" to everyone. What ends up happening is people don't pay the deductive.
What should have happened is politicians should have worked on costs, not on payments. They should have worked on dramatically increasing healthcare supply not availability. Trump tried, a bit, by forcing hospitals to release price lists, but I have not seen lower costs as a result.
And I don't just criticize, I have two ideas to help:
1: Encourage capitation[1] - people should pay a fixed amount that covers everything* no exclusions, no co-pays, or anything else. Care is gated by lower cost professionals who escalate to higher cost general practitioners, and then specialists, as needed. The Doctors are paid a fixed salary that does not depend on how many people they see or how many procedures they do.
2: Gut employer healthcare. Just give everyone cash (in a tax controlled way) that can only pay for healthcare. In a two person household they can pool the cash and it should be enough to pay for coverage, with complete competition. People with lower income would automatically receive subsidies that would help.
3: No more special Medicare coverage - it would be routed via the identical path that others use, except the subsidy is higher. I've helped people on Medicare - the government coverage is terrible, the only good coverage is Medicare Advantage which is private care paid for by the government, which works well.
Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
#27I have a question, which you may not know the answer to, but I'm just asking it to everybody these days.
Let's say hypothetically that all the medical providers suddenly all decide to stop being evil. They increase staffing to safe ratios. They even have extra staff so people can take vacations and have days off without it being a problem. They give everyone very good compensation and the big time administrators stop being unfairly overcompensated. They only make people work a maximum of 40 hours per week like normal humans.
If they decided to do this, the question is, are there enough staff available? Are there enough humans who have sufficient training in medicine, who are willing and able to fill all of those positions in every part of the country? In every part of the world?
Surely capitalism and greed are the immediate problem. But is it masking a deeper problem that there just are not enough medical resources to go around? I don't know. It might be, it might not be. If there is enough, then ok. The only problem we have is greed, and we're already fighting to solve that. But if the deeper problem is there, is there any short term solution? Sure we can start training people and make lots of incentives for people to enter the field, but that will take years.
Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
#28"Up in the ICU hopeless 95 year olds will sit on ventilators and other life support machines for weeks because doctors don’t have any discretion in stopping futile care. You can be a 30 year old pregnant woman, and you will die waiting for your ICU bed in the emergency room." I recently went through a situation where my family member was the 95 year old. The immediate family had no basis to judge whether the care bei…
This is an open debate in the medical community. I’m told there have been pilot programs for “end of life counseling” where folks at a certain age are given advice about quality of life expectations once this situation is reached. They often responded by talking to their families and creating plans for ending care before things are bad, solving the weird pressures that families feel in that situation. I’ve not yet go…
End of life counseling became a political third rail when it was rebranded as "death panels" by Sarah Palin in order to delegitimate the ACA. Since then, it has been avoided as a topic of public discourse by the media.
Discourse around death in general makes people queasy. We tend to avoid the cognitive dissonance between the idea that supplying less end of life care would dramatically reduce medical expenses and the idea that all people deserve the best chance at life[1]. We are similar avoidance when MAID is discussed specifically because we know incentives and values clash.
1. this could probably be phrased better. sanctity of human life and dignity if human life don't quite fit because those are meager at EoL and value of human life sounds a but off.
Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
#29I’ve been working in the health tech space for awhile now and it’s sad how you’re not alone in noticing this. It’s the dirty secret of the entire industry, and there’s too many things disincentivizing any fixes. The more I witness this the more I realize that having a single payer is necessary to actually break up enough of the monopoly to get some traction on this problem. Until then there are too many middle men an…
We already have a ridiculously regulated, stifling environment. More stifling is not the answer, just look at the wait times and patients being denied basic care in Canada and the UK. We need to end the ridiculous grip the AMA has on the # of doctors; get rid of the hospital certificates of need, and encourage a new industry of medical professionals who specialize in certain areas without unneeded training in other a…
“… encourage a new industry of medical professionals who specialize in certain areas without unneeded training in other areas.”
Sounds stifling. What’s the problem with holistic training? Except some admin does not want to pay for it?
Extreme division of labor will just create backups for some specialists and time to twiddle thumbs for others.
The opposite across society seems necessary; people need to become more self reliant across contexts. Remove industrial manufacture pipelines so more raw materials are available to the general public and make more holistic and well rounded people.
Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
#30Continued: Why did you end up in the ER in the first place? If you’re lucky enough to have a primary care doctor, they probably couldn’t see you for at least a week or two because they’re too busy. By busy, I mean filling out prior authorization forms - the bureaucratic stranglehold of the health insurance companies is immense. If you had abdominal pain the primary care doctor could easily order labwork and a CT scan…
> Patients yell, they are demanding, they are untrustworthy.
This gets a lot of comment, but it's half the story. I get most of my medical care abroad, but have escorted family through through local medical visits. I've noticed a marked decline in empathy among medical staff the past few years, even in the secretaries at the front desk. This seems to be a general social trend, not just a problem of bad patients.