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The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

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Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

#11

Post by AnimalMuppet »

orbz wrote: post #3

I’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 could see a single payer system having the same problems. All it would take is a system with some incentive to save money, and a bureaucracy. I could easily see Congress designing a single payer system that had both of those.

Would it be as bad? Hard to say. In one way it would be worse: There would be no alternative. You couldn't switch insurance providers to get something better.

And, in fact, just today I saw stuff about a lady in Canada who had to wait 7 hours (+/- a small amount, don't have it in front of me) for the ER, and wound up dying. People were saying "The system is broken." Well, isn't Canada single payer?

So maybe single payer isn't a magic solution. Maybe we should look at what's going wrong in Canada before we design such a system ourselves. (Single payer may still be the answer, but it's going to have to be a well-designed single payer system.)

Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

#12

Post by DrWorldwide »

"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 being given was futile or not. The doctors, the "palliative care" specialists, completely s** the bed there. We would have been open to good, quantitative, rational medical arguments -- the type of data-driven conclusions that guide the rest of the medical world -- but instead the palliative team (external consultants actually) seemed capable only of the basest emotional and social manipulations. We concluded from the lack of rational arguments that there was in fact no well-reasoned basis to discontinue care, and that the palliative team was really just a crew of hired guns brought in to lower hospital costs.

If you do in fact see this inefficient rationing of precious care as a major source of burnout, it seems to me that there is an enormous, wide-open opportunity to conduct studies on predicting outcomes for ICU patients & other patients with advanced conditions. It really made my spine tingle when every single doctor I asked about this simply had no reply.

Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

#13

Post by verdenti »

orbz wrote: post #3

I’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…

Single payer is good but it doesn’t solve the problem of really sick old people running up the bill for everyone. I don’t even see what the way out is. Really old people that are subjectively classified as irrecoverable have to get private insurance on top of single payer maybe otherwise you get cut off. That subjective decision maker will get called a “death panel” though. Someone’s got to make some hard decisions somewhere.

Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

#15

Post by sfuller808 »

AnimalMuppet wrote: post #11
orbz wrote: post #3

I’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 could see a single payer system having the same problems. All it would take is a system with some incentive to save money, and a bureaucracy. I could easily see Congress designing a single payer system that had both of those. Would it be as bad? Hard to say. In one way it would be worse: There would be no alternative. You couldn't switch insurance providers to get something better. And, in fact, just today I saw st…

[dead]

Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

#16

Post by pfraze »

DrWorldwide wrote: post #12

"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 gotten an answer as to why this hasn’t become a policy yet, but it seems like it could help.

Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

#17

Post by weakfortress »

CynicalMD wrote: post #2

Continued: 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…

I'd like to add one more thing to this you probably experienced as well. My family has several people in medicine. All of them have done a stint in a hospital before quitting for greener pastures.

The homeless problem (now renamed "experiencing homelessness" as if this is a cure-all) has reached such critical mass that hospital beds fill up with patients that have no ailments. How do they do this? I'm sure you know. A homeless person who is either withdrawing, or cold, or hungry, or just a nuisance will come into the ER and tell the attending that they are suicidal. At this point a bunch of alarms go off. At least here where I live this means they are issued a bed immediately ahead of nearly all other patients and subject to 24 hour monitoring. They can, depending on hospital load, be given free room and board for up to 72 hours before a psychiatrist is mandated to give them a cursory once-over before sending them back to the street. They'll be back next week, once again suicidal, and once again consuming more resources than they will ever in their life time put back in.

The hospital can do nothing because turning down one of them who is actually suicidal would damage the hospital. So, people with actual real problems are pushed even further to back or left to line the hallways on gurneys because a homeless person was mildly inconvenienced by their, in all likelihood, self-imposed suffering.

Your notes on primary care are spot on. That has been my experienced as a layman with medical family. I know what they are going through yet I still feel shortchanged and often ignored by my PCP. Private clinics are no better.

Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

#18

Post by mikeyouse »

endisneigh wrote: post #5

Seems 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-congress/house-bill/2256... https://www.congress.gov/bill/117th-congress/senate-bill/834...

Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

#19

Post by lotsofpulp »

AnimalMuppet wrote: post #11
orbz wrote: post #3

I’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 could see a single payer system having the same problems. All it would take is a system with some incentive to save money, and a bureaucracy. I could easily see Congress designing a single payer system that had both of those. Would it be as bad? Hard to say. In one way it would be worse: There would be no alternative. You couldn't switch insurance providers to get something better. And, in fact, just today I saw st…

>I could see a single payer system having the same problems.

You can look at the UK right now. The root problem has nothing to do with health insurance companies or who is paying. The problem is drastic increases in net benefit recipients relative to net payers/labor providers into the system.

I.e. declining proportions of healthy, working people willing to provide labor at a sufficiently low price, such that in order to keep providing the same level of service, more and more of the country’s resources have to go towards healthcare.

The other problem is also advancements in medicine that keep people alive longer and longer while utilizing ever more healthcare services.

Re: The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician

#20

Post by a-user-you-like »

orbz wrote: post #3

I’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 areas.
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