A view from the other side (healthcare reform)

[fpres]

This thread was inspired by a recent question related to Pres. Obama's proposed healthcare reform plan...

As a family practitioner, I’m greatly disturbed by what I see when looking at the state of healthcare in this country. (Just to qualify my statements, I’ve been practicing for three years...currently splitting my time between opening a solo micropractice and working as an outpatient provider for the county health district).


While some of what President Obama proposes is good (making generics more available, for instance), many other aspects of the proposed plan to reform healthcare show that there may be a fundamental lack of understanding in Washington with regard to just how bad things are and where the real problems lie.


To paraphrase... a large part of the proposed “cuts to Medicare and Medicaid” involves trimming payments to insurance companies, hospitals, and doctors. Dissecting this further, I’ll take a look at just two proposed methods for accomplishing this.


There’s a provision for the creation of a single bundled Medicare payment covering both the hospital stay and care for a patient for thirty days after discharge. How is that possible when the hospital docs and the outpatient primary care docs are two separate entities? Who decides who gets what? In today’s healthcare environment, it’s common for providers in each setting to not be in the same network (managed care or otherwise).


Another proposal would reduce or eliminate payments to hospitals that routinely readmit patients after they’ve been discharged. While this is being touted as a proposal to combat against “substandard original care,” I see no indication that things like disease severity, comorbid conditions, or patient noncompliance are taken into account. If you thought that emergency room wait times and wait times for admission were bad before, just wait to see how things look when primary care clinics are flooded with sicker patients that the emergency rooms feel compelled to punt.


The sad truth about medicine is that primary care is dying a slow death. Fewer and fewer med school graduates are choosing it as a profession for a myriad of reasons, from having to spend half your day fighting with insurance companies to get needed tests approved or get authorizations for medications that your patients need to be on...to fighting an ever increasing battle to get reimbursed so that you don’t have to lay off your staff or shut down altogether. Reimbursement from Medicare/Medicaid and other private insurers has indeed either fallen or failed to keep pace with inflation on a year-by-year basis if you look back into the previous century, to the point where many existing primary care physicians are leaving the profession in their 30’s or 40’s. Many feel that it simply isn’t worth it to keep treading water at that point when you’ve already given up a decade of your prime earning years getting trained and are now trying to support a family with a $200k med student loan albatross around your neck. Alas, people interested in medical careers are beginning to realize this: There was a 3% drop in first-time applicants to med school this academic year. Couple that with the declining percentage going into primary care and the early retirement of established primary care physicians, and you know where this is going...


Those providers who are deciding to fight the good fight and stay in the profession are being forced to adapt as well. Fewer are accepting Medicare or Medicaid at all (over 50% of Texas physicians now opt-out entirely, with numbers catching up nationally) and many more are limiting the number of Medicare/Medicaid patients they see. Nearly all of my friends and colleagues in the profession are instead going the route of fee-for-service (cash pay), micropractice with a limited slate of insurers, or academics rather than deal with the headache that a single-payer system brings. I find it ironic that the day may come when there truly is “universal healthcare” in the U.S., only to have everyone turn around and find that most healthcare providers choose to not accept it. (Yes, there are more than just a few who would retire if it comes to fruition.)


There’s plenty more to be concerned about (a nationalized Electronic Health Record, the impending transition to ICD-10, etc...all of which will be incredibly expensive), but I’ve been longwinded enough.

[JediKooter]

We'll just import all the doctors from India.

[Radii]

Good post. I work on the technical side of things, as an expert with the HIPAA/X12 data formats for claims and eligibility. When I first started working for a healthcare clearinghouse in 2003 the biggest shock was simply the delay in the system. A provider would send us a claim, we would format it and send it to the payer(Medicare or whoever), and if there was a bug somewhere in the system and the claim was formatted improperly, it would likely be 3 months before we found the problem.

Why 3 months? Because it took 4 weeks for the payer to initially reject the claim, then another 1-2 months while the provider tried to figure out what was wrong with the claim and go through the resubmit process. If there was a minor technical glitch that had gone unnoticed, it would not even be researched until this process had been exhausted. All the while the doctor has not been paid for his work, and has massive overhead with all the hours that the office staff has spent trying to deal with insurance.


The system is simply FUBAR. And no one seems to have a damn clue about how to even improve it, much less fix it, without going through a massive political mess where you end up with something like HIPAA, which turned into a giant clusterfuck that, at least from a technical perspective, had a ton of loopholes and didn't improve much at all. Some of the impacts of HIPAA as far as privacy go seem to be solid and useful, but the technical side is a giant mess.


Electronic Healthcare records excite me quite a bit. If done well that seems like it could provide a significant improvement to patient care. But it will be very expensive and there will be a lot of resistance in the short term, and the chances that its done really well seem slim.

Given the current state of things, I don't know why anyone would want to be a family/primary care doctor in the US right now.

[RainMaker]

While I understand your viewpoint, what would your suggestions be to fix the mess? I know there are some who don't agree with it, but I've seen few alternatives.

[gstelmack]

Originally Posted by Radii

Electronic Healthcare records excite me quite a bit. If done well that seems like it could provide a significant improvement to patient care. But it will be very expensive and there will be a lot of resistance in the short term, and the chances that its done really well seem slim.

My primary care doctor is already completely electronic. He brings one of the small netbooks in every time, has easy access to my records (whenever I have a foggy memory, it takes him about 15 seconds to go "oh yeah, back in April '07 we discussed blah"), and prints readable prescription forms to take to the pharmacy. It's great from a patient care perspective.

[cartman]

Originally Posted by Radii

Electronic Healthcare records excite me quite a bit. If done well that seems like it could provide a significant improvement to patient care. But it will be very expensive and there will be a lot of resistance in the short term, and the chances that its done really well seem slim.

This is something that my company is working on, and we have a really good pilot going on with a hospice company that is about to rolled out nationwide. We are also partnering up with some pretty big companies, and I think with the incentives put forth in the stimulus package for providers to move to EHR, it will happen sooner rather than later.

[Eaglesfan27]

Great post, fpres. I know many of my colleagues in primary care who feel the same way. I loved pediatrics before I started medical school, but when I saw the logistical nightmares that they go through, it quickly dropped off my radar.

The desire to avoid fighting with insurance companies was also a significant factor in my decision to initially work in academic medicine and then to work full time as a state employee. If some of these changes occur, it may become more difficult for me to continue as a state employee in the future.

[RainMaker]

I think the electronics move is kind of a petty argument from doctors. It's the future and it makes the industry more efficient. I understand there are costs involved, but that's life. I'm sure there are businesses who didn't want to put their stores online.

[Radii]

Originally Posted by gstelmack

My primary care doctor is already completely electronic. He brings one of the small netbooks in every time, has easy access to my records (whenever I have a foggy memory, it takes him about 15 seconds to go "oh yeah, back in April '07 we discussed blah"), and prints readable prescription forms to take to the pharmacy. It's great from a patient care perspective.

Yeah, mine is too and it is pretty awesome.

The nationalized healthcare records that fpres is talking about goes much further than that. The ideal is that each patient will have one universal healthcare record stored electronically and accessable by any doctor you seek care from, whether it be a primary care doctor, a specialist, or an emergency room/urgent care center.

The easiest benefit to be seen from this is that it reduces the risk of problems that can come when you take two medications that interact poorly with each other. With a well-done EHR system, there is no way a specialist you are seeing could prescribe a drug that will cause problems for another drug that our primary care doc has you taking. It would also provide instant and fully accurate access to your full medical history, allowing specialist and ER doctors to make faster and more accurate decisions.

The problems as i understand them are twofold:

a) security is obviously a HUGE concern
b) Many companies are coming up with solutions to this. there is a risk of having multiple solutions that don't work well together so that you can only get the best possible care by having your EHR made available if you go to a specialist that uses the same EHR software as your primary care doc.

[JediKooter]

As an outsider, I guess I really don't understand this whole thing. From my point of view, all I see is a group of people who are not happy with how something works, but, they keep going back to the same broken down old mule instead of shopping around for a brand new work horse.

The government will just make it worse in my opinion. Just look at the VA.

If this is to be fixed, it's going to have to be fixed from the inside, from the people (doctors, nurses, etc...) who work in the system, in my opinion.

[gstelmack]

I understand the security concern, as people have to be able to access them. The technical part just requires talking to Wall Street and the banking systems, they've been interoperating on this stuff for decades, transferring data back-and-forth to clearing houses, etc. There'll need to be a central data authority that mandates the communication formats and the like to keep it standardized.

[Radii]

Originally Posted by gstelmack

and prints readable prescription forms to take to the pharmacy.

e-prescribing is a reality in North Carolina now, though I don't know how many doctors/pharmacies use it. I'm out of touch on it now, but when I was working at a clearinghouse a couple years ago, it was something that each individual state had to legalize and only about 12 states supported it.

I never have to go turn in a paper prescription anymore, my doctor can send my prescriptions to my local CVS electronically and I can run by and pick them up.

[Eaglesfan27]

FWIW,

I'm completely in favor of the electronic record, as long as the security issues can be properly addressed and the infrastructure is in place to support it and the software is well designed. I think it can prevent mistakes and save lives if it is a good system. The VA had an electronic record system when I worked there, and it was a very poorly designed system that I actually believe led to more medication errors.

[DaddyTorgo]

exactly. the interoperability concerns are a joke. the security...fine...that's an issue. but if we can secure all sorts of government data electronically surely we can secure my medical records so no identity thieves can discover my blood pressure and cholesterol

[cartman]

Originally Posted by Radii

Yeah, mine is too and it is pretty awesome.

a) security is obviously a HUGE concern

This is the main focus of our company. We're providing a way for the data to be encrypted and transferred, and the only ones that can unencrypt the data are the folks predefined to do so. So we can audit the data all along the line. We've already helped a couple of companies fight HIPAA privacy violations based on our way of securing, encrypting, transferring and auditing data. That helped us get on the radar of some of the big boys in the healthcare software arena.

[sterlingice]

Originally Posted by DaddyTorgo

exactly. the interoperability concerns are a joke. the security...fine...that's an issue. but if we can secure all sorts of government data electronically surely we can secure my medical records so no identity thieves can discover my blood pressure and cholesterol

I don't have time to make the full post right now (meeting in a minute) but he's right about the interoperability of systems- not really a problem.

I interviewed at Cerner a couple of years ago. They already have something really similar in Britain but to keep all of their eggs from being on one basket, they split the country into 5 regions with 5 different countries doing the systems (Cerner being one of them).

SI

[fpres]

Originally Posted by Radii

Electronic Healthcare records excite me quite a bit. If done well that seems like it could provide a significant improvement to patient care. But it will be very expensive and there will be a lot of resistance in the short term, and the chances that its done really well seem slim.

I love the concept of Electronic Health Records, but I see many of the obstacles that you mention making the whole proposition a difficult one to pull off well.

The majority of physicians in the U.S. currently do not use an EMR/EHR, and that is due to a variety of reasons (cost, old habits, time, laziness, etc.). In order to develop an EMR/EHR that is truly nationalized and functional, it needs to be as useful to the family practitioner as it is to the cardiologist or psychiatrist or neurologist and so on. The list literally could go on for a good while, and that's not even taking into account ancillary health care services such as home health agencies, nursing facilities, hospice care, rehabilitation facilities, employee health centers, schools, and government facilities.

For each of these locations and specialties, there are those practitioners who have already chosen their own individual EMR/EHR from the vast amount of private-party products that are out there. Not only does a nationalized EMR/EHR have to be constructed and made compliant with HIPAA/JCAHO/etc. but there needs to be a built-in ability to seamlessly transfer information from all of these outside electronic sources into the new electronic system. Plus, like I mentioned...the majority of docs in the U.S. do not use an electronic system and instead may have years (or decades) of paper charts that need to be captured. This system would then need to be implemented nationally, from NYC to the country doc whose office is fifty miles from the nearest town.

I love the concept (I'm implementing one into my own micropractice). I just don't envy the job that someone is faced with pullling this off.

[Radii]

Originally Posted by DaddyTorgo

exactly. the interoperability concerns are a joke.

This should be true but many Healthcare companies are fighting like hell and charging more because HIPAA's technical requirements are forcing them to leave the 1970s/1980s and join the 1990s. This is not an industry that will go easily, or voluntarily, towards new technology or towards common sense standards even if they work perfectly well in other industries.

At least that is my perception based on my experience working with many large national payers. Hopefully that culture is changing/will change.

[sterlingice]

Originally Posted by sterlingice

I don't have time to make the full post right now (meeting in a minute) but he's right about the interoperability of systems- not really a problem.

I interviewed at Cerner a couple of years ago. They already have something really similar in Britain but to keep all of their eggs from being on one basket, they split the country into 5 regions with 5 different countries doing the systems (Cerner being one of them).

SI

Ok, to go back to this post...

The way they described this is that England (not Britain; sorry, was in a hurry) went through this in the last couple of (few) years. Not all of England was to be covered by any one company- could you imagine giving that kind of power?

So, they split the country into 5 regions and each company awarded the contract was given 1/5th of the country to make a system for. However, there are also parameters that all had to share so they could be interoperable. For example, if you live in London and your info is on System A in London's district but you are vacationing in Cardiff, which is covered by System B, System B can pull your info from System A.

Frankly, I'm certain it won't be perfectly secure. Are any of our systems? That said, it's not like any random criminal is going to get your medical records and, if so, how does that really harm you? I guess maybe if someone wanted to kill you and saw you had a peanut allergy or something. But that's something people tend to discuss with close friends. Similarly, celebrities or someone else in the public eye will probably have records that will leak out. But for the rest of us, who cares? It's not as if an employer is going to be able to legally see that you potentially have a disease and not hire you.

I'm less worried about my medical records being online than, say, financial records. Someone compromises my medical records, people know I had a broken toe when I was younger or that I have allergies. Someone compromises my finances, I lose money. But we're ok with one and not the other?

SI

[fpres]

Originally Posted by RainMaker

While I understand your viewpoint, what would your suggestions be to fix the mess? I know there are some who don't agree with it, but I've seen few alternatives.

I don't know that anyone does have a good suggestion to fix the mess. I certainly don't, but I'm still hopeful that someone comes forward with something eventually.

Within the medical profession itself, physicians are actually quite disorganized and piss-poor when it comes to trying to bring about change to the industry. Unless things change, I see the primary care field ultimately being staffed by mid-level providers (NP's, PA's, DNP's) with a small cadre of MD's/DO's on the fringe. There comes, with that, a difference in quality and length of training which I hope we are prepared to accept as a nation.

[Radii]

Originally Posted by sterlingice

Frankly, I'm certain it won't be perfectly secure. Are any of our systems? That said, it's not like any random criminal is going to get your medical records and, if so, how does that really harm you?

Assuming your medical record would contain your insurance history, or at least your current insurance information, Medicare, some state Medicaids, and some commercial payers I can think of off the top of my head use your social security number as your subscriber ID(ie, the primary key used to identify you to your insurance company).

Full name and date of birth are also key pieces of data used in insurance eligibility checks today, and presumably your home address will be available somewhere too.

Point being of course, the reason security is an issue isn't just medical privacy, stealing a database with a bunch of medicare patient information in it is probably nearly as good as stealing a credit card database.

[sterlingice]

Originally Posted by fpres

I don't know that anyone does have a good suggestion to fix the mess. I certainly don't, but I'm still hopeful that someone comes forward with something eventually.

Within the medical profession itself, physicians are actually quite disorganized and piss-poor when it comes to trying to bring about change to the industry. Unless things change, I see the primary care field ultimately being staffed by mid-level providers (NP's, PA's, DNP's) with a small cadre of MD's/DO's on the fringe. There comes, with that, a difference in quality and length of training which I hope we are prepared to accept as a nation.

I honestly think we are already there in a lot of situations in the US but people just don't want to believe. If you visit a "popular" doctor, you never see the doctor. If you want to see the doctor, you'd better be dying or be prepared to wait a few weeks or even months. And if you want something routine like a physical or any other "routine" checkup (i.e. dentist, orthodontist, gynecologist, etc), you won't get an appointment for months unless you are willing to see a nurse practitioner or associate or something.

This is also why I think that "horror stories" about having to wait months to see a doctor in "socialist" countries are no different than what we experience here now.

We just had this conversation last week at lunch at work where someone was making arguments about how they didn't want to wait months to see a doctor, horror stories about Canada, etc. And then I just pointed to another guy at lunch and everyone else at the table chimed in. He's a middle aged guy and has had some issue with his leg that developed last September or October- it's horrible pain in his leg and he was barely able to sleep most nights, at first.

His first appointment for it was 3 weeks from when it started with his primary care doctor. He then had to wait another 2 for a test. And then another 3 for another test. Then another 4 and 3 to see other specialists and another 2 for another test before they decided on some solution that sortof alleviates the pain but doesn't solve the root cause. Sure, you can say his primary care physician is a moron but the specialists have no clue either and it took them almost 4 months to arrive at a bad conclusion.

And what was his other alternative? Go to the emergency room, pay a ton of cash, and probably get the same answer. And we have what is supposed to be "good" insurance and we all work a decent middle class job in IT. God forbid he had an HMO or critical care only or was poor and had none at all. As an aside, how in the world do we consider this a good system now?

But back to the original point- I think we're already to a world where doctors see only the most urgent of patients and everyone else is already seeing NPs or waiting months to see a doctor so I fail to see how this is different.

SI

[sterlingice]

Originally Posted by Radii

Assuming your medical record would contain your insurance history, or at least your current insurance information, Medicare, some state Medicaids, and some commercial payers I can think of off the top of my head use your social security number as your subscriber ID(ie, the primary key used to identify you to your insurance company).

Full name and date of birth are also key pieces of data used in insurance eligibility checks today, and presumably your home address will be available somewhere too.

Point being of course, the reason security is an issue isn't just medical privacy, stealing a database with a bunch of medicare patient information in it is probably nearly as good as stealing a credit card database.

But the point of my post wss that it will be about as secure as a credit card db is now. No more, no less. But that's not a reason to not do it. As a society we seem to have accepted the risk of online monetary transactions. That's not to say we're happy when identity theft happens or companies should be absolved from negligence. However, if people didn't accept that risk, we would all still be paying for things in cash, paying all of our bills in the mail, and only buying from brick and mortar stores. Yet here we all are with credit cards, using online bill pay, and buying from Amazon. None of us are naive enough to think we're 100% secure when online and anyone claiming it is a complete fool or, much more likely, disingenuous.

SI

[Radii]

Originally Posted by sterlingice

But the point of my post wss that it will be about as secure as a credit card db is now. No more, no less. But that's not a reason to not do it. As a society we seem to have accepted the risk of online monetary transactions. That's not to say we're happy when identity theft happens or companies should be absolved from negligence. However, if people didn't accept that risk, we would all still be paying for things in cash, paying all of our bills in the mail, and only buying from brick and mortar stores. Yet here we all are with credit cards, using online bill pay, and buying from Amazon. None of us are naive enough to think we're 100% secure when online and anyone claiming it is a complete fool or, much more likely, disingenuous.

Oh, I agree completely, I was just responding to the specific statement:

Someone compromises my medical records, people know I had a broken toe when I was younger or that I have allergies.

As an aside since it doesn't directly relate, I have a major fundamental problem with some of these companies using the patient's SSN as an identifier... come on, give me a unique number for your insurance company, at least make people have to work a little bit to completely take my identity. Most companies do this, but Medicare alone is so big that it outweighs everything else.

[gstelmack]

Originally Posted by Radii

This should be true but many Healthcare companies are fighting like hell and charging more because HIPAA's technical requirements are forcing them to leave the 1970s/1980s and join the 1990s. This is not an industry that will go easily, or voluntarily, towards new technology or towards common sense standards even if they work perfectly well in other industries.

Bah. My favorite related issue was BCBS upping our rates something like 30% because they had to convert systems to stop using social security numbers as identifiers, something they weren't supposed to have done in the first place, and then taking like 3 years before they actually came off my cards.

[Eaglesfan27]

Originally Posted by fpres

Within the medical profession itself, physicians are actually quite disorganized and piss-poor when it comes to trying to bring about change to the industry. Unless things change, I see the primary care field ultimately being staffed by mid-level providers (NP's, PA's, DNP's) with a small cadre of MD's/DO's on the fringe. There comes, with that, a difference in quality and length of training which I hope we are prepared to accept as a nation.

Absolutely agreed and I'm appaled by it. Last year, I became the youngest officer of the Louisiana Psychiatric Medical Association in over a decade because there were so few psychiatrists interested in being politically involved. We have over 450 psychiatrists in the state and it was routine for only 20 to show up for our big annual meeting. In Texas, the show rate for their psychiatric associaition's annual meeting was so poor that they began inviting psychiatrists from neighboring states. I don't know if participation is as poor in other states and other specialities, but from talking to friends I get the sense that it is and it saddens me to see so many physicians politically apathetic.

Edit: This is especially true of residents who only attend meetings if they are in town and offer some free food. In the last 9 years, I've seen 1 other resident regularly attend meetings besides myself.

[JonInMiddleGA]

Originally Posted by Eaglesfan27

This is especially true of residents who only attend meetings if they are in town and offer some free food. In the last 9 years, I've seen 1 other resident regularly attend meetings besides myself.

Have we met? I'm Emmett Litella, Emily's brother.

I read this and had to stop to figure out why the general public (i.e. "residents") were supposed to be attending a professional group meeting.

Never mind.

[Galaxy]

I've always been impressed by Mass General in Boston. Everything is electronic. X-rays, CTs, medical records (and doctor reports), appointments. Accessed from any place on the campus (your doctor's offices, the OR, nursing floors, ect.) and its satellite locations, where according to wikipedia, your talking about, "The hospital has 905 beds and admits over 45,000 patients each year. The surgical staff performs over 34,000 operations yearly. The obstetrics service handles over 3,500 births each year. The hospital handles over 1 million outpatients each year at its main campus, as well as its six satellite facilities in Boston at Back Bay, Charlestown, Chelsea, Everett, Revere, and Waltham. Architect Hisham N. Ashkouri, working in conjunction with Hoskins Scott Taylor and Partners, provided the space designs and schematics for the pediatrics, neonatal intensive care, and in-patient related floors, as well as the third floor surgical suites and support facilities.".

[fpres]

Originally Posted by sterlingice

We just had this conversation last week at lunch at work where someone was making arguments about how they didn't want to wait months to see a doctor, horror stories about Canada, etc. And then I just pointed to another guy at lunch and everyone else at the table chimed in. He's a middle aged guy and has had some issue with his leg that developed last September or October- it's horrible pain in his leg and he was barely able to sleep most nights, at first.

His first appointment for it was 3 weeks from when it started with his primary care doctor. He then had to wait another 2 for a test. And then another 3 for another test. Then another 4 and 3 to see other specialists and another 2 for another test before they decided on some solution that sortof alleviates the pain but doesn't solve the root cause. Sure, you can say his primary care physician is a moron but the specialists have no clue either and it took them almost 4 months to arrive at a bad conclusion.

And what was his other alternative? Go to the emergency room, pay a ton of cash, and probably get the same answer. And we have what is supposed to be "good" insurance and we all work a decent middle class job in IT. God forbid he had an HMO or critical care only or was poor and had none at all. As an aside, how in the world do we consider this a good system now?

I agree, the healthcare system in its present form is FUBAR. I don't think many people believe that what we have now is a good system, but it's probably a better system than what lies ahead.

Let me illustrate a typical new patient encounter in the county system (keeping things anonymous, of course):

• A patient comes in to see me for the first time who has a history of severe heart disease (multiple MI, decreased ejection fraction...the whole nine yards). They're toting with them twenty pounds of old paper records, imaging films, EKGs, and echo reports.

• I can address and manage most of their problems, but they obviously need to establish care with a cardiologist to have things done which can and should be done in a controlled environment (i.e., stress testing, cardiac cath). So, I put in a referral complete with lengthy detail about all of the prior work that's been performed.

• Said patient is told to wait 10 days to call a scheduling department.

• When the patient calls, they are told that the referral has been denied by a case manager (the cardiologist never knew of the referral's existence to begin with) and to go back to see their PCP (who is not told of the denial).

• Chagrined, I call the case manager and am told that since none of the studies were done in our system, they do not exist. I must reorder every single test that has already been done, even the ones done last month.

• I order everything again, apologizing profusely for wasting my patient's time but having to resort to saying that my hands are tied.

• 3-to-6 months later, with all tests redone, I resubmit the original referral and a specialist appointment is made for the patient to see a cardiologist 6 months later (oftentimes a year after I first saw them).

• Rinse and repeat.

This is not the exception. It's the rule, and it's not exclusive to one health network. I suppose you could argue that, having experienced the system for such a long time, I should know that this is how things would turn out so I should go ahead and just order everything from the get go. Some docs undoubtedly do, but I'm still on the side which advocates evidence-based medicine instead of brute force wastefulness.

The problems in the system come in many forms: not enough providers, an ungodly amount of inefficiency, emphasis on "sick care" rather than "health care"... Probably the biggest problem of all are the insurance companies since it seems every other problem at least ties in indirectly to insurance. After all, I've never run into anyone who has thought that the whole "seven minute per visit" idea is a good one.

BTW, to Eaglesfan27, I've been tempted to go the route of state employment myself, but I just don't know with all the uncertainty and changes that are in the pipeline.

[RainMaker]

Originally Posted by sterlingice

I honestly think we are already there in a lot of situations in the US but people just don't want to believe. If you visit a "popular" doctor, you never see the doctor. If you want to see the doctor, you'd better be dying or be prepared to wait a few weeks or even months. And if you want something routine like a physical or any other "routine" checkup (i.e. dentist, orthodontist, gynecologist, etc), you won't get an appointment for months unless you are willing to see a nurse practitioner or associate or something.

This is also why I think that "horror stories" about having to wait months to see a doctor in "socialist" countries are no different than what we experience here now.

We just had this conversation last week at lunch at work where someone was making arguments about how they didn't want to wait months to see a doctor, horror stories about Canada, etc. And then I just pointed to another guy at lunch and everyone else at the table chimed in. He's a middle aged guy and has had some issue with his leg that developed last September or October- it's horrible pain in his leg and he was barely able to sleep most nights, at first.

His first appointment for it was 3 weeks from when it started with his primary care doctor. He then had to wait another 2 for a test. And then another 3 for another test. Then another 4 and 3 to see other specialists and another 2 for another test before they decided on some solution that sortof alleviates the pain but doesn't solve the root cause. Sure, you can say his primary care physician is a moron but the specialists have no clue either and it took them almost 4 months to arrive at a bad conclusion.

And what was his other alternative? Go to the emergency room, pay a ton of cash, and probably get the same answer. And we have what is supposed to be "good" insurance and we all work a decent middle class job in IT. God forbid he had an HMO or critical care only or was poor and had none at all. As an aside, how in the world do we consider this a good system now?

But back to the original point- I think we're already to a world where doctors see only the most urgent of patients and everyone else is already seeing NPs or waiting months to see a doctor so I fail to see how this is different.

SI

That's kind of how I see it now these days. I went in to my internist a little while back with an issue. He literally spent 2 minutes in the room with me and couldn't wait to get out. Nurse did almost all the work. My last trip to the ER was the same way.

I don't know if this is just a necessary element of the industry or if it's just become the routine these days. It seems that the doctors just don't give a crap anymore about patients long term.

Would be interested to hear some feedback from those in Canada and the UK on how their system is. My business partner spent a few years in Canada and said the system was great. Laughed at the thought of having to wait to see a doctor for something life threatening. Said the worst he saw was a guy at work who had to wait 3 weeks for some minor knee surgery.

[RainMaker]

Here is my suggestion for health care:

1) Create a government health insurance company. Eligible people would include those who can't get health insurance because of pre-existing conditions, age, or other factors. It would also work as a supplemental insurance policy for those who have insurance but won't cover certain pre-existing conditions. Thus if you have diabetes and your insurance won't cover you for it, the government would policy would fill in the gaps. People would apply and provide evidence that they were rejected by these companies.

2) Create a subsidized plan with the major insurance companies. The government would help pay for what the individual can't. Can be based on a health care cost vs income setup. For instance if you make $50,000, the government could decide you are able to pay up to $3000 a year for health insurance. The rest the government pays for. Basically means that everyone pays for what they can. Government uses its buying power to negotiate better rates.

3) Some tort reform to cut down malpractice costs. I still think this issue is overexaggerated but would help.

4) Tax breaks and subsidies for hospital/doctor equipment. If a hospital can get an MRI machine at half it's cost, it can reduce its charges per MRI.

5) Strict laws on insurance companies. They should never be allowed to dictate a patient's treatment. Perhaps this means setting up a committee that would pan out what treatments and drugs must be covered by insurance. Also perhaps a committee that handles disputes between doctors and insurance companies. Doctors face penalties for frivolous treatments.

6) Strict laws on pharmaceutical companies "wooing" doctors with trips and gifts. There should be no bias in your treatment.

7) Tax incentives for businesses offering health care.

7) Bankruptcy reform for those with large medical bills. Currently it's way too hard to file when someone is hit with massive hospital bills.

I think implementing that wouldn't cost us as much as a complete universal health care system. It would also improve the overall care. My biggest concern is that we have a lot of people in this country who can't get health care because they didn't win the genetic lottery. I'm also concerned with how much power insurance companies are getting over doctors. A solution like this would fix those problems and keep the private sector people happy.

[Galaril]

Originally Posted by JediKooter

We'll just import all the doctors from India.

lol.

[Galaxy]

Can doctors and nurses write off any portion of their student loans (beyond getting a B.S. degree)?

Also, what about quality of life vs. cost issues? Is spending a large amount of money to keep a person's life, who may have a poor quality of life regardless, going? What about senior citizens (in their 70's and up) and are on taxpayer-funded Medicare? Would it be worth it to extend one's life by 6 months, regardless of course? Are those critical/extending life costs eating up a huge portion of our health care dollars? Should doctors have the right to end (I'm talking life-support, feeding tube, surgeries that would only improve's one situation by very little, if at all) or reject treatment if they do not feel that the cost of make one's situation better? I'm not giving my view, just wanted to get your thoughts. It's a tough and ethical situation, but is this something we have to look at it?

Hospitals and doctors will have to cover those incredibly high costs somewhere. It'll be through higher bills, which means higher insurance costs, or a higher tax bill.

[sterlingice]

Originally Posted by JediKooter

We'll just import all the doctors from India.

Crooked H1-B's for teh win!

SI

[gstelmack]

Originally Posted by fpres

emphasis on "sick care" rather than "health care"...

Is this really true? I'd argue that one of the issues that brought us to this place was the emphasis on "health care". Insurance companies got going to help with catastrophic sick care, costs started to rise, it was decided that preventive care was the best way to control costs, insurance started covering basic doctor visits, everyone started seeing the doctor regularly, costs continued to climb, now all of a sudden insurance is REQUIRED to get even basic care and everyone needs it (yes, generally healthy people can probably pay out-of-pocket for annual visits), people without insurance are forced to use ERs for basic care, costs go up further, drug companies start advertising and foisting pills on everyone, costs go up further, etc etc etc.

When I see things like it costing me more money to buy a prescription than my insurance company would get charged, there's a problem with the fundamental system of how health care providers are paid for what they do.

Stop allowing drug companies to advertise, get that out of the system and back to EDUCATING doctors on individual drugs, their pluses and minuses, and let them decide. Take basic health care back out of the insurance system and have people pay for annual visits and minor sick care (with some system for the poor to get government help to pay for this) and keep insurance for catastrophic care rather than a system for funneling money. I know people say the government would do worse, but I'm not all that sure, the current insurance system is just a different bureaucracy. I'd rather have neither.

Okay, meandering wandering thoughts done.

[JediKooter]

Originally Posted by sterlingice

Crooked H1-B's for teh win!

SI

Mmmm nothing like the smell of H1-B in the morning

Seriously though, I think if it's left up to the fed, and knowing that the fed really isn't the group you want to go to, to get things fixed, I see that happening as their 'solution' to the problem.

It think the doctors here (not here on the board) need to start being more pro active or they will just end up with a shiny new system that doesn't work.

Oh yeah, and work on that handwritting too please.

[sterlingice]

Originally Posted by fpres

I agree, the healthcare system in its present form is FUBAR. I don't think many people believe that what we have now is a good system, but it's probably a better system than what lies ahead.

I agree with a lot of your suggestions- my point was just that I love how nationalized health care is the boogeyman because government is inefficient.

Some of the best customers of the company I work for are insurance companies and those giant corporate headquarters filled with tons of opulence and waste, on average more than any other industry I visited when I was a field engineer.

As someone dealing with people's health, their ethical responsibilities should be higher than the average corporation when it comes to making profit versus providing service. That's why I'm not at all opposed to giving the government a competitive advantage (i.e. larger customer base for volume discounts) when it comes to dealing with life and death.

If they can't adapt to be better (re: cheaper) at it than the government, then they deserve to fail.

SI

[sterlingice]

Originally Posted by gstelmack

Stop allowing drug companies to advertise, get that out of the system and back to EDUCATING doctors on individual drugs, their pluses and minuses, and let them decide. Take basic health care back out of the insurance system and have people pay for annual visits and minor sick care (with some system for the poor to get government help to pay for this) and keep insurance for catastrophic care rather than a system for funneling money. I know people say the government would do worse, but I'm not all that sure, the current insurance system is just a different bureaucracy. I'd rather have neither.

I love this idea and have said it on these boards quite a few time: Drug companies should never ever ever be allowed to advertise or try to influence what is being prescribed. It should be done on merits alone!!

SI

[RainMaker]

Originally Posted by Galaxy

Can doctors and nurses write off any portion of their student loans (beyond getting a B.S. degree)?

This is something that bugs me only because I was in a similar situation of sorts. There is a income limit to where you are allowed to write off student loans. It's at $75,000.

Now I'd imagine that many doctor end up making that kind of money within 10 years of graduating. I'd also imagine that they have massive loans for being in school for so long, especially if they went to a top notch school. So you could have a doctor with $150,000 in student loans that is making $75,000 a year and unable to write off any of the nearly $10,000 a year in interest he is paying.

I absolutely hate the age limit on writing off student loans as it penalizes those who get advanced degrees in highly skilled fields.

[Eaglesfan27]

Originally Posted by sterlingice

I love this idea and have said it on these boards quite a few time: Drug companies should never ever ever be allowed to advertise or try to influence what is being prescribed. It should be done on merits alone!!

SI

Absolutely agreed. I think I've mentioned it on here before, but I had a mentor in medical school who was always rallying against the pharmaceutical companies and their influence on doctors. Nofreelunch is a great web site to check out. I'm proud to say that I haven't gone to a drug company dinner in 9 years and I've never been on any drug company trips. The only thing that I take from drug companies are items that directly help patients. For example, I recently got 80 trapper keepers that were all given out to patients. However, that drug is my least prescribed as it is brand new, and I'm not a fan of prescribing medications for kids until they have been on the mass market for at least a year or two, as there are limitations on pre-market studies.

[Eaglesfan27]

Originally Posted by RainMaker

This is something that bugs me only because I was in a similar situation of sorts. There is a income limit to where you are allowed to write off student loans. It's at $75,000.

Now I'd imagine that many doctor end up making that kind of money within 10 years of graduating. I'd also imagine that they have massive loans for being in school for so long, especially if they went to a top notch school. So you could have a doctor with $150,000 in student loans that is making $75,000 a year and unable to write off any of the nearly $10,000 a year in interest he is paying.

I absolutely hate the age limit on writing off student loans as it penalizes those who get advanced degrees in highly skilled fields.

Yeah, I hate this as well. I have over 170k in medical school loans and I've never gotten any tax breaks on them as I was too poor as a resident to pay them and kept them in deferrment. Ever since I was done my residency, I've made too much to get any tax breaks.

[flere-imsaho]

Originally Posted by RainMaker

6) Strict laws on pharmaceutical companies "wooing" doctors with trips and gifts. There should be no bias in your treatment.

This is already reality. A new law went into effect this year that severely curtails this type of activity.

[Galaxy]

Originally Posted by flere-imsaho

This is already reality. A new law went into effect this year that severely curtails this type of activity.

Any link to this?

[DaddyTorgo]

Originally Posted by Eaglesfan27

I'm proud to say that I haven't gone to a drug company dinner in 9 years and I've never been on any drug company trips. The only thing that I take from drug companies are items that directly help patients. For example, I recently got 80 trapper keepers that were all given out to patients. However, that drug is my least prescribed as it is brand new, and I'm not a fan of prescribing medications for kids until they have been on the mass market for at least a year or two, as there are limitations on pre-market studies.

You're good peoples.

[flere-imsaho]

Originally Posted by Galaxy

Any link to this?

Not offhand, except for this blog (which indicates it is a new industry guideline, not a law - my bad), but having been working as a consultant for pharmas for the past 3 years, I've been made aware of massive changes they've all made to comply with the new "marketing" rules that went into effect this January.

[Galaxy]

Originally Posted by flere-imsaho

Not offhand, except for this blog (which indicates it is a new industry guideline, not a law - my bad), but having been working as a consultant for pharmas for the past 3 years, I've been made aware of massive changes they've all made to comply with the new "marketing" rules that went into effect this January.

They just need to outlaw ban advertising and promotions together. Maybe it'll make the "drugs" cheaper.

[RainMaker]

The new law is a reality, although I think there are still some loopholes of sorts. I know a friend who was married to a cardiologist and they would go out to eat at some of the fanciest restaurants in Chicago all the time free of charge.

[JPhillips]

Originally Posted by RainMaker

This is something that bugs me only because I was in a similar situation of sorts. There is a income limit to where you are allowed to write off student loans. It's at $75,000.

Now I'd imagine that many doctor end up making that kind of money within 10 years of graduating. I'd also imagine that they have massive loans for being in school for so long, especially if they went to a top notch school. So you could have a doctor with $150,000 in student loans that is making $75,000 a year and unable to write off any of the nearly $10,000 a year in interest he is paying.

I absolutely hate the age limit on writing off student loans as it penalizes those who get advanced degrees in highly skilled fields.

I'm torn on this. On the one hand I get your point, but on the other allowing the deduction on below market rates ends up being a huge subsidy for college grads. Why should non-college grads give a subsidy to people that already have a much higher earning potential?

That said, I took my deduction and liked it!

[fpres]

Originally Posted by Eaglesfan27

Absolutely agreed. I think I've mentioned it on here before, but I had a mentor in medical school who was always rallying against the pharmaceutical companies and their influence on doctors. Nofreelunch is a great web site to check out. I'm proud to say that I haven't gone to a drug company dinner in 9 years and I've never been on any drug company trips. The only thing that I take from drug companies are items that directly help patients. For example, I recently got 80 trapper keepers that were all given out to patients. However, that drug is my least prescribed as it is brand new, and I'm not a fan of prescribing medications for kids until they have been on the mass market for at least a year or two, as there are limitations on pre-market studies.

I'm in agreement as well. My residency was completely anti-pharma (no drug reps in clinic, no noon conferences catered by pharm reps, no pens with logos, etc.), and I'm glad it was. Whenever possible, I try to convince my patients to go with drugs on the $4 discount programs (Target, Walmart, Krogers, etc.) I just wish that more people didn't equate cheaper medicine with substandard medicine. If you really take a good look at the $4 "formulary," most of the bread-and-butter medications are there and their efficacy is backed by solid science.

BTW, I also hate the TV ads. If I see another "Yaz" commercial, I'm going to puke...

[RainMaker]

Originally Posted by JPhillips

I'm torn on this. On the one hand I get your point, but on the other allowing the deduction on below market rates ends up being a huge subsidy for college grads. Why should non-college grads give a subsidy to people that already have a much higher earning potential?

That said, I took my deduction and liked it!

Because the guys with the higher earning potential are paying in much more in taxes annually and most likely over the course of their lifetime.

I undestand why people wouldn't want it, but I think people underestimate how much money in loans in can take to get through something like medical school. I guess I feel that it's in the nation's best interest to have more highly skilled and well educated people in society. We should be doing everything we can to make it easier for people to enhance themselves.