The Collapse of U.S. Healthcare – The Perspective of a Primary Care Physician
Doctors don’t run hospitals. Due to EMTALA, every single patient that shows up to your emergency department has to be treated. When insurance companies and private equity realized that you can’t say no to doing the work, then why should they pay you? Ultra lean staffing prior to covid led to the sh*tshow during the pandemic and, now that everyone is quitting, things are now in total collapse.
Go to any hospital in the country and, even if you have a serious problem like a heart attack, sepsis, a kidney stone blocking off your ureter while your kidney fills up with pus and you’re turning grey and shivering because you’re dying, well, chances are you’re going to be lying in a bed in the hallway.
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. There are 30 rooms in the ER, but 3 nurses overnight…what do you think happens if you have an accident and urinate or have a bowel movement in the bed? That’s exactly what happens. Good luck getting pain medicine for your kidney stone, there’s 10 other patients and they’re all sicker than you.
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[ 2.6 ms ] story [ 260 ms ] threadWhy 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 and treat you outside the hospital - but now every CT scan is denied as a matter of fact - the only way to get it approved is an x-ray first, or an ultrasound, or getting the labs done, then a series of byzantine forms and “peer to peer” conversations with someone who is probably a retired psychiatrist and has no medical knowledge whatsoever and will lose their job if they let too many CT scans get approved. Easier just to say “go to the ER” and wash ones hands.
When I say lucky enough to have a primary care doctor, that’s because they’re all quitting. Due to the politics of covid, trust in the healthcare system and physicians is at an all time low. Patients yell, they are demanding, they are untrustworthy. 50% of the workload of a primary care physician is filling out spurious sick notes for work, for school, accommodation letters for the clinically lazy, emotional support animal letter requests, FMLA, short term disability, long term disability, etc. the bureaucratic nonsense is never ending. The “my finger hurts why is that I want an MRI” messages in the inbox are never-ending. The mental health crisis always makes its way into the primary care doctors office or the ER.
There are many failing institutions in the U.S. that are failing or have failed: the family structure, the system of employment for anyone with a low I.Q., the war on drugs, the criminal justice system. All of these failures lead to broken human beings who eventually end up at their PCP’s office or in the emergency room. One lonely night in the ICU as a trainee I realized the majority of our beds were taken up by hardcore alcoholics withdrawing to the point they needed to be put on a ventilator and sedated into a coma.
Doctors are also considered prey by the legal system. Patients are looking to sue and win the lottery. Our education system produces too many hungry lawyers. They are looking to get lucky, your medical malpractice insurer is looking to settle - it’s cheaper. The big scam now is that your malpractice insurer has the authority to settle with someone suing you without your permission. When you settle you get put in a national database of doctors who settled, your reputation is tarnished.
Why be a primary care physician? You are a tool of the health insurance companies. You get 15 minute visits (5 minutes in reality), unreasonable “metrics” with the only goal being decreasing compensation. Patients feel shortchanged, the medicine you practice is hurried, unsafe. Your inbox fills up with endless requests, the paperwork piles up, you get ever more burdened, and tired, and underpaid. In this endless grind if you make a mistake you will get sued. We are taught in medical school not to prescribe antibiotics needlessly as it harms people, but in reality that’s what patients want and now you get a customer feedback metric, which incentivizes hurting people.
It’s simply impossible to practice medicine in an ethical manner. It’s the same for allied health professions like nurses, lab techs, pretty much everyone except for the health insurance company execs who profit. Don’t get me started on the revolving door between the FDA and pharmaceutical companies. We get to pay for drugs like aducanumab that don’t do anything but bankrupt the system, but the officials who approve this corruption will get nice private industry gigs in a few years on the down low.
There is so much wrong and so much corruption at this point, the examples are endless. I could literally write a book on all that is wrong. But I don’t have to. The system is collapsing in real time. The next time you get sick, or...
Years ago my father had a stroke. Luckily there's a stroke ICU that was close. He got good care/attention there and for the week or so after (out of the ICU) before going home.
After that, to your point, pretty much a shit show. He was just a number. Care, consideration and compassion was effectively rationed. It not about health, wellness and outcomes. It's about money. Money. Money.
To me, the only short term solution is to stay healthy. Eat right. Exercise. Etc. That said, that's not where the masses are headed. Into the iceberg we go...
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-driven society super-structures (gradual corruption, then selective-outrage decision making, then more corruption, then a form of centralized control that removes innovation/investment incentives, then the down-fall in quality of function/service, then the destruction).
So the only solution to that, and I am 'stealing' this idea from the US founding fathers -- is to avoid having these near-centralized super structures.
Many think that we need this superstructures (including near-monopolies in business) to build complex things: planes, vaccines, CPU chips.
But we do not, and we should find a political and economical systems that are effectively based on many localized 'guilds' and decision centers linked into ad-hoc-chains to create increasingly better outcomes (with the cost of some repetition, some anarchy, and some missteps).
Military and supreme court are the only institutions that I think should be centralized, but they have to be ran with checks and balances that are distributed across the many 'local' decision and power centers.
So that's the only way I can think of to avoid this constant periodic death of the human-led super-structures.
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...
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.
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.
While recovering from a major surgery started getting terrible abdomen pains. Doctors could hardly even be bothered to tell her to deal with it, completely dismissed her.
about a week later a new resident comes in, pokes and prods her a bit (no doctor prior could even be bothered to do that), looks horrified and orders some scans.
Her stomach had burst and was leaking into abdominal cavity the whole time, she later passed from the complications.
I gained a ton of sympathy for folks for fight and push back against doctors after that.
I was in the A&E (what is the ER in singapore and the UK I think) and I had severe chest pain due to chest infection. There were like 40 of us in there and like 5 nurses that one nurse just blew me off when I asked for pain killers because she didn't read my record properly and thought I took acetaminophen that morning. It took the pain getting worse to the point I was rocking and screaming for them to give me tramadol. that said, I sympathize with the situation, given they were running around and hardly able to fill out the paper work and do their normal tasks AND be attentive to the sick.
That said, hey I hear you. That doctor fucked up and it was on them yes, it does not absolve them. That said, things sure are getting worse in total across the system in the US, and bad attitudes doesn't explain nationwide scales. For that, you must look at systemic solutions, especially if you don't want more people to die in such situations again.
tbf, it sounds like you're just saying the US will collapse because while the health care system is a big part of it, the whole US is facing issues as you pointed out.
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 and bureaucrats blocking this change.
Thanks for fighting the good fight so far.
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.)
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.
And ultimately voters have no-one to blame but themselves. (or half of them anyway.) leaving the EU is epically dumb on a truly impressive scale.
So now looking at the NHS, complaining about under-funding and under-staffing, when those were completely predictable outcomes of Brexit isn't going to inform good health system forces.
Japan might be a better place to look if you want examples.
In truth the US has plenty of money in the pot to implement effecient health care. But for-profit companies will not go quietly into the night.
I don't agree with this. I don't live in Britain, so I'm not fully aware of how Brexit has affected things over there.
I live in France. Didn't leave the EU, as a matter of fact it's one of the countries pushing the most for it. Same issues with the health system. A few months ago we were rationing paracetamol. Now we're back to not allowing sales of it online because of shortages.
I'm not saying Brexit helped, but I doubt it was the main cause, seeing how the same exact effect happened elsewhere, at the same time, while staying in the EU.
It would seem to me that, for whatever reason, many countries chose efficiency of the healthcare system above all else. Meaning closure of hospital beds, reduction of medical staff, etc.
This may be great for producing cheap Toyotas. No one cares if theirs is one week late because something unforeseen came up. It doesn't work as well for medical emergencies.
And yes, national health is always tempting for budget cuts because its a huge number, and trimming it 5% gives real returns.
Shortages of drugs and equipment are often tied to supply-chain issues more than budget, and again that's a barrel of worms best left for another thread.
Clearly single-payer can work, but it does need the single-payer to, well, pay.
Brexit is a large factor because the UK was a net-importer of aid from Europe. And Europe was the biggest trading partner. Predictably leaving has decreased the economy such that tax revenues are down, which in turn means less to spend on social services.
Then we can talk about freedom of movement, and the number of Europeans who staffed the NHS and who no longer do so, and cannot be replaced by other Europeans.
So sure, the global economy is taking strain at the moment. Brexit is not the only cause. But its a pretty big sucking chest wound.
But my point was that if multiple systems, some of which seem different (US vs EU), all with different apparent wounds, appear to fail in the same way at the same time, maybe there's something that's common among them which is the actual cause. Perhaps it's just a coincidence. But which is more likely?
The US system is "failing" in the sense that health services are not available/affordable to all.
The NHS has issues with funding and staffing.
France has issues with supply chains.
Any system will have flaws, but just because no system is perfect it does not mean that all are imperfect in the same way.
For the US, there sure is the affordability issue, but I don't think that's anything new. However, OP's point is that there had already been staff shortages for a while before COVID, but now the proverbial camel's back has been broken:
> Ultra lean staffing prior to covid led to the sh*tshow during the pandemic and, now that everyone is quitting, things are now in total collapse. [...] There are 30 rooms in the ER, but 3 nurses overnight…
This is the exact situation in France. The hospitals are physically still there, but there's not enough staff.
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[0] French only, but the title reads "Health ministry admits to emergency services being closed" https://www.lefigaro.fr/conjoncture/urgences-le-ministre-de-...
This will be a large investment (if doubling the training budget produced double the graduates that would not be enough), and will NOT bear fruit until those people actually graduate, which is 6 years minimum, and mostly 10 years away. So for 10 years, it means paying through taxes while getting minimum to no improvements in return. Furthermore, such a large increase is not possible at short notice, even if the money is available, so it will take more than 10 years time.
For research one might take profit margins of large pharma as an indicator: a fully nationalized, but equally capable, pharma research system would cost some 15% less, assuming nationalizing introduces zero inefficiencies. BUT that money would have to come from taxpayers directly through the government budget.
And nobody is looking for 15% reduction in drugs costs. That just won't move the needle enough. So in reality the government would have to increase the drug research budget to make drugs cheap.
Failing to do this will mean medicine becomes less accessible to people, regardless of whether we switch to a single payer system or not.
So let's get real here: we will fail to do this, and it will get worse.
https://time.com/6051754/history-filipino-nurses-us/
The difference this time is “extra” young Filipinos may not be as numerous:
https://www.macrotrends.net/countries/PHL/philippines/fertil...
And they might have more preferable work options such as work in IT fields.
Let poorer countries pay to train nurses and doctors, and then wealthier countries take the best because they can pay more for them due to economic dominance.
We do it in New Zealand by importing a lot of doctors (Chinese and Indian seem common), and nurses . The reason we need to import doctors is because we export a lot of doctors and nurses to wealthier countries such as the USA.
In New Zealand, we get people from poorer countries because we can pay more, and we also get people from first world countries because people want to move here for the lifestyle or for their children.
At a time when there were already staffing difficulties conservatives dis-incentivised people from becoming nurses by removing training bursaries.
Parts of the system have already been stealthily privatised with the associated drop in quality and additional costs. In many cases employees of the NHS are simultaneously being paid private rates using public money through schemes like "right to choose".
At a time when staff nurses are being told they don't deserve higher pay, private agencies are being paid >3 times the staff rate in order to fill gaps in staffing caused by lack of pay and overwork. The result is artificially inflated staffing costs and an incentive for the remaining staff to move over to the agency for what is often double what they'd be earning.
The correct course of action is to bring costs back into line by expunging the parasitic private healthcare system. Every agency position eliminated pays for 2 staff nurses with a healthy pay rise. The improvement to staffing ratios would further improve the nature of the job.
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.
It all needs to happen in my opinion though: let the current provider models stay, but let in lots of other educational models, and empower people to take more care of themselves by giving them access to what they need. Everything is far too overregulated in medicine, or at least is regulated in the wrong way.
Even within the physician model it's broken and overregulated. Board certification is ridiculous and insane in some specialties.
I think medicine is just an amplified version of a lot of problems in the US, but it also has significant consequences for life and wellbeing.
https://savegme.org/
No, it's well organizes, very well paid, lobbying on behalf of a profit-based health system. A system that generates lots of profits for nice big companies.
And make no mistake, they're not going to roll over.
And sure, doctors are depressed because they're finally coming to realise that medical care (in the US) is not about "helping sick people" (despite their good intentions.)
Doctors and nurses set out with the noblest goals, then find themselves inside a system where the one true goal is to separate people from their money. They rile against "adminustrators" while at the same time failing to note that those administrators are the _reason_ for yhd business, and actual doctoring is just medical janitoring.
Yay free markets!
> No, it's well organizes, very well paid, lobbying on behalf of a profit-based health system. A system that generates lots of profits for nice big companies.
I am not a lobbyist or an owner of an insurance company. I am a "person on the street". I do not want single payer.
https://thehill.com/blogs/congress-blog/healthcare/484301-22...
When there is a fixed amount of X available, a fair division of X across Y people gives everyone X / Y.
When you need more than X / Y, you are screwed (ask anyone in england who's needed cataract surgery on their second eye and was told that QoL improvement was not there, like it was for the first, so GTFO)
Since I can afford to buy a lot more than X / Y of healthcare for me and my family, should it be needed, the outcome for that limited and, to be honest, complete set of people whose well-being i care about is better in the current system.
I completely agree that the current system is excellent for those who can afford it, and queuing-based-on-worth certainly appeals to those with worth.
In the US this worth translates into money, which translates into lobbying. You are not marching in the streets because you don't need to. Your money speaks for you.
I say this not to patronise you, since you clearly understand this is the case. I say it merely to point out that this system works for the few, not the many. And yes it works well for the few.
Regarding your cateract example, if the queue is need based, and you have two patients, then one with 2 cateracts is ahead of someone with 1. That's another system, a system I agree which would be most distressing to someone with 1 careact and lots of spare cash.
I get that any system other than the current one will make you worse off. Equally I hope you see that any system at all will be a massive step forward for huge numbers of people.
Sure, I get it. I prefer systems that favor me. The seething masses aren't "real" to me. I don't know them like I know me and the people I care about. I care about my medical needs now, not some hypothetical "other person". Like you, I can pay for my medical, and I appreciate that I can.
But I also wonder if this is the best way. It works for me, but maybe there's something better for us all.
It wouldn’t be distressing to someone with lots of spare cash in the UK because they would just get the surgery done privately. There seems to be a common misconception that private healthcare is not available in the UK.
A bad example, given that private cataract surgery is quite affordable in the UK. You could quite easily pay that much in the US even if you had insurance.
https://lp.opticalexpress.co.uk/cataract-v1-0/?cam_id=20230&...
New technology, new knowledge and training all increase X. It's relatively fixed at a given moment in time (where your point is very true), but society shouldn't be making a major structural decision one moment at a time.
Aside from the incredible arrogance of assuming that GP is just so much stupider and more manipulable than you, it's also factually wrong in enough cases that it instantly discredits you. For example, many people who are upper-middle-class and above are better off in the current system.
We are the leader in it partly because we pay these exhortation prices when the rest of the developed world simply won't play that kind of game.
I'm okay with biting that bullet, and taking a global reduction of health research by some double digit percent for awhile, but that's a serious unintended consequence of single payer.
I'm a Bernie voter who supports single payer, but it's not sunshine and roses everywhere, and crooked capitalism really does do some "not bad" things for us.
This may not be the case, since much research is subsidized by the government and educational funding providing labs that train the scientists the pharmaceutical companies utilize. Single-payer may result in lower costs and therefore more money for support of research and laboratories. Also, pharmaceutical companies would not need to spend vast amounts for marketing their drugs direct to consumers.
In theory we could nationalize the whole industry, and let government bureaucrats decide which clinical trials to fund. I'm skeptical whether that would produce better results. Government employees with no skin in the game have a poor record of picking winners.
I doubt it would. Private drug companies would still exist and charge the same money regardless of whether the insurance is paying for it or "the single payer system".
That, plus the loosening of donation rules aka "corporations are people", is all you need to know about the state of American healthcare.
By "single payer" do you mean the European model of "socialized" healthcare? That may be necessary (I don't know) but it's clearly not enough.
I'm in France, and I hear the exact same complaints from physicians here [0], and the hospitals seem to be in terrible shape. People quitting or being on leave, hence understaffing, so more people quitting because of burnout, etc.
[0] Basically, the gist is that for some time, hospitals have been run "like an enterprise", seeking (cash) efficiency above all. There was absolutely no slack in the system, so when COVID hit, medical professionals ended up in a terrible situation. This situation has not subsided even after the epidemic became less of an issue.
Second, if an employee isn't covered by employer healthcare, the employer side of FICA should be increased to provide for employee coverage. That way if someone is working 40 hours a week, but for multiple part-time employers, they still get the same medical coverage as a full-time employee.
Third, when I go in for a procedure, I want all bills to go to the insurance provider, they pay everything. Then the insurance sends me a bill for my co-pay. Make that a law. That way I'm not stuck with getting dozens of separate bills up to years after a procedure, with no way of really knowing what should have been covered by insurance or not.
The great irony is that the initial Obamacare proposal was a Republican policy — originally proposed in the mid-‘90s as an alternative to the proposal from the Clinton White House, and implemented in Massachusetts by Mitt Romney when he was the governor. The Republican congress and conservative media machine were so invested in seeing Obama fail that they instead branded it socialism and fought it tooth and nail. It would’ve been a fantastic opportunity for a resurgence in bipartisanship in government, and could potentially have averted the subsequent 14 years of animosity and bitter obstructionism. Ah well, so it goes.
Its socialized healthcare. You dont have to put in quotes. It was first advocated by socialists in the First Socialist International at the end of 19th century. It constitutes part of the social democratic program.
If you need dental work, glasses, etc, you better have either cash or a "mutuelle", which is usually tied to your employer (though you can purchase your own above that if you like). Lower-level jobs don't always have one (or it doesn't cover much).
However, procedure prices might be lower than in the US, though (I don't actually know) which is a big part of the issue with access to healthcare.
Here in Japan, everyone has insurance, either private through their company, or public through the government, and the insurance pays a flat 70% of the cost, and the patient pays the other 30%. But the procedure costs are generally not that high to begin with, so the 30% copay ends up being pretty cheap usually.
That's the result of the privatization that has been pushed by the Anglosaxon business lobbies to Europe and everywhere else since Reagan/Thatcher period. They forced privatization of whatever they could get away with. Its still a socialized system with some forced privatization being pushed through. France is not the only country - all US satellites have been pushed to do some degree of privatization.
I think pushing for single payer specifically is one of the biggest mistakes of the American left, because it's that much harder to sell in US due to more restrictions - and that's inherent in the model. If we took something like the German model instead, I think we'd be way ahead by now.
https://www.congress.gov/bill/117th-congress/house-bill/2256... https://www.congress.gov/bill/117th-congress/senate-bill/834...
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
https://www.aamc.org/news-insights/medical-school-enrollment...
https://www.vox.com/22989930/residency-match-physician-docto...
Yes residents need to be supervised, but one doctor can supervise many residents seeing many more patients than they could alone. If hospitals didn't have residents they would have to hire more doctors.
Also consider that a resident costs less to employ than a nurse and that the hospital bills for all the work residents do.
Finally, doctors in teaching hospitals tend to be payed less than doctors in non-teaching hospitals.
"A world of optimal and widespread health is obviously a world of minimal and only occasional medical intervention. Healthy people are those who live in healthy homes, on a healthy diet, in an environment equally fit for birth, growth, work, healing, and dying; they are sustained by a culture that enhances the conscious acceptance of limits to population, of aging, of incomplete recovery and ever-imminent death."
“Man's consciously lived fragility, individuality and relatedness make the experience of pain, of sickness and of death an integral part of his life. The ability to cope with this trio autonomously is fundamental to his health. As he becomes dependent on the management of his intimacy, he renounces his autonomy and his health must decline.”
“The more time, toil, and sacrifice spent by a population in producing medicine as a commodity, the larger will be the by-product, namely, the fallacy that society has a supply of health locked away which can be mined and marketed.”
"Health designates a process of adaptation. It is not the result of instinct, but of an autonomous yet culturally shaped reaction to socially created reality. It designates the ability to adapt to changing environments, to growing up and to aging, to healing when damaged, to suffering and to peaceful expectation of death. Health embraces the future as well, and therefore includes anguish and the inner resources to live with it".
""Health," after all, is simply an everyday word that is used to designate the intensity with which individuals cope with their internal states and their environmental conditions. The society which can reduce professional intervention to the minimum will provide the best conditions for health."
I looked up Ivan Illich, and this essay critiques modern medicine as creating "lifelong patients." That indeed is what has happened, but the alternative is for people to just die. The reality really is I don't really believe anyone ever took death "peacefully" as he puts it here, they too raged and cried and felt all the painful emotions people feel today, they just would actually die and so those emotions would eventually cease. The argument then should be about values: do we actually value human beings as sacred, important things, and their lives are worth preserving just because they are human? The only way you can accept his argument is your answer to this is no.
But we won't do that because it'll make some very rich people upset and it'll reduce individual liberty. We value individual liberty over a healthy population.
Look at your body. It's multicellular, not one living thing. Your very cells both compete and cooperate with one another for resources to survive (just as we humans do amongst ourselves). For the greater good of the organism (you), individual cells are programmed to die when they are in poor health or old age or in too much stress, to allow younger healthier cells to take their place for the greater good of the organism as a whole. When this process is averted, or goes awry, old/unhealthy cells remain and the organism suffers, as it has to support these old/unhealthy cells which don't contribute their fair share to the organism. It has to divert resources which could otherwise go to new younger healthier productive cells. Worse, is cancer, which is literally when cells rebel their original programming, and become selfishly greedy. Obviously, as we all know, these things can lead to the organism becoming dysfunctional and even dying.
This reality applies to cells, and to organizations like companies, governments, and even species.
So to answer: are lives worth preserving? Yes. But reality is, there can come times when the preserving the lives of the old, is directly at odds with the lives of the young, and choosing to preserve old lives over young lives, is harmful to lives as a whole.
Groups focused on longevity and removing age related diseases, in theory, should eventually get us to a point where the best parts of youth (including learning and plasticity) should make it unnecessary to have children any more, save for replacement of those who die from other causes (and maybe populating other planets etc).
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.
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.
This is a myth.
That reduction is simply not achievable unless you can accurately predict who is going to die, which turns out to be very difficult to do.
The most significant health costs are for chronic conditions, and their ongoing consequent costs.
Your point is as non-sensical as saying we could save millions of dollars by killing 10% of the population at random.
It seems like the hard part is making sure people have had the conversation. If I'm over 80 years old and can't communicate or feed myself, I'm not expecting much of a recovery. I think a lot of people would acknowledge that if they were asked to think about it.
(of course there are lots of situations where a good recovery is pretty likely, but hopefully the doctors aren't waffling about what to do in those situations)
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.
[1]: https://en.wikipedia.org/wiki/Capitation_(healthcare)
I don't understand this. Are you saying everyone just lets the bills for the deductible go to debt collections?
(n.b. I have some relatively significant physical health issues, so if I can't afford medical tourism and/or get on an absurdly good plan before I'm 26, I may end up being forced into a strategy like this)
Yes. Nothing happens as a result. They mail letters, and try to call, and that's about it. It doesn't even hurt credit scores, since they exclude medical debt.
What does this mean? The Affordable Care Act did not directly increase deductibles. It even provided huge subsidies from the young and healthy to the poor and old via age rating factors, restricting of pricing criteria (removal of pre existing conditions exclusions), and implementation of out of pocket maximums.
> 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.
This was a non starter during Affordable Care Act negotiations due to upper middle class people being up in arms about their premiums going up due to being in the same risk pool as poorer and sicker people.
My deductible before the ACA was around $500 before, and around $4000 after. In one year it changed that much. Other people I've spoken with had the same experience.
> It even provided huge subsidies from the young and healthy to the poor
Only to people not in employee health care plans, which always have high deductibles.
> about their premiums going up due to being in the same risk pool as poorer and sicker people.
I'm not seeing the connection. People can buy whatever plan they want, receiving the money in cash doesn't force people into any particular risk pool. Not to mention the ACA majorly combined pools, and in fact did cause premiums to go up for this exact reason.
I meant the deductible increase was not a statutory part of ACA, but an inevitable part due to the drastic increase in benefits (all preventative care, all medicines assuming there was efficacy data, out of pocket maximum instead of benefit maximum).
Before ACA, insurance could deny you healthcare easily. After ACA, they had to provide the benefit, even if the medicine cost $1M per month, and the insurance company could not choose to drop you as an insured.
> Only to people not in employee health care plans, which always have high deductibles.
As far as I know, this applies to all ACA compliant health plans, even ones that employers subsidize:
https://www.healthcare.gov/how-plans-set-your-premiums
> I'm not seeing the connection. People can buy whatever plan they want, receiving the money in cash doesn't force people into any particular risk pool. Not to mention the ACA majorly combined pools, and in fact did cause premiums to go up for this exact reason.
Being part of an employer subsidized insurance plan’s risk pool can result in you being in a better risk pool than the public ones on healthcare.gov. For example, white collar businesses with lots of young, healthy employees like law firms and tech companies.
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.
No.
> Sure we can start training people and make lots of incentives for people to enter the field, but that will take years.
Yes. But it should be done.
Also, there shouldn't be shortages of saline IV solution and bacteriostatic water -- but no one's rebuilding the factories destroyed by hurricanes in Puerto Rico because there's not "enough" of a shortage to make ROI on new factories.
Most medical supplies need to be moderately overproduced every year via subsidies just like our crops and basic foods are. Otherwise the rationality of the commodities markets will ensure there's constantly a light/partial shortage of basic healthcare goods like..."water".
Seriously though, if the people responsible for hospital cutbacks had to rely on the same level of care the average American gets, we would never have gotten to this state.
Whereas from a profit point of view fewer doctors is good, more insurance red tape is good, effeciently increasing bills and billing customers is good.
The health system is set up to maximise profits. And it is doing so most effeciently. If you want a different outcome then you need a different system.
Even with zero greed in the system we would still have to ration things.
I'd argue that we are not currently 'fighting greed' at all. The US healthcare system is not capable of prioritizing anything. It's a mishmash of corporate and government entities hobbled by regulation with no clear entity in charge.
Ultimately, there is no escaping the market. No amount of public-funding, socialism, or outright communism can escape the simple facts of supply and demand. Right now, medicine is expensive because demand exceeds supply. Do insurance companies and bad administrations exacerbate that? Yes, of course they do. But they are only exacerbating an existing problem.
These people could easily be brought back into bedside care but the pay and conditions are absolutely abysmal.
Given that it's not "solvable" (at least not without a nice pandemic targeting old people, who can be convinced not to protect themselves) it's worth then looking at "best", not necessarily "perfect", systems that may deal with it.
The approach of "best healthcare for those who can afford it" is one way to go. All resources ploughed into some sub-section of humanity, those who can pay the most.
Or we might go with "good healthcare for everyone", so alas limited heart transplants.
And I get it. There will be winners and losers. At an individual level you can have all the money in the world, and yet die when some poor person is ahead of you in a queue. "Surely the queue should be in order of net-wealth?".
No system is going to make every medical intervention on all patients all the time. We won't in fact live forever.
That doesn't necessarily mean that the current system is the best alternative. (unless you're a share-holder, then it clearly is.)
Given Gen-X is both the smallest and next cohort to start retiring, I'm guessing medicare, SSI, etc. will have a few years to 'catch-up' before the Millenials start retiring.
It's not a matter of "are there enough humans who have sufficient training in medicine who are willing and able to fill all those positions?" It's are there enough humans with sufficient training in whatever positions there could be to meet the health needs that exist?
Just for example: it's pretty clear many things done by physicians could be done by other providers, like pharmacists, psychologists, dentists, optometrists, if we broadened our idea of what those specialties (and their subspecialties) could look like. There are also probably types of providers that could exist that don't exist at all now, that we're not imagining because the healthcare system makes so many assumptions about what it looks like. Maybe all these things will involve additional training opportunities or whatever, but if you let people do what they are capable of, they'll find a way.
Sure, train more physicians. They'd be there. But you'll find even more people willing to do all sorts of things in ways we aren't currently imagining. We're constrained by convention.
Nurse too expensive? Get a CPA!
Most of the time I go for checkups I see a CPA for the majority of the time, a nurse for less, and almost no time with a doctor. Excepts are usually for surgery or other intense operations.
This idea of "just let less holistically trained people do the work" honestly sucks. Dentists are better on average at teeth cleaning than dental cleaning specialists. MDs are better on average at putting IV needles in, etc
Spoken like someone who's never lived NOT under capitalism. It amazes me how young people today say things like this, as if they are self evident. I used to think that I'd not wish that life on anyone, but really y'all could use some, to see the contrast.
What, for example, is "NOT capitalism?" You mean like communist countries? You seem to be making the old mistake of thinking communism and capitalism are opposites of one another.
What is more, the problems with the communist countries was massive cryptic bureaucratic systems preventing practical problems being solved. If you hadn't noticed (or just ignore OP entirely) we have this exact problem right now with the health care/insurance system under the capitalist US system.
This is what I mean by capitalism and communism aren't opposites. Capitalism is turning our society into something like what was seen under more oppressive communist governments. And simply voting as if "things are better here, now, than it was under communism" won't solve the very real, pressing problems that OP was talking about.
Ok then. Get started on it now! This has been a known issue for decades, so I’m not expecting much action until it gets so bad that a revolt occurs.
The private insurance model is still a horribly broken concept that needs to be addressed as well. Single payer seems to be the only reasonable alternative to prevent the broken feedback loop (insurance companies are driven by higher premiums which are driven by higher costs so there is no accountability) of the current system.
Number one recommendation: spend $$$ on a concierge primary care doc. Depending on your market can be anywhere from $1,500 to $15,000 per year. Why? Concierge doc will help you triage your problems, give you great access, keep you out of the hospital/ER, and help you cut through red tape if you need to engage the system.
Number two recommendation: seek care in facilities in high-income communities with relatively small general hospitals (i.e. Greenwich Hospital in CT) UNLESS you need tertiary/quarternary care. Why? Much better staffing. Much less riff-raff common people stuff (i.e. like homelessness) and much higher patient expectations about quality of care.
Number three recommendation: pay up for/seek out a cadillac insurance plan from a high quality insurer like Aetna or United with a low deductible (not high) and low copays. Why? Makes the patient experience much better on the back end with much less paperwork if you do engage the system.
Yes, I understand that I'm saying "be rich", but if you can afford any of the three recommendations above your healthcare experience will be MUCH better.
I like sticking to BCBS insurers, such as Elevance, Regence, Independence, Horizon, etc.
And BCBS desperately wants to force you to use only their approved pharmacies, but as of late last year there is a new law here in Texas that makes that illegal. So, what BCBS does is make their preferred pharmacy "optional", but what is not optional is that you can't get any drugs from any other pharmacy until you call up their preferred pharmacy on the phone and speak to a human being to get them to opt you out of the "optional" preferred pharmacy. And imagine how hard that process is these days.
Fuck BCBS.
Now, as bad as BCBS Premera is, it's still better than Aetna. Maybe it's because CVS bought Aetna, or some other reason, but they've definitely taken a major nosedive here in the last few years.
Not familiar with Kaiser being in NYC, but I can say that Aetna is probably the best insurer here (again, depending on your plan).
Broken arm? great. Straightforward / well known ailment? Check check check. Psychiatric care? Hit or miss, but was not good in our experience (I can attest to some close friends and family who did receive quality care). Need an uncommon specialist or research doctor? Horrible.
My partner has a relatively rare thoracic spinal herniation issues, and Kaiser just wanted to put her on drugs and tell her "too bad, its all we can do". No physical therapist specializations, only 1 standard MRI and was looked at by a doctor who was not a specialist in thoracic spinal issues. When we balked at that, they then tried to turn around say it was "all in her head". We had to go out of pocket to see a physical therapist who specialized in this sort of thing to get any real help, and we have as of yet to meet a doctor who's willing to take on her case and advocate for specialized care, who then recommended us a chronic pain psychiatric specialist who's job is, to tl;dr, to help train the mind to lessen the daily chronic pain. That combined with a pretty strict diet & regiment of physical activities are the only thing giving her quality of life. Kaiser blew it. I can only imagine how much worse off we'd be had I not have a good job to cover the costs out of pocket.
Why would the size of the deductible/copay affect the amount of paperwork? My naive assumption would be that the amount of paperwork would be O(1) with respect to the amount of money changing hands -- same way you will always be asked if you want a receipt in a store, regardless of how much stuff you bought.
Also, how do I know if an insurer is "high quality"? Neither Aetna nor United is available in my state.
(Thanks in advance for any replies -- I still have about 3 days during which I can switch my insurance for 2023; was thinking of switching to a high-deductible plan since I don't anticipate using my plan much in 2023)
If, however, if you have a situation where you are using co-insurance (you pay x% and the insurance pays 1-x%) the backend bills and related paperwork can be a nightmare.
In terms of quality I'm really talking about the plan design moreso than the insurer and I'm really talking about a benefit rich plan, which is always going to cost more (and a lot more upfront).
And God-forbid you use a narrow network plan like an EPO because it's hard to figure out ahead of time what services are covered by the network and what's not. I went to see a doc who was in-network and only paid a $25 copay, which was great, but the lab where my routine blood work was sent was NOT in network and now I'm looking at $1,000 in lab bills for a test I didn't ask for.
But if the provider can't communicate with the insurance in order to figure that out, why would a different deductible/coinsurance change that?
I was actually told that I met my deductible in 2022, and then I got another big bill in the mail. So that made me think deductibles are a scam and I should just pick the plan with the lowest premium.
(Thanks a lot for answering my questions by the way!)
So some aspect of the coverage might be a 20% coinsurance, where you pay the full cost up to the deductible and then pay 20% of the cost after that until you have reached the out of pocket maximum.
Most of the fees you pay count against both of them, so like if you pay $35 to visit your primary care doctor, you are $35 closer to meeting your deductible, and then also $35 closer to reaching your out of pocket maximum. Lots of frequently used services are covered as a fee based co-pay rather than as coinsurance.
If you have a major expense for something that is covered as 20% coinsurance, the amount up to the deductible would be 100% out of your pocket, and then the coverage would kick in and pay for 80% of the rest (until your 20% exceeds the out of pocket maximum).
I kind of wonder if disallowing insurance companies to negotiate deals with providers would actually end up improving things a lot (because it would create pressure to normalize prices vs fucking around to save a little bit).
Most providers do communicate with the payor and have a decent idea of what you owe, so I was being a bit snarky there. If they know you have a zero copay, you make no payment on site with no follow up bill afterwards.
If you have sufficient cash flow and savings to afford out of pocket maximum (usually $10k or so for a family), and you can max out contributions to an HSA, it is always advantageous to opt for an HSA eligible plan (which are legally defined as High Deductible Health Plans, but they will say “HSA” in the name of the plan).
This is due to the triple tax advantages of an HSA, which surpass any other type of investment vehicle.
You can put pre tax money in an HSA, all investment earnings are tax free, and withdraw all of that free of tax to reimburse yourself for healthcare expenses you incur at any time during your life.
So you keep a spreadsheet of all your healthcare expenses, pdfs of receipts, and do not touch it until you absolutely need to. Use a free Fidelity HSA to have access to all investment options (you can continuously transfer from any HSA your employer uses to fidelity HSA).
In the absolute worst (best?) case that you simply do not have healthcare expenses, the HSA functions as an IRA, and you pay regular income tax when you withdraw after age 65.
Can you please elaborate? I need something like this and I'm willing and able to pay for it.
How would I get started finding one?
Good example is MDVIP - https://www.mdvip.com/. I have no relation to the company other than being a customer. I pay $1,600 a year for my Mom to be a member and it's the best money I've ever spent.
https://www.forbes.com/health/healthy-aging/concierge-medici...
Fuck the country I was born in if this is the solution I need to keep myself healthy in a place I pay more than my fair share of taxes and rent to scumbag landlords just to live. Fuck this world.
I hate the US healthcare experience and try to avoid it, but somehow after all the craziness you hear about half the country uninsured and $500k medical bills, the life expectancy numbers are actually not that terrible. I'm not sure why.
https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...
For places like UK and Canada, leaders have to answer to everyone for why access and quality of healthcare is declining. In the US, using the MCOs, leaders can more easily direct sufficient healthcare to who they want it to go to without being able to be identified as the cause.
For example, leaders can tell MCOs to reimburse healthcare providers less for Medicaid (poor people), and more for Tricare (military) and Medicare (old people who vote), and even more for federal government employee health plans (for themselves). Or they can tell MCOs to require more “prior authorization” (PA) for Medicaid so people give up more quickly at getting medicine, whereas federal government employee plans can require fewer PAs.
Add employer specific risk pools/deductibles/copays/out of pocket maximum limits into the mix, and there are multitude of levers that can be pulled to ensure people are getting the quantity and quality of healthcare corresponding to their socioeconomic level.
Rich people always had concierge medical care. But with the use of MCOs, you can drill it down to income/wealth/political quintiles or even deciles.
1) cash pay / direct / concierge
Agreed - especially if employer plan not great. Some of these folks do house calls. I did this for a while
2) high income area
Sadly agreed. Even in a city if a hospital is more accessible etc that can be tough. I did a walk in to sf general once a long while back - took me 20 minutes to walk out. Great hospital, but waiting room was nuts. Had a finger burned being an idiot and got seen very quickly at a different sf hospital - night and day difference in waiting room
3) mixed view on this. Kaiser brings some peace of mind - grandfathered hsa plans w 2k deductible and some free base car not a bad experience - key for me is not coordinating/ dealing w multiple bills. Their issue resolution team is terrible though on billing
You're a veteran doctor. You are presumably fully aware of the health statistics in this country. And yet, you did not list the number one correct recommendation:
If you are overweight, lose the weight.
~80% of healthcare costs in this country are attributable to chronic conditions, and ~80% of chronic conditions are caused by obesity or lifestyle directly connected to obesity.
You improve your own health outcomes, and reduce the burden on the healthcare system as a whole, by ~64% if you're not fat.
And your response, as a doctor, mirrors the most infuriating thing about your profession:
When the hell are the "professionals" in your line of work going to stop medicating away the consequences of this absolutely absurd epidemic and actually address it? The only time I've ever heard of a physician actually advising an obese person to lose weight is for conditions where pharmaceutical interventions don't exist, such as non-alcoholic fatty liver disease. The rest of the time? Take these drugs so you have a couple more years to enjoy your triple bacon cheeseburgers and large fries.It's absolutely maddening.
But it's unfair to blame doctors. In a typical office visit they only have a few minutes with the patient which isn't enough time for useful lifestyle counseling. And it isn't even really their job anyway; diet counseling should be provided by Registered Dieticians who are specifically trained in that field. Any real improvements will require major national political policy changes to better align incentives and shift resources away from treatment and towards prevention.
Yes, I am a former fatty who has kept it off for well over a decade now. It's really quite trivial to do.
if you are already fat and prediabetic, you have a lifestyle problem, not a medical problem a doctor can fix.
If they were truly interested in un-clogging their hospitals and clearing their dockets, they'd be actively engaged in treating root causes. Sure, maybe alongside the pharmaceutical interventions, but the focus ought to be on the cause.
To your points:
- Most moderately overweight people do not, in fact, know they are. Humans operate on the basis of visual comparison, not medically significant measurements like BMI or visceral fat measurements. If you look approximately like your other overweight coworkers, friends, etc, then you'll assume you're fine (in the genpop case, HN denizens and other data-driven folks likely excluded).
- Many of those who are morbidly obese to the point it's obvious they're much larger than their peers, are likely blind to the actual health consequences of their behavior. The general population is vaguely aware that being fat is not super healthy, but they have no idea of HOW devastatingly unhealthy the actual medical literature indicates. On top of this, you have HAES/fat-acceptance nutcases convincing huge swathes of the obese population that they are perfectly healthy.
Any major changes will have to come at the state and federal government level. The medical industry can't do much to change that on it's own.
She was vocally critical of the mere concept of "fat" and would find any excuse to pick fights about it. During a company-wide meeting of about 1200 people it was announced that we'd be inviting employees and their families to a theme park for the day, all to ourselves. She stood up during the Q&A portion and asked if the company would be, in her words "giving people who didn't fit on the rides a sum of money equal to the cost of admission, travel expenses, and meals." The HR rep asked for clarification, to which she said "those of us who were born too big to go on rides shouldn't be denied benefits other people get because they fit. That's discriminatory."
She would also frequently and passionately argue about how the idea of "overweight" or "underweight" is an invention of capitalism - a tool to get people to spend money on books, gyms, diet programs. No amount of rational debate would alter her stance. She'd cite supposed medical journals from memory disputing the concept of obesity if anyone asked "aren't there health risks?"
Denial is a crazy, sometimes heart breaking, thing. There are people who don't believe that being fat is unhealthy.
She was one of them. I say "was" because she died of cardiac arrest at the age of 27 while at work, 20 feet away from where I was sitting. Even now, I still have a hard to reconciling who she was (smart, rational, kind) with what she believed and how she died. Utterly tragic.
In general high deductible health plans can be good option for consumers who are in good health and have the financial means to absorb an occasional large medical bill. There are also tax incentives for such plans.
https://www.healthcare.gov/glossary/high-deductible-health-p...
I haven't set foot anywhere in North America in almost ten years, and frankly I don't miss it.
The food is better, the transport is far better, the weather is better, and my health care costs are literally a rounding error.
Where do I live, you ask?
Not in the US.
I am an US expat living in a country with free universal healthcare. It is also affected by a war that started a year ago. I could not leave then because I had a life threatening health emergency and had to spend 2 month in a hospital. Luckily, it was finally resolved, but i need to stay on heavy meds to remain in remission.
And they just discovered that I have a tumor in my kidney that requires major surgery. To have surgery here is almost certain death from complications/infections/neglect (i've seen it happen)
So I have to go back to US.
My plan is to move back, buy a "cadillac" health plan on ACA market place. I understand that one can enroll after enrollment period if moving from overseas. Then try to get a treatment.
What is the best approach to get the treatment as fast as possible? Is concierge thing only way to go? I checked major cancer centers in an area where I plan to settle, they are all accepting new patients. Does it mean I can go directly to them and expect them to treat me right away?
Most important question. What if I denied insurance or it is delayed and I end up uninsured? Is there a way to get a treatment first and pay later/negotiate price, payment plan, etc
Any advice is appreciated
Thank you
Too soon friend.
Honestly I didn't lay in a bed in the hallway when the shot's mycarditis got triaged as "might be a heart attack". And as for who pays, well that dose cost me $3000[2] and my insurance another $20000, good thing I didnt take an ambulance there. But I guess I should be honored to pay it in the name of social contract and social good. The government gave free vaccines, but didn't own up to the expensive part. I'm all for saving the lives of the elderly at the cost of the young... in vampire movies. But, in real life the boomers should at least have had the decency to at least cover the cost -- something they easily can afford to do[1]
[1]: https://youtu.be/lQQPicCoaG4?t=129
[2]: https://webcache.googleusercontent.com/search?q=cache:FA4cPr...
Don't give people inflation adjusted raises for a decade, remove all nurse to patient ratios, run them through hell, and then you're right it's inevitable
1) Free time-saver perks for all hospital staff. I'm talking cleaners to the houses, pre-cooked take-home family meals, the whole nine yards.
2) Temporarily lower the threshold for trained medical professionals. There are many students and immigrants with plenty of education and skills. Get them in hospitals until we reach the point where it becomes a space issue rather than a staffing one. Give more experienced staff priority pick on working hours. Stem the bleeding and stop the work exhaustion/burnout.
3) Start longer term efforts to ramp up training of medical professionals. It's only gonna get worse with the baby boomers retiring and needing their own care.
4) Tell "big insurance" and "big healthcare" to put up or shut up. Slap on metrics and quotas focused on efficiency and net outcomes. Tweak the metrics until they get the picture. Set the bars high enough that the majority of issues are solved if the bar is met. If they can't meet the bar, hit their pocket books until they go bankrupt, nationalize them, then convert to single payer.
https://www.nytimes.com/2022/12/15/business/hospital-staffin...
Healthcare is highly dysfuctional but I want to dampen the notion a little bit that it is in some unique and new kind of collapse today. Everything you are stating is nearly verbatim what was being said in the 1980s at the dawn of HMO legislation which was somehow supposed to fix things.
There has been a lot of pushing the food around the plate since then. My view is that there are three legs to the tripod of the healthcare system, providers, patients and insurers. For fourty years those three legs have been fighting each other on many fronts and no leg is willing to give substantial ground. If I had a magic wand I would bring into existence a being of profound integrity and leadership that could negotiate meaningful compromises between those three groups but I think practically speaking, that is a pipe dream. The current status quo will continue, more or less, how it is for several decades yet.
I will agree with the other comentator that if you are sick a direct access primary care doctor or concierge doctor can really help. In many cases they can end up saving money versus deductibles and by helping you find specialists and facilities in your budget and timeframe. They vary but can be found in most markets for $1500 - $3000 per year. That's not cheap by any means but something that can pay for itself quickly.
I would also say to OP, seriously consider becoming a direct access provider. Feel free to reach out to me and I can put you in touch with some folks who you can talk to. You are not alone in your sentiment and in large part those sentiments are what led to the creation of direct primary care.
du@50km.com
In particular if you have say a chronic condition which remains unresolved after several interactions with the general purpose health system a direct primary care doctor has the time to put towards your case on an individual basis to potentially get to the bottom of it. My experience has been that they also do a much better job at management of chronic conditions but I would really like to see some more studies done in that area.
A massive number of calls are simply untreated low-grade fevers where the patient was unaware of the fever. I am OBLIGATED and MANDATED to send them to the ED if they request transport. Furthermore, I am LEGALLY bound to offer transport to the ED. I have ZERO authority to tell them to take a fever reducer and call back if that doesn't fix their medical concern.
We are taught to use differential diagnosis in paramedicine. However, we are not allowed to diagnose per medical guidelines from the medical director. Working with this dichotomy has made the entire pre-hospital care system complete bullshit. Based on what I see in the ER, the entire system is on the precipice of complete failure. This collapse is unique and new due to the absurd volume of patients and bullshit policy that has not changed.
Who is trying to make level 5 AI doctors?
My dad has serious kidney stone problems and does not have to deal with the dystopian shit you're talking about.
KP was famously overcrowded during COVID, but the dysfunction you describe is simply not on that level throughout the whole country.
Really, we could bandaid a lot of these harms by making it easier to get access pain killers. I think the opioid crisis was worth allowing legitimate people to get access to strong pain killers quickly on negative utilitarian grounds.
Sometimes when I see the healthcare system in USA I cannot believe how the country could be like that, how people cannot think for a moment about other people in needing, I really cannot believe why there is people that cannot want universal healthcare. It is beyond my worst imagination.
It is an human right, it is someone suffering. I know that is expensive, I know that there is a lot of things to do, but people is dying, because they are poor, because they cannot pay an insurance, because the insurance is for profit and is not hiring more doctors, etc.
Healthcare system and education system is something that I cannot believe how bad it is in usa. And is sad af.
[1] Before the Obama administration, your health insurance could be denied or cut off based on arbitrary reasons ("pre-existing conditions"), and if you did not have a job that provided health insurance, you had to pay this cost entirely yourself - unless you qualified for Medicaid through absolute destitution. The Affordable Care Act ("Obamacare"), despite being a massive compromise from universal health care, allowed the sick and poor to get subsidized insurance, shielding tens of millions of people from the worst outcomes of the system.
[2] https://www.healthaffairs.org/do/10.1377/hpb20220506.381195/
Every non-payer added to the system lowers the quality for the existing members.
This all reads like complete and utter FUD
EDIT: Never mind engagement, I see this is nothing but a SP propaganda thread.