gift link (my last one!)
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Thank you for the link.
I am viewing the choices doctors have through the lens that Albert O. Hirschman articulated: Exit, Voice, or Loyalty. I was just speaking to an old friend of mine from medical school and we remarked on the young students and resident doctors who were protesting and organizing to try to change the system. We applaud them, but we both agreed we were too exhausted to join them; it’s going to be Exit for us.
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I fear that we are losing highly capable talent who would have previously considered becoming a doctor (or PA, or NP, etc) because of our healthcare system. Not to mention those who are leaving the profession/those who are graduating med school who choose to go to Wall Street or consulting, or any of the many options they have.
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I had the same primary care physician for 35 years. I got to know him. Originally he was independent. During one visit we started chatting and he mentioned that he had 3 1/2 full time employees just to do the paperwork for him alone, and it wasn’t enough. Very soon after this he gave up being independent and joined a large corporate practice.
I know someone who manages a home care nursing program. A bit over a year ago they got a helpful summary from the federal government that summarized the changes that had been made to health care regulations effecting home care after the last change in administration. The helpful summary was 400 pages long, and this is just for home care nursing and home care nurse’s aides.
We have made all of this far too complex. What the insurance companies require is too complex. What the government requires is too complex.
Healthcare should not be about filling out paperwork. “Quality” and “paperwork” are not the same thing (they are sometimes claimed to be the same thing by people who require more paperwork in the name of quality).
Someone needs to wake up and realize that complexity has a very real and large cost. Someone needs to pay for all of this complexity. In the end, it has to be either the taxpayers or the patients or both who pay for it.
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One my daughter’s friends from HS who just finished their FM residency went to work for the Indian Health Service last fall. They love it. They are expected to see no more than 3 patients/hour and since they work for a single payer system, there’s minimal paperwork. Also they cannot access the IHS’s computer from outside of the clinic–so there’s no temptation to look at charts/do paperwork at home. They work 8am to 4pm and go home. Done for the day.
Edited to add: salary is about 20% lower than if they had gone with one of the big group health care systems nearby, but they feel it’s fair trade off. Plus the federal government offers great malpractice coverage and good benefits.
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My H was an excellent pediatrician–not just my opinion, but voiced by anyone who ever worked with him or brought their kids to him. Like one of a kind good. He worked, except for two years in the suburbs, in a central children’s hospital and in inner city clinics for very low income and/or homeless families. He won major awards.
The hours that never got shorter, the endless paperwork and fighting with insurance companies, plus the systemic poverty that was/is never fixed, made him more and more stressed, to the point of endangering health, not to mention the strains on family.
A bit over fifteen years ago, he retrained as a teacher, and now is back to being a human again, teaching HS bio. Teaching is another thankless job, with ridiculous hours, and he went right back to being that award-winning overworked guy he tends to be, but none of that is like what it was like when he was in medicine. Leaving it was one of the best decisions he ever made.
I wish I’d talked him out of ever getting into it.
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They do it for different reasons. The government does it because it naively, but innocently and incorrectly, believes that it improves outcomes and access. Private insurers do it with malice to create a barrier to payment.
The bottom line is that this house of cards all traces back to insurance, the secondary lack of pricing transparency, and thus ridiculous costs in the US for no better outcomes than the world leaders.
A heart transplant in India cost about $60,000. By all measures, they are very good at it. The average price in the US is $1,600,000.
We need a MASSIVE rethinking of how we pay for healthcare in this country.
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I’m glad he found a better work/life balance. But I’ll bet he was a gem to many parents and children. Pediatricians are a special breed. 
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If the current situation gets the AMA and its doctors to drop its opposition to single payor healthcare, it will be one of the few bright lights from COVID.
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Single payer is not a panacea. Be careful what you wish for. It’s easy to criticize the US system but do we really want a health system where striking is commonplace and it’s government running everything instead insurance companies? Is that actually an improvement?
And do we even understand what single payor would mean? There’s many different models already in use. Which one is proposed for the US?
https://axenehp.com/international-healthcare-systems-us-7versus-world/
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These are all arguments designed to instill fear and distract from two major facts. We spend FAR more per capita than any other country on healthcare, yet hover around 30th in life expectancy. We have to endure some pain, somehow, or the system will implode.
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I was talking to a friend of mine who is a surgeon… in his 28th year of practice. He was bemoaning the less rigorous medical school grading practices many are moving to a pass/fail system. Do you think this is because we need more doctors and a way to get more retention?
We have more than one model of single payer for some populations. Examples are Medicare for the age 65+ and Medicaid for the poor (with state variations).
Of course, many other populations in the nominally competitive private market have little choice, since their options are based on the employer’s choices, and insurance companies are not enthusiastic about individual plans anyway.
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Medicare is crazy. While having a CAT scan a nodule was found on my thyroid gland. I went to see a specialist. (It took 4 months, but he is the best in the state, and the holidays were coming up.) The doctor is 2 hours from home. My first appointment was just talking to the doctor. My second appointment was the ultrasound. My next appointment is the biopsy. He wants to biopsy it because it is a bit larger than he thought, but he still feels it is benign. Medicare said that he could not ultrasound me on the first visit. Then, he could not do the biopsy during the second visit. The government is responsible for much of the large cost of medical care in this country.
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The medical establishment is responsible for most of the current state. There are tens of thousands of qualified doctors and nurses seeking entry to the US today-their immigration is thwarted by our restrictions, largely imposed at the request of the AMA. Tens of thousands of US kids would eagerly enter med or nursing school, but the AMA opposed opening new schools and residencies. For decades, they kept medical supply low and their salaries high, and are now complaining
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Those decision trees are put in place for cost containment. Are they always efficient and effective? No, but it keeps providers from always jumping to the most expensive option, the one that happens to pay them the most, immediately, when the majority of the time it would turn out to be unwarranted.
Private insurers impose even more strict rules.
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This is not a Medicare issue. Ask me how many hoops I had to jump through with my excellent private plan to get some things done. $10k in visits to get approved for a $3k procedure - all because the insurance said it was doing things that way.
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Social Medicine is not the answer either.
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I posted on the other thread about how visits to our MD’s have changed. It also applies to this thread, so changing to here.
We lost another great MD (imho). I recently received an email with the announcement that my (and DH) PCP (of over 20 years) is going concierge. I know she has struggled trying to balance what she feels is “best practice” vs. corporate mandates (and paperwork). I think it finally reached the tipping point. I understand.
Their former office is not absorbing or accepting transfer patients who choose or cannot afford to follow into the concierge practice. I also know (from experience elsewhere), finding good doctors with experience, who take new patients on Medicare is NOT EASY, so of course I’m concerned for our own next steps to find a replacement. Disappointing of course. But also concerning for all of us.
Fewer Medical students are choosing General Practice, and instead continue to Specialties, which pay far more. Given the cost of Medical School, not surprising. So this translates to fewer MD’s who practice at the “preventative” level, and more at the “treatment” level. That is just backwards. Of course it cost more when treatment could have, and probably should have started early, but that only works if caught early! We may have one of the best specialized care in the world, but our system does not reward or even encourage preventative care.
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One of the biggest issues associated with a reduction in total healthcare spending would be that doctors have to get paid less. There’s only a small percentage that could be saved in admin costs, most of the cuts would have to come from lower reimbursement rates. There are already massive controversies whenever there is an attempt to reduce Medicare rates by the amount mandated by law. Concierge type healthcare is simply a cream skimming approach of refusing to serve poor people with no money and more complex needs, much like doctors who refuse to serve Medicare clients.
Doctors who’ve taken on massive loans to go to medical school are always going to resist foreigners who don’t have debts and could accept lower reimbursement rates, or any attempt to move to a single payer model where the government decides how much they will pay for treatment.
So anyone saying that “things have to change” needs to explain how to get from here to there. Otherwise we’ll just end up with another Obamacare that buys the AMA off, then raises taxes and spending, rather than reducing them.
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