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So are you using MEDLINE or UpToDate instead of JAMA? NEJM? Lancet? I'm just curious since so much of practice is keeping abreast of new developments.
Reasons Not to Become a doctor
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So are you using MEDLINE or UpToDate instead of JAMA? NEJM? Lancet? I'm just curious since so much of practice is keeping abreast of new developments.
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Yes. The only physicians that are required to see every patient are Emergency Physicians. However...and this is a big however...this is stipulated in our contracts and is part of our regular job description. Family Physicians, General Surgeons (when not on call to the Emergency Department), Internists...they can and do refuse to see patients that can't or won't pay. And they often fire patients with outstanding bills, allowing of course for the usual "thirty days" of "emergency" treatment while the deadbeat...uh...the patient...finds a new doctor.
Now, many (most) physicians do some pro bono work, I plan on volunteering a little myself through my church, but there is no requirement that we do so. The "Takings Clause" of the Fifth Amendment forbids government from forcing you to see patients for free or a for a discounted rate.
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I read specialty specific journals like ACEP and the like. I also get most of my practical information from Tintinalli and Rosens (the Bible and Koran of Emergency Medicine).
I use Emedicine and UptoDate for quick searches.
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Gotcha. I tend to follow CCM and MEDLINE.
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Thank you, Karl Marx, for blessing us with your well informed opinion and the ways in which we all should be welcoming socialism. Yes, NOT ONLY should we all sacrafice 10-14 years of our lives to education&training, BUT we should do that in addition to terrible hours, AND PRAY that we have our salaries and "perks" lowered.
You know what I'd like to see done away with in this country? LIBERALISM! Yes, the kind of ideology that resorts to logic such as- "We want to pay for all these great entitlement programs with money from Santa Claus."
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Which is why healthcare can NEVER be defined as a right. You do not have a "RIGHT" to something which obligates a 3rd party in order to excerise that right. That would be considered a "positive freedom," and the US Constitution (Amendments 1-10) only deals with "negative freedoms," those which are inherent and do not require the obligation of a 3rd party. "Your rights end where mine begin."
Since there is no chance in hell that the 5th amendment will be repealed, there is no chance that healthcare can be defined as a "right" under the US Constitution. God am I glad you brought that point up. So to all of the liberals who say that universal healthcare is coming and I can leave if I dont like it, how bout if you like Germany's healthcare system so much MOVE THERE!
I am just going to quote this, but it has to do with the perception of doctors in general.
You guys, and hopefully me someday, go though more crap to get a job than any other professional I have ever seen.
I applied to law school a month ago. I spent 3 months studying for the LSAT, and with a 3.3, I was accepted to 4 law schools, at this time, will probably be more as time goes on, but I wont be attending. After three years, lawyers are done (in some cases 2.5), making, in most cases more than a doctor will ever make.
And still, most people hold physicians and lawyers on the equal ground.
Why do physicians get a bad rep? Is it because of ignorant Americans that can't see past bull**** numbers like those below, thinking, OMG, they make 1,000,000$ a year, well I should too. So they cry to the president elect Obama, "we didn't do anything but drop out of high school, and take the first job that fell to our feet, or majored in business and now cant do anything but manage a convenience store because we didnt work hard enough when it mattered, but we still deserve everything those doctors who spend 4 years working harder than any other college student, spend 4 years in the hardest graduate program available, spend 4 more years, making around 35k a year, as a resident, get." Just to pay insurance companies 400k a year for malpractice. But if you look close enough, it's the lawyers who are fighting to hurt physicians so the lawyers are gods to the average American, then you have the MBA's who are handing out the money, so everybody think they are great....
http://www.allied-physicians.com/salary_surveys/physician-salaries.htm
ORS - Spine Surgery
$398,000
$670,000
$1,352,000
Even beyond physicians, theres injustice when it comes to graduate students and PhDs in science. There are graduate students in my lab, that have to work 50-60 hours a week, not including the time they are teaching, grading papers, in their own classes or studying, to make what a 24,000$ stipend a year. In some cases as low as 18,000$. The balance of power needs to tip away from those skum bag lawyers, who are trained in taking advantage of people, and tilted toward those who, frequently work harder than lawyers, and do it to actually help others.
I think, while we are getting trained to save lives, lawyers are out learning how to manipulate facts, and smooth talk their way into getting what they want. That's why there is an over propionate number of lawyers in politics.
Don't get me wrong, I decided not to go to law school, because I want to help others, like most of you. But you can't be content with the amount of bull**** med students and physicians have to go through, because of lawyers both in and out of politics and the ignorance of the average American.
Please, tell me what you think.
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A law degree does not guarantee you will make bank. Doctors on average earn more than lawyers. There are obviously exceptions, but many people seem to think a law degree means big money and in most cases it doesn't.
Who's to say X career is superior to Y? It's all personal preference/opinion.
When did the public start loving lawyers?
A modest stipend is better than a tuition bill and the loans that follow. Also, salary is not based on hard work. Within a single profession it may account for some of the varience, but between different professions it is useless.
You give lawyers to much credit for the world's problems.
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I'm pretty sure if there is anything else worse to go into than medicine ... it's law. For profit law schools where just about anyone can get it - I've seen peers with sad gpas and low LSAT get into ones you've NEVER heard of. Only certain areas of law make bank, just like in medicine ... the big corporate lawyer is akin to the big plastic surgeon etc ... hard to get, don't think you can waltz into either. As far as I know, the average GP still makes more than the average lawyer ... medicine probably looks bad (trust me, I'm having major doubts myself lately) but the grass is ALWAYS greener on the other side.
Everything is tough to a certain extent ... I had a buddy who quit pre-med for business, had the same misconceptions that he'd graduate with no real work experience and an econ degree and be making 100k at 22 ... basically with the economy the way it is, coupled with the fact that no one really wants to hire a random college kid with no experience ... he can't get a job, having to intern for free and might go back and get his MBA to get an edge up. So I mean, add all that time and struggle up, and suddenly it doesn't seem like the get rich quick scheme.
Everything is tough to a certain extent ... I had a buddy who quit pre-med for business, had the same misconceptions that he'd graduate with no real work experience and an econ degree and be making 100k at 22 ... basically with the economy the way it is, coupled with the fact that no one really wants to hire a random college kid with no experience ... he can't get a job, having to intern for free and might go back and get his MBA to get an edge up. So I mean, add all that time and struggle up, and suddenly it doesn't seem like the get rich quick scheme.
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No.
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They've tried. The lawyers make the rules.
Sure, we all want to make money; however most students will have undergrad debt in addition to med school. It's expensive, and I can't imagine physicians making less than they currently are and being able to pay $2500/mo in loans, plus a mortgage, car payments, utilities, KIDS!!!, etc. It's a lot. No way they would actually live without that type of income, which by the way is heavily taxed.
Totally agree 👍 I can't tell you how many times a patient will come to the ED and say they couldn't fill their $4 prescription, yet they bought their pack of cigarettes for the day.
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Here's the real scoop on this -- the numbers are misleading. There are many many times more lawyers than doctors. As such the range is much greater. The average lawyer earns a lot less than the average doctor. However since there are so many more lawyers than doctors, more lawyers earn more than doctors. Currently about 20% of lawyers come right out of law school to salaries over $150k. But again there is a huge range, so I wouldn't be surprised if the lowest salaries were below $30k. And you have to realize that this is after only 3 years of school (so a year less debt) and no residency. So if you take into account the time value of money (ie compare doctor and lawyer salaries in today's dollars) this is worth well over $200k. Also lawyers tend to get decent year end bonuses in good years, while many doctors don't.
The trick in comparing doctors and lawyers is to compare apples and oranges -- you cannot compare averages when one group is so vastly larger than another. If you compare the equivalent number of lawyers from the top down to all of doctors (because honestly this is the group of lawyers you would be in anyway if you chose this path, in my opinion and experience), it's not going to be a huge difference in salary, but the lawyers get the money years earlier, without as much debt.
As for the reference to the allied salary website, the above poster should know that recruiting sites are notoriously bad places to get salary data. This is a site which is trying to get you to use their services, not provide objective salary data. You will not, in all likelihood earn anything close to a million dollars in salary as a doctor, sorry. The public might believe that, but folks on a premed site shouldn't.
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See my above post. More lawyers make money than doctors, but because so many can get into law school there is a huge range of lawyers out there, ranging from the successful to the not so successful. In comparing it to medicine, you really have to compare to the group you would be in if you chose law over medicine, not compare to the folks with C averages who got into crummy law schools. So you don't want to compare averages, because with a group as large as law the average is not an apples- apples comparison. It's like lumping NYC into a group with a rural Kansas town and talking about the average of those two -- it has no semblance in reality. So the fact that the average lawyer may make $50k is meaningless if the group of lawyers you could have been in comes out of law school earning $160k (as a first salary, with less debt, and 5 years earlier than the average doctor). So when you compare apples to apples, the difference isn't as you suggest, but if you compare to averages, which you likely won't be if you are choosing it over med school, then that isn't a fair comparison. In one of his articles, Gawande made this point, and he is accurate. The person who had the choice of either careers was not close to the average in law -- he was more often in that top 20% of law grads who was going to start in the six digits. Such is the nature of that profession.
I can honestly say, having had a nice taste of both career paths, that if it were all about money, law was still a better path. Fortunately it isn't. Career changers get reminded of this a lot -- in every interview the interviewer will make sure such an applicant understands that s/he is unlikely to get back to the princely salary where they were, salary-wise in medicine. They aren't exaggerating. Doctors live quite comfortably. A greater number of lawyers live more than comfortably. Because their really isn't a ceiling in law the way there is in medicine, where income is set through reimbursements. You can charge what the market bears in law, but not as a physician.
Not that I'm saying anyone should go be a lawyer. You have to work hard to do well, and for most people in medicine, the function of law may not be as appealing. And it's really about how you want to spend the next 40 years of your life, not what you are going to earn. But if you are looking to be a professional and maximize wealth, it's not a bad path. Certainly not as bad as the folks on SDN like to assert. You simply cannot be close to the average to succeed. Which shouldn't be a problem because the folks who got into med school were similar distances from average throughout their college career. I would suggest that the current financial market is going to close a lot of doors in law for the moment. In times of slow economy, no businesses do "deals", and so the transactional end of the law business slows up. The other issue with law is that you don't stay at jobs as long. The current model is to change jobs every 5 years. So you don't have the stability in law that you have in medicine. Some people are okay with this -- increased risk leads to enhanced income as you tend to be able to renegotiate your terms favorably each time if you are good. Others don't like the lack of stability. I wouldn't choose a career based on stability, but it is something worth noting.
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Law2doc summed up everything wonderfully, I just want to add that Law schools especially in the middle rank range are much more willing to give out scholarships. So it is only 3 years, no residency and will cost less. From what I've heard medical schools don't give out many scholarships.
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Well said. If that kid who is spouting that physician salaries should go down more and more gets into med school he will change his tune real quick when he sees the amount of work it takes.
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All of you who are ready to take a drastic pay cut as some sort of self-immolation ritual are a bunch of suckers. First, because you are the only people in the who medical industry who will accept a pay cut without a fight. I assure you that nurses and hospital administrators are not going to join you in your quest to save the bloated health care system by cutting their own salaries. Therefore, even though you as physicians are the most important part of the medical care industry The Man knows that he can punk you out and save a little money on your back, not to mention using you as a convenient scapegoat. When the Kennedys, the Clintons, the Kerrys, and the Obamas of the world take vows of poverty and when every government policy wonk and lawyer agrees to work for "what they make in Germany" then we'll talk.
Secondly, you don't understand money because you never had any and don't have any now. It's just an abstraction to you so, as you haven't yet had to work for it, you view the translation of the proverbial sweat of your brow into a portable medium of exchange with something of a cavalier attitude and can easily dispense with large chunks of your future earnings, willingly giving your labor away to a growing number of fat, lazy, stupid people. Suppose I instead asked you to devote half of your day working as an unpaid servant to the Holy Underserved. You could scrub their toilets, take care of their babies, cook their meals, and clean their houses. After you got done with that you could agitate to give their children your precious spot in your precious Ivy League university or your "Top Ten" medical school. I mean, it's only your hard work, right? Your desire to not work hard for the poor is nothing but naked greed and the Holy Underserved have a right to some large percentage of your work day and your free time.
Secondly, you don't understand money because you never had any and don't have any now. It's just an abstraction to you so, as you haven't yet had to work for it, you view the translation of the proverbial sweat of your brow into a portable medium of exchange with something of a cavalier attitude and can easily dispense with large chunks of your future earnings, willingly giving your labor away to a growing number of fat, lazy, stupid people. Suppose I instead asked you to devote half of your day working as an unpaid servant to the Holy Underserved. You could scrub their toilets, take care of their babies, cook their meals, and clean their houses. After you got done with that you could agitate to give their children your precious spot in your precious Ivy League university or your "Top Ten" medical school. I mean, it's only your hard work, right? Your desire to not work hard for the poor is nothing but naked greed and the Holy Underserved have a right to some large percentage of your work day and your free time.
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Inside every cynical person, there is a dissapointed idealist.
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Whoa, Buddy. My idealism just runs more towards freedom, personal responsibility, free enterprise, self reliance and all manners of other traditional values. Why the converse, that is, the rush towards dependency, mediocrity, and the regulation of every aspect of life by bureaucrats is considered idealism while my ideals are not has yet to be explained.
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I wish I could come out and say these things in an interview
I couldn't be in any further agreement with PandaBear, although as it stands, there is a need for sweeping reform in the medical industry. I think that before we can talk about medical care as something EVERYONE should have, we should talk about stipulations... Like taking care of yourself.
I could go on and on about this, but the fact of the matter is that if a person obviously isn't taking care of themselves, or isn't doing anything for their health, e.g. smoking, heavy drinking, recreational/hard drugs, then I don't think they DESERVE healthcare.
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DO NOT GO TO LAW SCHOOL THERE ARE NO JOBS YOU WILL DIE ALONE!!!
Don't believe me? Ask them
http://forums.somethingawful.com/showthread.php?threadid=2968400
Don't believe me? Ask them
http://forums.somethingawful.com/showthread.php?threadid=2968400
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Well, the problem is that this kind of idealism also has a tendency to use caricatures instead of accurate pictures. While there are plenty of people who are lazy and unmotivated, there are many who are not and who are basically ****ed by the system, who will get further screwed by the idealism of "freedom, personal responsibility, free enterprise, self-reliance, and all manners of other traditional values". You need a healthy blend of rosey glasses, coat-off-your-back BOHICA self-sacrifice AND free market self-reliance to get at realistic and meaningful changes in society.
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I'm a little horrified by how many think the free market will cure all. Sure, there are people that don't take care of themselves, but that's not the whole story. Some of you sound like neocons ranting about "welfare queens" - when they found a handful of people who abused that system, and plenty more who it helped. And blaming HMOs on "liberalism"? what? I think bureaucracy is toxic in a non-partisan way.
My job does not have decent health care, and I was rejected on the open market due to a surgery I had 9 years ago (a congenital problem which is totally over). I'm not fat, I don't smoke. I try to put aside money each month since I don't have health care, but the truth is that if something really bad were to happen I would be rapidly bankrupt.
My job does not have decent health care, and I was rejected on the open market due to a surgery I had 9 years ago (a congenital problem which is totally over). I'm not fat, I don't smoke. I try to put aside money each month since I don't have health care, but the truth is that if something really bad were to happen I would be rapidly bankrupt.
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Well, I feel for you, but the problem is that managed care has driven prices way up and since a third party pays for everything, there is no incentive to cut costs.
Also the bureaucracy and red tape drives prices up and lowers quality. If managed care is completely removed, and if health insurance does only what insurance should do, then costs will fall due to competition and the incentive for hard work and achievement. If doctors could focus on patients instead of dealing with hassles with insurance companies, then health care will be far cheaper. LBJ's signing of the Medicare bill was a tragedy that we are still dealing with today.
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Yes and no. Managed care did in fact drive costs up and increase bureaucracy, but removal of red tape and a return to a free market approach isn't a cure all. *In principle* (i.e., on paper), that is the way the market is supposed to work, but there have *always* been confounding variables that prevented this from being the case (e.g., while competition lowers relative costs, in the absence of oversight in can produce monopolies, price fixing, and lowered quality of care to get return on investment, in addition to only subsidizing low risk investments (low risk patients are cash cows; high risk patients require pay-outs), so people with pre-existing conditions get screwed). It's like pure communism - looks great on paper (mutual support, lack of class distinctions, significant natural altruism), but has never worked as a system without significant modifications (e.g., communism under Mao is very different than it was under Stalin, Minh, Castro, etc.).
The issue of health care financing is *a lot* more complex than is being presented here - I just finished four weeks of economic scarcity and models of health care financing with my students, and there was a lot of information we did not have the chance to discuss.
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Unless I misunderstand your proposal because of missing filigrees, it seems to be an oversimplification. Let's say that you have a 1000 patient base. That's 20K a month and 240K/year. If you allow 3 visits each per year, that's about 3000 total and an average of about 12 patients per day. Ok, maybe not bad. But let's look a bit deeper:
- You yourself specialize in just one area. So let's say you're an internist. What happens if you patient needs to see a dermatologist, rheumatologist, or an oncologist? Is she supposed to pay a monthly fee to every conceivable specialist just in case she needs him?
- What happens to the fixed number of visits when your patient gets sick? What happens when 30% of you patient base becomes sick and needs more visits?
- What happens if someone with cancer or HIV tries to get your pre-paid plan? Are you going to charge them a special inflated fee or refuse service altogether?
- What happens when your loyal customer base gets old with time and requires more of your services?
- Who pays for emergency visits?
- What happens once your patient base dwindles so much that your salary is cut by 40% or more? Are you going to refuse service to the rest of your base?
I am not antagonistic to your idea. In fact, I am interested in your solution because it is exceedingly rare when a medical student/resident offers any solutions, other than complaining how bad the doctors are doing. So it is refreshing to see a proposal. I just want to see you develop it further and explain what exactly will $20 get one.
Personally, I tend to think that if one believes in the free market (if you are yelling socialism without even knowing what it means, then you must), then there is a reason why insurance companies exist. It's probably because directly paying the doctors has not worked on a national basis. Therefore, I'd start looking at how insurance companies can be modified before deciding to overhaul them. This can be done by anti-trust laws, regulations, etc. It seems that we have a problem because free market is not working as it's supposed to work. Instead of insurance companies competing against one another, they seem to act as a singular monolithic block dictating prices in a uniform manner, as if they are in a partnership - they work with one another and compete against the doctors and patients. Since there isn't enough tough competition, there isn't a drive to drive the costs down. And I don't know what AMA does, but it is either powerless or ignorant or both. Though when you see so many pre-meds saying here that they'll settle for the lowest income possible, that explains a lot of things. But still I'd think that the majority of these people are changing their mind once they accumulate the debt and start paying it off.
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Im equally as horrified at the people willing to acquiesce every decision that they have to make on a day-to-day basis to the government. Neocons are not in favor of smaller government so why would you even bring them up? You clearly cannot differentiate between a neo-conservative and a true conservative. Neo-conservatives support big government, defecit spending, and they compromise on welfare programs, they try to be like democrats while still calling themselves republicans.
PERHAPS a completely free market is not the total solution for healthcare, but neither is full blown socialism in healthcare. If you would like your healthcare to be run in the same manner as the DMV or other inefficient government agencies which have no incentive to provide a quality service or to keep costs down, then good for you. I personally would like to retain control over my healtcare, when I get seen, what courses of treatment I can pursue, and not have those things dictated to me by a government bureaucrat who pushes paper and does not care about my health one bit.
The best government is the government which governs the least.
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Yeah, the thing is, this isn't an accurate portrayal of socialized medicine. It's back to the same caricatures I was arguing against above. I've also been grading for the past six hours, and my eyeballs are about to explode, so I can't get into at this point. Suffice it to say, there has been a ridiculous amount of misinformation making its way around the net and pop culture about the Canadian and British health models that just isn't true. Socialized medicine doesn't remove treatment options, doesn't necessarily result in lengthy waiting times, has produced occasional drops in the bucket in terms of Canadians coming to the U.S. for treatment (less than 1% of individuals who *could* come actually do), ends up producing less infant mortality, longer expected life, decreased consumption of GDP and produces greater overall coverage for those affected while maintaining a satisfactory quality of care, and I have the stats and public health analyses to back these up. If you *really* want to get into it, it will have to wait until tomorrow, and I would *really* suggest checking the actual figures and analyses instead of anecdotes and talking points before we discuss it. Wiki and Drudge aren't public health institutes, so their figures aren't reliable.
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I think Panda's suggestion was for primary care practices, which have been hit the hardest by recent events. Obviously, it wouldn't work for EM or Oncology. People would still need catastrophic insurance when they get hit with life-altering illnesses. The PCP's role would be the same under this pricing plan as any other: refer the patient to a specialist.
Also, "free market" is just a mechanism for arriving at a price, not some new brand of political philosophy or unfounded belief system. People who have such a hard time with it need to explain why some other agency determining the price of a service is a better alternative.
One of the big reasons health insurance as we know it "exists" isn't because the "free market" failed. That's like saying auto insurance exists because of the failure to pay auto-mechanics. The reason we have a BROKEN insurance industry, is most likely because the government stepped in and restricted employers' abilities to pay wages. As a result, employers looked to alternative means to entice employees to sign on, such as health benefits. And these companies DO compete, but they're not competing to provide care. It doesn't help that the government currently gives HUGE tax breaks to corporations who give the benefits, furthering our dependency on a broken system.
To get back to the original posts, that's why it going to suck to be a doctor. We have to deal with these cumbersome companies propped up by the current tax system, who aren't competing to provide better quality care, but are only looking to build wider, crappier coverage, in addition to a government that has arbitrarily decided that its going to reimburse procedural work more than diagnostic/preventative medicine. And the trendiest solution to this is more of the same.
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Most specialists are in fact doing low-level "primary care" in their own specialty, handling things that a primary care doctor could do except that the reimbursement environment has made it much more cost-effective (and easier) to consult a specialist for everything and anything. Ideally, specialists should be used as consultants where they offer their expertise on a limited number of difficult cases. Instead, specialists and sub-specialists are increasingly being used as "physician extenders" for hurried primary care physicians.
If you were a reasonably confident and competent internist and ran a strict fee-for-service practice seeing a reasonable number of patients every day to who you could devote the required time, you wouldn't need to consult nearly as many other doctors as you think.
On the other hand, suppose your major health problems are mostly cardiac. Why not pay a cardiology practice a retainer as well? Maybe you need a nephrologist too but this begs the question, how many doctors does one patient really need? You will see when you get out there many, many patients being followed by a squad of doctors which leads to expensive, redundant, fragmented, and sub-optimal care.
Which brings me back to my original thought, namely that people should pay for their own routine medical care and have insurance, either private or government sponsored, for major medical catastrophes.
If you were a reasonably confident and competent internist and ran a strict fee-for-service practice seeing a reasonable number of patients every day to who you could devote the required time, you wouldn't need to consult nearly as many other doctors as you think.
On the other hand, suppose your major health problems are mostly cardiac. Why not pay a cardiology practice a retainer as well? Maybe you need a nephrologist too but this begs the question, how many doctors does one patient really need? You will see when you get out there many, many patients being followed by a squad of doctors which leads to expensive, redundant, fragmented, and sub-optimal care.
Which brings me back to my original thought, namely that people should pay for their own routine medical care and have insurance, either private or government sponsored, for major medical catastrophes.
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You're right, a completely free market isn't the solution. Along with being impossible to implement, it also causes the lowest classes to be overlooked completely, and the middle classes not to get the specialty care that they may need. That being said, we need a free market with notable countercurrent individuals. These individuals are the ones who give free care and provide to those that a capitalistic system misses. You can't mandate that these people exist, but by enacting pure capitalism, enough of them will come out to adequately help the poor based on the social return that they get. Thus, we keep doctor reimbursements high enough to keep the field competative and we don't compromize the quality of our care.
On a side note, don't ever knock those who go into medicine for the money. Not only do I sincerely doubt that anyone does it purely for financial gain, but a profession where doctors are paid well is not a bad thing. High pay will only increase competativeness throughout the application, residency, and attending process, thus causing our health care system to produce better physicians. At least take note of the difference between high patient costs due to insurance and those that come from reimbursement of quality physicians.
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If your a chick, I will propose to you right now...
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That's going to be awkward if Cardiac isn't.
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Beautiful
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Isn't this already what the insurance companies are for? I mean most can afford to go and see a doctor for a regular check up for $100 or so. But that's not why we have an insurance. We have it exactly for the catastrophes that you mention, which really can be classified into anything that requires intervention - you require an allergy treatment, need an appendix removed, or get necrosis from a simple wound infection. I'm not sure "catastrophe" is the right word. We can call them "expensive treatments" instead. That's exactly why the insurance companies are there.
I understand what you are trying to do, but the real question is how much do you think we'd save on insurance if we decide that from now on they will not be covering regular office visits for non-major treatments? I don't think this will have much of an effect since the function of the insurance is already set up to mainly address major treatment needs.
I also don't think that a heart patient can pay $20 a month to a cardiac doctor and expect to have his heart valve surgery covered when the time comes. Neither will it work for the neurosurgeon. Again, we're going back to the insurance companies. Need a revised proposal.
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I really think you're obfuscating his point. I'm sure Panda was referring to non-invasive specialists for things like checking up on what beta blockers 90 year old Mr.Smith is prescribed if he needs to see the cardiologist once a month. I dont think any of us are suggesting your recieve $50,000 surgerys for $20 a month. I think in theory his proposal sounds great, its probably the best one I've heard so far. Now if we can just get 60% of the US population to lose their "entitled" ideology and make them believe that doctor visits should not be free or covered by health insurance then we will really be making some F'in progress...
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Exactly. Most doctors visits, most of the time, are mostly routine and do not result in a hospital admission. Additionally, in many cases people with serious medical conditions can be safely managed as outpatients provided they have good follow-up and a doctor who has the time and the incentive to deal with them, two things sorely lacking in our current system and only fixin' to get worse.
You also have to realize that many patients who receive the super-deluxe procedural interventions could be just as well managed (from a morbidity and mortality standpoint) with conservative medical therapy. Unfortunately, since the reimbursement milieu heavily favors procedural medicine, we end up doing probably ten times more heart catheterizations, as an example, than we really need to.
Finally, we have got to accept that people die. Remember, three percent of the population use fifty percent of all medical resources and much of it at the extreme tail end of their lives when the vast sums of money poured into dying patients have only a marginal effect. There is currently no rationing of medical care at this end. None at all. Zero. Stroll through any ICU you care to mention and tell me if you think your money is being well spent.
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Depends on the ICU. 😉
My last trip through the ICU involved a number of young patients (<55 y.o.) recovering from grievous injuries. But this was a trauma ICU, and I think there's a lot of truth to the point otherwise.
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No. You are wrong. Most medical insurance provided by employers or the government is comprehensive. Some requires a copay but this amount is a fraction of the true cost of the visit. That's the problem with medical insurance, namely that it is not set up to only deal with major medical treatments but every little thing imaginable.
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The money that we waste, and I mean to the extent that we might as well flush it down the toilet, on futile care would astound you and is probably where most of the "We spend twice as much as (insert European mammary state here) and don't live as long" comes from. Like I said, three percent spend fifty percent and that fifty percent is not buying us a lot, statistically.
Consider a congestive heart failure patient. After an acute exacerbation, the one year mortality approaches sixty percent, meaning that they have a probability of being dead after a year of 0.6. Roughly this means that six out of ten CHF patients will be dead in 365 days no matter what we do...but in those last days we ram enough medical care into them so you'd think were really going to give them another ten years.
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Exactly exactly exactly...If health insurance only covered catastrophic events then premiums would plummit. As it stands now, everytime someone sneezes they goto their PCP, pay a small copay ($5-$20) for a $90-$150 visit. If we allowed the vast majority of people to absorb that cost they would only visit the doctor when it was necessary. This is where liberals and fiscal conservatives part ways, because we believe that people should be accountable for themselves and seek care when they believe they need it. In contrast, liberals will say that by letting people pay for their own visits for minor health problems "discourages" people from seeking treatment. I counter that argument by saying, unless that person is living below poverty than they can damn well spend that $100 on a doctor visit over 7 packs of cigs and a 12 pack for the week. Yes, anecdotal evidence at best, but I'm just using pure logic here.
People really need to get their prioritys in order in this country, and lose that damn entitled attitude that they all have. This government is not REQUIRED to give you healthcare, nor do I think my money should be stolen in the form of taxation to provide you with healthcare. As mentioned previously, if we allow the free market to work and reimbursements become reasonable again, there will be a surplus, and doctors will be able to engage in charity care. As it stands now, the doctors are pressed against the wall and probably cant even think about charity at this point.
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First, absolutely hilarious to see this thread again. There's one like this every month from October to March for the application cycles each year. Everyone says the same things over and over.
Second, that would be very expensive for a lot of people who can't afford it. I'm willing to pay a janitor more than $19000/yr, but most people aren't. "Routine medical care" is pretty expensive.
Second, that would be very expensive for a lot of people who can't afford it. I'm willing to pay a janitor more than $19000/yr, but most people aren't. "Routine medical care" is pretty expensive.
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Are you saying that the visits for the little things are the main cause for the high cost of healthcare? That's not very credible. Can you give some numbers to back that up? I think that insurance prices are high because of those specific, high cost procedures.
I agree that seeing a doctor for a flu is waste of resources, but if you are trying to concentrate on preventive care, you'd have to see a completely healthy patient twice or so a year. One of the visits might as well be at a time when the patient has a flu.
Keep in mind that while $20/month might be good business for doctors, it will never work if similar benefits do not materialize for patients. If they pay $20/month for "every little thing," they are going to expect their insurance premiums to be significantly lower to cover virtually everything else than a checkup. It is even questionable whether you would be able to do certain preventive procedures like colonoscopy that costs over $3k. All this means that the insurance will have to handle pretty much every real procedure, while the $20/month will only cover things that do not require treatments - such as the flu. I don't see this system affecting the prices of the insurances and the customers will therefore have no need to pay their doctor even $5/month for things that might as well be included in their expensive insurance coverage.
To me it sounds like your proposal will benefit doctors a lot, while patients will not be affected in the best scenario. I don't see that working.
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Panda, I sometimes marvel at your reasoning. OK, I understand that there is a lot of money being wasted in very special circumstances, such as a brain-dead patient on life support or a junkie who comes in for a quick fix, but how can you classify heart failure treatment as a waste? You yourself say that 40% of the patients survive. So are we to stop treating 100% of them just because 60% is going to die anyway? As a doctor, isn't it your job to make sure that the 60% death rate drops to 0%? Yet you almost seem to promulgate raising the 60% death rate to 100%! Would you still think that a treatment is waste of money if your mother or your wife were at the receiving end? C'mon! I know you are trying to save money, but try to be rational. I have yet to see you attack the insurance companies, which are the real culprit of why you are wasting so much time filling out paperwork. If we are going to cut, let's make sure that the target is correct.
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Its a question of if doctors are responsible for individuals or society
It used to be society, population doctoring. When we eliminated Small Pox, we risked 0.1% of the population dieing from the Vaccine, but it was WORTH it for society as a whole. Everytime we give someone antibiotics, we are evolving stronger bacteria. Everytime we save an HIV patient from dieing by giving them antivirals, we increase the disease. To not do any of these things seems repulsive, but the big question of our career will be where to draw the line. How much care can we give a patient in exchange for the detriment of the whole population over time?
It used to be society, population doctoring. When we eliminated Small Pox, we risked 0.1% of the population dieing from the Vaccine, but it was WORTH it for society as a whole. Everytime we give someone antibiotics, we are evolving stronger bacteria. Everytime we save an HIV patient from dieing by giving them antivirals, we increase the disease. To not do any of these things seems repulsive, but the big question of our career will be where to draw the line. How much care can we give a patient in exchange for the detriment of the whole population over time?
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Jesus that is beautiful. Officially a fan. Couldn't have said it better.
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I bet you would find that their is no correlation between money spent and mortality after your first big CHF exacerbation and that almost nothing we do effects mortality and won't until such a time as we can cure, and I mean cure, ischemic or other structural damage to the heart. There was a Dartmouth study (look it up) that actually showed an inverse correlation between intensity of therapy and mortality, albeit it was not specifically about CHF.
I assure you, everyone gets everything spent on them all the time. By the time you get to this point, rich or poor, uninsured or insured, you get the kitchen sink. It's not the treatment that's expensive (nitrates, diuretics) but the needless admissions and redundant testing and consultations.
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So I guess these heart patients shouldn't even be admitted! Nice. Redundant testing and consultation could be an area to make some cuts, but if you look at why those are done, you'll find out that the main reason is not to help the patient, but cover the doctor's ass. Therefore, the issue here is not the admission of the heart patient, but the legal liability that forces doctors to do unnecessary things. That's what needs to be changed.
I'll assume you agree with what I said about your insurance proposal.
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No, I hear you, and was actually agreeing with your take on inappropriate care. I've spent a lot of time studying (and teaching) health care economics. My point was just that the last time I took a cruise through our trauma ICU, the patients in question weren't receiving inappropriate care, considering their conditions (e.g., a guy who had severed his thumb and had it reattached, a woman who had been hit and dragged by a car, a new quad, several septic patients, etc.). The trend towards overexpenditure is definitely there, but it's not categorical, which was my point. It's entirely possible for resource expenditure to be excessive without it necessarily being expensive in any particular ICU. And while there is definitely expense inflation due to highly focused spending at the end of life, the savings in other health systems isn't entirely (or mostly) due to this. It certainly contributes, but the shift towards preventative medicine has been shown to be more significant in reducing GDP spending on health care.
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Well look, there is no one solution to the problem nor am I proposing that we can cut medical spending in half. But suppose we had something like a "Futility Score" with points assigned for age, comorbid conditions, and quality of life. Past a certain score you would be an automatic "comfort care only" and I assure you that the money we saved keeping severely demented, immobile, terminal nursing home patients alive for no other reason than because we can would shave five percent off of our total spending. Suppose also that we made most people pay for most of their own primary care; would it be too much to suppose that this might knock another five percent off of what the government is bound and determined to currently spend? How about if the reimbursement structure was reworked to pay primary care doctors adequately for their time? How about a little tort reform?
A little here, a little there and pretty soon we've almost effortlessly cut spending by twenty percent.
