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I'm actually surprised this didn't take place in Florida. Pill Mill Central.


Though for those of us actually in the Psych field, the Tomah VA is the case to follow.
I thought the VA is the model for single payor. As a government run hospital, I would think there would be no problems like this.
That Dr. Houlihan has really good reviews too. http://www.vitals.com/doctors/Dr_David_Houlihan/reviews
 

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I thought the VA is the model for single payor. As a government run hospital, I would think there would be no problems like this.
That Dr. Houlihan has really good reviews too. http://www.vitals.com/doctors/Dr_David_Houlihan/reviews
I don't see how the VA is a model of single payer. It's a transactional benefit, paid for by general taxation for the benefit of a small segment of the population.

Medicare is probably the closest thing the US has to a single payer plan.
 

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I'm actually surprised this didn't take place in Florida. Pill Mill Central.


Though for those of us actually in the Psych field, the Tomah VA is the case to follow.
I was just doing some reading about this. Apparently per VA policy (or at least that VA's policy), you're supposed to get written permission before starting "hazardous medications." What's a hazardous medication? I could see any argument for all psychiatric medications being hazardous in some way or another (prolonged QTc, lowered seizure threshold, etc). Is that going to become the norm? What a bureaucratic pain.
 

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I was just doing some reading about this. Apparently per VA policy (or at least that VA's policy), you're supposed to get written permission before starting "hazardous medications." What's a hazardous medication? I could see any argument for all psychiatric medications being hazardous in some way or another (prolonged QTc, lowered seizure threshold, etc). Is that going to become the norm? What a bureaucratic pain.
as a VA attending this is news to me.
 

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Maybe it was just a Tomah VA policy, or maybe it just applies to Suboxone. Or the news article is wrong. I did work at a place that required written consent before starting anyone on an antipsychotic.
State law where I was at previously required consent for any psychiatric med on inpatient, even prozac. We actually weren't sure how to read the law for outpatient though some places were doing those consents as well.

FWIW, my current VA doesn't do much suboxone so not sure on that one
 

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I thought the VA is the model for single payor. As a government run hospital, I would think there would be no problems like this.
That Dr. Houlihan has really good reviews too. http://www.vitals.com/doctors/Dr_David_Houlihan/reviews
It's almost as if the VA isn't so much a single monolithic system but a series of individual sites with their own unique leadership who make decisions on how to do things. I seem to remember someone posting such a thing upthread :whistle:

Also, FWIW, Tomah is in the middle of f-cking nowhere. The place isn't exactly going to be crawling with good psychiatrists. I'm not sure if the OIG report for the place is open for public reading, but it's really really damning, even moreso than what you read in the media.
 

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I suspect a lot of VA's are being run like Tomah. At my last VA, a psychologist is the interim Chief of Medicine.
 

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It's almost as if the VA isn't so much a single monolithic system but a series of individual sites with their own unique leadership who make decisions on how to do things. I seem to remember someone posting such a thing upthread :whistle:

Also, FWIW, Tomah is in the middle of f-cking nowhere. The place isn't exactly going to be crawling with good psychiatrists. I'm not sure if the OIG report for the place is open for public reading, but it's really really damning, even moreso than what you read in the media.
I can't find any medical board action on him..
 

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I don't see how the VA is a model of single payer. It's a transactional benefit, paid for by general taxation for the benefit of a small segment of the population.

Medicare is probably the closest thing the US has to a single payer plan.
Hows Medicare doin?
 
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Hows Medicare doin?
Well I guess however medicare is doing doesn't change the fact that birchswing was right. I guess the VA resembles "single payer" in that there is for the most part no billing but one could argue that its highly restricted access (only veterans) makes it quite different in spirit from "single payer" as its generally understood when people argue for this type of health care system.
 
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birchswing

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Hows Medicare doin?
I said it was the closest the US has to something like single-payer. I said that because a majority of Americans will eventually receive Medicare benefits and that many Americans have paid into the system. It's not exactly a single payer system in that not everyone pays into it and not everyone receives it or will receive it. Beyond that, I don't know how it's working or not working. Unlike the VA, it's an insurance system, so in terms of how it's working, I would assume that if a doctor takes Medicare, it works or doesn't work for the patient as well as any other insurance coverage does. I know it's very expensive and creates large expenditures, but I would argue that's a result of the very fragmented system the US has.
 

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I said it was the closest the US has to something like single-payer. I said that because a majority of Americans will eventually receive Medicare benefits and that many Americans have paid into the system. It's not exactly a single payer system in that not everyone pays into it and not everyone receives it or will receive it. Beyond that, I don't know how it's working or not working. Unlike the VA, it's an insurance system, so in terms of how it's working, I would assume that if a doctor takes Medicare, it works or doesn't work for the patient as well as any other insurance coverage does. I know it's very expensive and creates large expenditures, but I would argue that's a result of the very fragmented system the US has.
So if many have paid into the system, they are guaranteed benefits in the future?

And in terms of rationing and limited formularies, that is how the VA is close to single payor. And let's not forget about fraud, waste, and top heaviness.
 

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So if many have paid into the system, they are guaranteed benefits in the future?

And in terms of rationing and limited formularies, that is how the VA is close to single payor. And let's not forget about fraud, waste, and top heaviness.
You know more about the VA than I do. I have never argued that the federal government is efficient or even terribly functional (I have more experience with the FDA than any other federal agency, and that experience is enough to make me think the system is mired in dysfunction). But I do think efficient and functional single-payer healthcare systems exist. Satisfaction with the NHS, for example, is quite high. And within the US, state governments are often more functional than the federal government (though in recent times have needed bail-outs from the federal government), and programs like Medicaid seem quite successful, although underutilized.
 

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You know more about the VA than I do. I have never argued that the federal government is efficient or even terribly functional (I have more experience with the FDA than any other federal agency, and that experience is enough to make me think the system is mired in dysfunction). But I do think efficient and functional single-payer healthcare systems exist. Satisfaction with the NHS, for example, is quite high. And within the US, state governments are often more functional than the federal government (though in recent times have needed bail-outs from the federal government), and programs like Medicaid seem quite successful, although underutilized.
What are you talking about? People hate the nhs.
And Medicaid is successful?
What?
 

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The va may not have reported it. Cover it up. It makes the va look bad too. All those checks and balances...
:confused: conspiracy theory much?

You've never had to clean up a mess of a patient who had a private provider think QID xanax was a great solution for his GAD? Or the private practice addiction board-certified psychiatrist who tells your patient "here's some benzos to help you with the anxiety of me having to prescribe you suboxone" (yup, saw that one last year)?

A lack of proper oversight by state medical boards is hardly a VA-specific problem. But you seem to be more about arguing a specific agenda rather than discussing the case at hand.
 

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What are you talking about? People hate the nhs.
And Medicaid is successful?
What?
I follow international news. NHS satisfaction is generally high. Google it.

Medicaid, quite simply, works. It provides insurance to those who would otherwise not have it. It improves health outcomes. There was a study in Oregon where they gave people Medicaid randomly by lottery. Those with Medicaid had a 10% lower incidence of depression and many other better health outcomes. If you don't think Medicaid is successful, what do you think the alternative is? ER visits for the indigent?
 
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TikiTorches

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I follow international news. NHS satisfaction is generally high. Google it.

Medicaid, quite simply, works. It provides insurance to those who would otherwise not have it. It improves health outcomes. There was a study in Oregon where they gave people Medicaid randomly by lottery. Those with Medicaid had a 10% lower incidence of depression and many other better health outcomes. If you don't think Medicaid is successful, what do you think the alternative is? ER visits for the indigent?
Show me the exact links
 

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:confused: conspiracy theory much?

You've never had to clean up a mess of a patient who had a private provider think QID xanax was a great solution for his GAD? Or the private practice addiction board-certified psychiatrist who tells your patient "here's some benzos to help you with the anxiety of me having to prescribe you suboxone" (yup, saw that one last year)?

A lack of proper oversight by state medical boards is hardly a VA-specific problem. But you seem to be more about arguing a specific agenda rather than discussing the case at hand.
I know lots of pp docs in WI who have lost their licenses over these issues. Esp with prescriptions of opiods as this is a big problem there.

For this guy to have no board action at all does mean something. The DEA has swept in and crushed the pp docs. Must be nice to be unscathed in the VA. I definitely say that is protected.
 

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I follow international news. NHS satisfaction is generally high. Google it.

Medicaid, quite simply, works. It provides insurance to those who would otherwise not have it. It improves health outcomes. There was a study in Oregon where they gave people Medicaid randomly by lottery. Those with Medicaid had a 10% lower incidence of depression and many other better health outcomes. If you don't think Medicaid is successful, what do you think the alternative is? ER visits for the indigent?
And works how? Where is the money comong from? Yhe sky?
 

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The NHS is basically sacred in Britain, and one of Labour's favorite rhetorical moves is to shout about how the Tories are trying to gut it. Jeremy Corbyn just won the Labour leadership on a platform that included calling for an "NHS for education". It is a magic talisman that can be used to grace all kinds of proposals with positive affect.

So to say people generally hate the NHS is a serious distortion of reality.
 
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I follow international news. NHS satisfaction is generally high. Google it.

Medicaid, quite simply, works. It provides insurance to those who would otherwise not have it. It improves health outcomes. There was a study in Oregon where they gave people Medicaid randomly by lottery. Those with Medicaid had a 10% lower incidence of depression and many other better health outcomes. If you don't think Medicaid is successful, what do you think the alternative is? ER visits for the indigent?
Unfortunately reduction in depression was the only significant positive health outcome in the Oregon insurance lottery study to date. It was rather disappointing that none of their physical health measures improved much. Maybe this is an artifact of the time-scale of the study to date, and the work is ongoing, but it turns out in the short run surprise health insurance for indigent folks mostly helps them feel less anxious about not having health insurance.
 
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State law where I was at previously required consent for any psychiatric med on inpatient, even prozac. We actually weren't sure how to read the law for outpatient though some places were doing those consents as well.

FWIW, my current VA doesn't do much suboxone so not sure on that one
That just offends me. Do they also require written consent for every non-psychiatric medication? I think the implication is that our medications are somehow more dangerous than non-psychiatric medications or less necessary.
 

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That just offends me. Do they also require written consent for every non-psychiatric medication? I think the implication is that our medications are somehow more dangerous than non-psychiatric medications or less necessary.
Nah, we psychiatrists do scary mind control and whatnot.

Basically it's anything with a psychiatric indication: Propranolol for anxiety would require a consent. Lorazepam for catatonia would not. (at least that's how our risk department read the law)
 

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Nah, we psychiatrists do scary mind control and whatnot.

Basically it's anything with a psychiatric indication: Propranolol for anxiety would require a consent. Lorazepam for catatonia would not. (at least that's how our risk department read the law)
That so implies that the benefit of medications for psychiatric uses is less than the benefit of medications for non-psychiatric uses. Stupid, stupid, offensive policy. It shows you the stigma that we're facing.
 

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Unfortunately reduction in depression was the only significant positive health outcome in the Oregon insurance lottery study to date. It was rather disappointing that none of their physical health measures improved much. Maybe this is an artifact of the time-scale of the study to date, and the work is ongoing, but it turns out in the short run surprise health insurance for indigent folks mostly helps them feel less anxious about not having health insurance.
This is my understanding as well, which actually isn't a small thing. And you're right, the benefits of preventative/routine health care aren't often apparent until years down the road.

I'm sure we've all seen people without coverage just not get needed treatment. In medical school, I saw a patient in our free clinic who had a non-movable firm mass on her neck that she had had for about one year. No insurance, and it took us about a year of advocating to get treatment. Luckily for her the diagnosis was papillary thyroid cancer, so she's probably still fine. My home state only provides medicaid for children and pregnant women. I can't think about examples like that and not be in favor of universal coverage.
 
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masterofmonkeys

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I follow international news. NHS satisfaction is generally high. Google it.
Patient satisfaction generally has pretty poor relationship to quality of care or outcome. It's one of the crappiest quality measures in a host of crappy quality measures in medicine.
 

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Britain generally has population outcomes similar or superior to the US and the majority of care is delivered through the NHS. I agree that most medical quality measures are terrible, but with the exception of wait times, none of them offer a basis for American triumphalism in this arena. Note that this does not mean this country can simply clone that system and expect it to work as well, and it may not maintain its current form over the next few decades, but it is very hard to argue it is a grossly inferior system.

Edit: before anyone gets Rand-happy US healthcare is in no way primarily governed by transparent market forces.
 

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The fact that Britain has general outcomes similar to ours, despite our VASTLY worse lifestyle behaviors from nutrition to exercise, to workload to everything is actually pretty damning. As I've said a few times before, the success of the American healthcare system is proven by the fact that we arne't further down.
 

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Have you ever seen a traditional British diet or hoe many binge drinkers are on any given high street looks at closing time? Britain is not quite as obese as this country (only Mexico manages that) but it is definitely much worse lifestyle wise than any place else in Western Europe. Britain gave the world the chip butty, for goodness sake.

Edit: sorry, Malta and Iceland are fatter. Here is a good summary:
http://www.theguardian.com/news/datablog/2014/may/29/how-obese-is-the-uk-obesity-rates-compare-other-countries

Double edit: also entrenched poverty,violent crime (far fewer murders, though), thriving drug trade. A lot fewer deaths associated with IV drug use, but then, having maintenance heroin be a thing rather helps with that. Which lifestyle factors being hugely better did you have in mind?
 
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birchswing

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The fact that Britain has general outcomes similar to ours, despite our VASTLY worse lifestyle behaviors from nutrition to exercise, to workload to everything is actually pretty damning. As I've said a few times before, the success of the American healthcare system is proven by the fact that we arne't further down.
What about the fact that we spend about twice as much as countries with nationalized healthcare? Our government spends enough to do what other countries do, it's just very inefficient as the whole thing is balkanized and we don't have twice as good of outcomes--in fact, in most cases our outcomes are worse when it comes to the basics like life expectancy and infant mortality.
 
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Shikima

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What about the fact that we spend about twice as much as countries with nationalized healthcare? Our government spends enough to do what other countries do, it's just very inefficient as the whole thing is balkanized and we don't have twice as good of outcomes--in fact, in most cases our outcomes are worse when it comes to the basics like life expectancy and infant mortality.
You can thank lawyers and hospital systems for the amount we spend. It's not because of what physicians charge.
I won't demonize drug companies because they spend a metric ****-ton on R&D and only have a 10 year grace period of their patent.
 
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clausewitz2

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You can thank lawyers and hospital systems for the amount we spend. It's not because of what physicians charge.
I won't demonize drug companies because they spend a metric ****-ton on R&D and only have a 10 year grace period of their patent.
Tempting as it is to blame lawyers for the amount we spend on healthcare, this is actually a multifactorial issue. I know, it is far less comforting to have an easy scapegoat for the system's cost issues, but reasonable attempts to try and estimate how much extra cost is attributable to tort comes up with estimates in the2-10% range. Here is a good example: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/

The point about drug companies is a good one; there is a very real sense in which the profits possible in the US market subsidize drug development for the rest of the world.

Physician compensation is a piece of healthcare costs roughly equal to tort:

http://www.beckershospitalreview.com/compensation-issues/physician-pay-accounts-for-86-of-total-healthcare-expenses.html

It is worth pointing out that the one other major country that makes a fee for service model work at a much lower price point with better outcomes is France, where physician incomes are about 60% of their US counterparts in PPP terms.
 

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I suspect a lot of VA's are being run like Tomah. At my last VA, a psychologist is the interim Chief of Medicine.
Is that better or worse than having what Gyn can or can't do dictated by the US Conference of Catholic Bishops?
 

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Medicaid, quite simply, works. It provides insurance to those who would otherwise not have it. It improves health outcomes. There was a study in Oregon where they gave people Medicaid randomly by lottery. Those with Medicaid had a 10% lower incidence of depression and many other better health outcomes. If you don't think Medicaid is successful, what do you think the alternative is? ER visits for the indigent?
Really? It continues to be woefully inadequate in my state, so much so there is constant legislation to help bolster it through additional funding/programs. Many providers can't afford to take it (myself included) and people may "have" medicaid, but that doesn't mean they can actually use it effectively.

As for alternatives…out-pt clinics staffed mostly by mid-levels and support staff to see 95% of what comes through the ED that isn't actually an emergency. Keep the overhead down and push more preventative medicine and case management for chronic/frequent flyers.
 
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Therapist4Chnge

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The fact that Britain has general outcomes similar to ours, despite our VASTLY worse lifestyle behaviors from nutrition to exercise, to workload to everything is actually pretty damning. As I've said a few times before, the success of the American healthcare system is proven by the fact that we arne't further down.
We also don't scale well (pun acknowledged) compared to other industrialized countries, as we are far far larger than EU countries that are often cherry-picked to point out how much better they are than the USA in regard to outcomes.
 
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I suspect a lot of VA's are being run like Tomah. At my last VA, a psychologist is the interim Chief of Medicine.
OMG…the horror!!

Do you need a hug?

Administrative positions are….leadership positions, not clinical positions. Most CMOs may have a small clinical practice, but the vast majority of their jobs involve administrative duties like evaluating budgets, reviewing operations, attending board mtgs, etc.

Longnecker et al. (2007) wrote a nice article titled, "Roles and Responsibilities of Chief Medical Officers in Member Organizations of the Association of American Medical Colleges" on the topic. It is a nice overview of why promoting clinicians to administrative/leadership positions w/o significant additional training and mentorship in healthcare administration is usually a bad idea.
 
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clausewitz2

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We also don't scale well (pun acknowledged) compared to other industrialized countries, as we are far far larger than EU countries that are often cherry-picked to point out how much better they are than the USA in regard to outcomes.
Don't entirely understand this point. Why again does a larger population mean worse outcomes on average per se? I get that small samples skew distributions, but when comparing a country of 60 million to one of 300 million I don't think that is what is operative. It's not like we are drawing conclusions based on Luxembourg.

I am not especially a pro-NHS partisan or anything, but the numbers do not simply allow you to say "oh that system is obviously inferior" in a way that I think many people who have responded in this thread would like to. Endorsing the current US system in all its current structure seems rather Panglossian.
 
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I find it rather amusing that this thread morphed into a universal healthcare debate. I'm not sure how we get from psychiatrist attempts to kill her husband to this debate. I guess not too many people would take the side of "it's okay for psychiatrists to shoot spouses" or maybe I'm way off base and everyone thinks it is ok. :)
 
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Therapist4Chnge

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I think the USA system is fraught with problems, but I'm not sure it can be done much differently due to our culture and medical utilization patterns.

For instance, utilizing the ED for Primary Care treatment is obviously an issue, though so is pre-auth'ing everything under the sun and delaying treatment.

As a clinician I'd support universal healthcare w. private/outside options for those willing to pay. As a tax-paying citizen, it drives me nuts that i'm paying more than my fair share.
 
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clausewitz2

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I think the USA system is fraught with problems, but I'm not sure it can be done much differently due to our culture and medical utilization patterns.

For instance, utilizing the ED for Primary Care treatment is obviously an issue, though so is pre-auth'ing everything under the sun and delaying treatment.

As a clinician I'd support universal healthcare w. private/outside options for those willing to pay. As a tax-paying citizen, it drives me nuts that i'm paying more than my fair share.
I am with you in thinking there are many reasons why state-run systems would not work as well in this country as they do elsewhere.
 
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