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[2win]

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http://www.asahq.org/news/asanews031309.htm

March 13, 2009
Message from ASA President Roger A. Moore, M.D., regarding health care reform

Dear Colleagues:
As we weather the changes in our world economy, our political environment, and even the social fabric of our country, I think it important for the American Society of Anesthesiologists to provide some guidance and perspective in regard to possible changes in the health care system that could directly affect you – the practitioner. However, trying to provide guidance at this time of uncertainty and confusion is akin to trying to navigate a small plane through a hurricane. Of course, the ultimate goal is to traverse the hurricane intact and functional; but without having any details on the prevailing winds of change for health care, it is hard to set the least damaging course.
The message you each need to understand is that there will be change. The goal of ASA is to help responsibly manage that change for the ultimate benefit of our patients’ safety, and improved quality care, while ensuring fair payment for our services.
In the past two months, President Obama and several Members of Congress have offered their perspective on potential changes to the American health care system. The proposals have thus far been broadly outlined, rather than having specific plans, and most conversations continue taking place behind the scenes.
However, although we may not know when or where or how, one thing is certain based on all proposed plans: major health care change is coming, and the change will impact our specialty and the patients for whom we care.
For anesthesiologists to be effectively engaged in current discussions, it is important to understand the various proposals and their implications for the specialty, as well as the general environment in which these changes could take place.
General reform — President Obama
President Obama has indicated his intention to push for comprehensive health care reform by the end of 2009, perhaps with legislative enactment by Labor Day. He has not released a specific proposal to-date, but has repeatedly stated that reform must be “as transparent and inclusive as possible.”
In what is believe to be a “kick-off” of the health care reform effort, on Thursday, March 5, the President hosted a Health Care Summit at the White House. At the summit, the President, speaking to invited stakeholders, described the current U.S. health care costs as a significant threat facing the country. “We're here today to discuss one of the greatest threats not just to the well-being of our families and the prosperity of our businesses, but to the very foundation of our economy -- and that's the exploding costs of health care in America today,” said the President. He affirmed his strong commitment to reform stating, “Health care reform is no longer just a moral imperative, it's a fiscal imperative.”
The President’s recently-released FY2010 budget proposal includes more than $630 billion over 10 years as a “reserve fund” for health reform efforts, which the Administration has admitted may not be enough to cover reform that would extend health insurance to all. The budget calls for these reforms to be financed, in part, by $316 billion in various cuts to Medicare and Medicaid. These cuts and their estimated 10-year savings include:

• Encouraging hospitals serving Medicare patients to reduce readmission rates —$8.4 billion
• Creating quality incentive programs—$12 billion
• Establishing competitive bidding programs for Medicare Advantage—$176.6 billion
• Promoting efficient use of primary care by bundling payments for hospital post-acute settings—$17.8 billion
• Addressing conflicts of interest in doctor-owned specialty hospitals—savings considered negligible
• Ensuring appropriate payments through the use of radiology benefit managers—$260 million
• Providing “private sector” enhancements to ensure Medicare pays accurately—$2 billion

Regarding physician payment, the budget document indicates the Administration’s willingness to reconsider the current Medicare physician payment system.
With the announcement of President Obama’s nomination of Kansas Gov. Kathleen Sebelius as the Secretary of the Department of Health and Human Services, it is anticipated that the Administration will soon begin substantive discussions with Congress toward health care system reform.
Call to Action: Health Reform 2009 — Sen. Max Baucus (D-MT)
Earlier this year Senate Finance Committee Chairman Max Baucus released a white paper outlining a plan for comprehensive health reform. “Call to Action: Health Reform 2009” includes broad proposals intended to strengthen America’s health care system and provide insurance coverage to all Americans.
The Call to Action includes three main points:

• A policy that ensures coverage and care to all Americans
• An insistence that any expansion be coupled with an emphasis on higher quality, greater value and reduced costs
• A commitment to weed out waste, eliminate overpayments, and design a sustainable financing system that works for taxpayers, and for recipients and providers of health care

This document is available on the ASA website at the following link: http://www.asahq.org/news/Baucusfinalwhitepaper.pdf

Healthy Americans Act — Sen. Ron Wyden (D-OR)
Sen. Ron Wyden has introduced S. 391, bipartisan legislation that would guarantee that every American has quality, affordable health care. The “Healthy Americans Act” aims to:

• Give Americans choice in where they get their health care
• Modernize the employer-employee relationship by making health care portable from job to job and continue if workers lose their jobs
• Promote personal responsibility and preventive medicine
• Reform the insurance market so insurers are forced to compete in price, benefits and quality

The Healthy Americans Act would implement a standard health tax deduction that averages $17,000 for a family of four and provides subsidies to help Americans afford quality health coverage.
AmeriCare — Rep. Fortney “Pete” Stark (D-CA)
Rep. Fortney “Pete” Stark recently introduced H.R. 193, the “AmeriCare Health Care Act of 2009.” With the legislation, Rep. Stark aims to achieve universal health care for all Americans.
AmeriCare includes a public plan option using Medicare’s existing administrative infrastructure, but with significant changes to address current gaps in coverage.
With a number of proposals on the table and the likelihood of additional ones forthcoming, ASA remains in close contact with leaders on Capitol Hill and the Administration to discuss anesthesiology’s role in reform efforts. We will closely follow proposals that contain efforts to expand government programs including Medicare and Medicaid, or that seek to create new public health plans. Further, we will monitor proposed payment changes and provide feedback to legislators on emerging proposals, including the possibility of bundled payments that might involve anesthesiologists.
ASA will continue supporting policy that:

• Establishes a pluralistic system building on the best features of public and private coverage, administration and financing, ensuring access to health insurance for all;
• Recognizes and values the leadership role of physicians as champions of high quality, cost efficient patient care based on their advanced education, skills and experience; and
• Promotes and further supports efforts to improve quality, specifically research that improves patient safety and clinical outcomes.

I repeat my earlier statement, there are not enough details available yet to determine exactly how coming changes will effect anesthesiology. What is important for you to do is to be prepared to engage in the debate so that when details emerge, you can serve to affect the process for the good of our patients and our profession.
Please stay tuned for additional information, and be prepared to take action when called upon. Being informed and involved is more important now than ever before as critical issues for medicine and our patients come forward rapidly.
Responsibility for the future safety of our patients lies with each of us. For more information, please consult our website on a regular basis at www.ASAhq.org.

Sincerely,

Roger A. Moore, M.D.
President
American Society of Anesthesiologists
​

 

[ProRealDoc]

http://www.asahq.org/news/asanews031309.htm

March 13, 2009
Message from ASA President Roger A. Moore, M.D., regarding health care reform

Dear Colleagues:
As we weather the changes in our world economy, our political environment, and even the social fabric of our country, I think it important for the American Society of Anesthesiologists to provide some guidance and perspective in regard to possible changes in the health care system that could directly affect you – the practitioner. However, trying to provide guidance at this time of uncertainty and confusion is akin to trying to navigate a small plane through a hurricane. Of course, the ultimate goal is to traverse the hurricane intact and functional; but without having any details on the prevailing winds of change for health care, it is hard to set the least damaging course.
The message you each need to understand is that there will be change. The goal of ASA is to help responsibly manage that change for the ultimate benefit of our patients’ safety, and improved quality care, while ensuring fair payment for our services.
In the past two months, President Obama and several Members of Congress have offered their perspective on potential changes to the American health care system. The proposals have thus far been broadly outlined, rather than having specific plans, and most conversations continue taking place behind the scenes.
However, although we may not know when or where or how, one thing is certain based on all proposed plans: major health care change is coming, and the change will impact our specialty and the patients for whom we care.
For anesthesiologists to be effectively engaged in current discussions, it is important to understand the various proposals and their implications for the specialty, as well as the general environment in which these changes could take place.
General reform — President Obama
President Obama has indicated his intention to push for comprehensive health care reform by the end of 2009, perhaps with legislative enactment by Labor Day. He has not released a specific proposal to-date, but has repeatedly stated that reform must be “as transparent and inclusive as possible.”
In what is believe to be a “kick-off” of the health care reform effort, on Thursday, March 5, the President hosted a Health Care Summit at the White House. At the summit, the President, speaking to invited stakeholders, described the current U.S. health care costs as a significant threat facing the country. “We're here today to discuss one of the greatest threats not just to the well-being of our families and the prosperity of our businesses, but to the very foundation of our economy -- and that's the exploding costs of health care in America today,” said the President. He affirmed his strong commitment to reform stating, “Health care reform is no longer just a moral imperative, it's a fiscal imperative.”

The President’s recently-released FY2010 budget proposal includes more than $630 billion over 10 years as a “reserve fund” for health reform efforts, which the Administration has admitted may not be enough to cover reform that would extend health insurance to all. The budget calls for these reforms to be financed, in part, by $316 billion in various cuts to Medicare and Medicaid. These cuts and their estimated 10-year savings include:

• Encouraging hospitals serving Medicare patients to reduce readmission rates —$8.4 billion
• Creating quality incentive programs—$12 billion
• Establishing competitive bidding programs for Medicare Advantage—$176.6 billion
• Promoting efficient use of primary care by bundling payments for hospital post-acute settings—$17.8 billion
• Addressing conflicts of interest in doctor-owned specialty hospitals—savings considered negligible
• Ensuring appropriate payments through the use of radiology benefit managers—$260 million
• Providing “private sector” enhancements to ensure Medicare pays accurately—$2 billion

Regarding physician payment, the budget document indicates the Administration’s willingness to reconsider the current Medicare physician payment system.
With the announcement of President Obama’s nomination of Kansas Gov. Kathleen Sebelius as the Secretary of the Department of Health and Human Services, it is anticipated that the Administration will soon begin substantive discussions with Congress toward health care system reform.
Call to Action: Health Reform 2009 — Sen. Max Baucus (D-MT)
Earlier this year Senate Finance Committee Chairman Max Baucus released a white paper outlining a plan for comprehensive health reform. “Call to Action: Health Reform 2009” includes broad proposals intended to strengthen America’s health care system and provide insurance coverage to all Americans.

The Call to Action includes three main points:

• A policy that ensures coverage and care to all Americans
• An insistence that any expansion be coupled with an emphasis on higher quality, greater value and reduced costs
• A commitment to weed out waste, eliminate overpayments, and design a sustainable financing system that works for taxpayers, and for recipients and providers of health care

This document is available on the ASA website at the following link: http://www.asahq.org/news/Baucusfinalwhitepaper.pdf

Healthy Americans Act — Sen. Ron Wyden (D-OR)

Sen. Ron Wyden has introduced S. 391, bipartisan legislation that would guarantee that every American has quality, affordable health care. The “Healthy Americans Act” aims to:

• Give Americans choice in where they get their health care
• Modernize the employer-employee relationship by making health care portable from job to job and continue if workers lose their jobs
• Promote personal responsibility and preventive medicine
• Reform the insurance market so insurers are forced to compete in price, benefits and quality

The Healthy Americans Act would implement a standard health tax deduction that averages $17,000 for a family of four and provides subsidies to help Americans afford quality health coverage.
AmeriCare — Rep. Fortney “Pete” Stark (D-CA)
Rep. Fortney “Pete” Stark recently introduced H.R. 193, the “AmeriCare Health Care Act of 2009.” With the legislation, Rep. Stark aims to achieve universal health care for all Americans.
AmeriCare includes a public plan option using Medicare’s existing administrative infrastructure, but with significant changes to address current gaps in coverage.
With a number of proposals on the table and the likelihood of additional ones forthcoming, ASA remains in close contact with leaders on Capitol Hill and the Administration to discuss anesthesiology’s role in reform efforts. We will closely follow proposals that contain efforts to expand government programs including Medicare and Medicaid, or that seek to create new public health plans. Further, we will monitor proposed payment changes and provide feedback to legislators on emerging proposals, including the possibility of bundled payments that might involve anesthesiologists.

ASA will continue supporting policy that:

• Establishes a pluralistic system building on the best features of public and private coverage, administration and financing, ensuring access to health insurance for all;
• Recognizes and values the leadership role of physicians as champions of high quality, cost efficient patient care based on their advanced education, skills and experience; and
• Promotes and further supports efforts to improve quality, specifically research that improves patient safety and clinical outcomes.

I repeat my earlier statement, there are not enough details available yet to determine exactly how coming changes will effect anesthesiology. What is important for you to do is to be prepared to engage in the debate so that when details emerge, you can serve to affect the process for the good of our patients and our profession.
Please stay tuned for additional information, and be prepared to take action when called upon. Being informed and involved is more important now than ever before as critical issues for medicine and our patients come forward rapidly.
Responsibility for the future safety of our patients lies with each of us. For more information, please consult our website on a regular basis atwww.ASAhq.org.

Sincerely,

Roger A. Moore, M.D.
President
American Society of Anesthesiologists
​

We'll be bracing for impact.

 

[coprolalia]

These changes may ultimately become the death of our speciaty as we currently know and enjoy it.

Brace for impact? I say instead, "Diversify yourself."

-copro

 

[pgg]

Brace for impact? I say instead, "Diversify yourself."

How so? Fellowship? MBA? Day trading?

 

[McSnappy]

How so? Fellowship? MBA? Day trading?

Seems like most of the PDs and many residents on the trail were saying they were going or strongly considering fellowship.

Home builder Most attorneys go there sooner or later

 

[undecided3]

These changes may ultimately become the death of our speciaty as we currently know and enjoy it.

Brace for impact? I say instead, "Diversify yourself."

-copro

Why do you say this will ultimately become the death of our specialty? If it would adversly affect anethesiology would you not expect it to do so in many other fields?

Please expand on this as many of us are considering a career in anesthesiology now and are interested in hearing your thoughts.

 

[ProRealDoc]

These changes may ultimately become the death of our speciaty as we currently know and enjoy it.

Brace for impact? I say instead, "Diversify yourself."

-copro

Unless you'll be expanding your domain outside of healthcare, I don't see how looking into other areas of medicine will help. The changes will be universal not specialty specific.

 

[coprolalia]

Why do you say this will ultimately become the death of our specialty? If it would adversly affect anethesiology would you not expect it to do so in many other fields?

Please expand on this as many of us are considering a career in anesthesiology now and are interested in hearing your thoughts.

To be clear, I didn't say it would be the death of our specialty. I said it will be the death of our specialty as we currently know and enjoy it.

In other words, all of you who voted for "change" this past November are going to get it, like it or not. The American people put an activist crusader into the White House, and now we're going to see sweeping "reform" of our healthcare system by consumers, not by the people who work within it day-to-day (because we're seen as too deeply immersed in and part of the problem).

Let me preface what I'm about to say with the following: if you are a prospective med student considering a career in medicine, don't. I would not get into the healthcare field right now. It's too uncertain. Heck, everything is uncertain right now, but in a couple of years the economy should rebound and things will get better in the business sector. If you want to get into healthcare, go into the management side.

For those of you who are already in the system, I feel that you should broaden your portfolio as widely as possible. This means picking up and specializing in as many skills as possible. The person who's going to make him/herself valued is someone who will be able to provide slick, cost-effective care in a timely manner.

For our field, this means knowing regional anesthesia like the back of your hand. It's being adept at outpatient-type anesthesia, where the patient has an anesthetic that doesn't (1) cost more to give than you can bill for (e.g., "using all the drugs in the drawer" type anesthetic), (2) leave the patient nauseous, in pain, and sitting in the PACU for 10 hours, and (3) slowing down turnover of the room. Efficiency is going to be key, because you're going to have to increase your volume to get your share... why?

Because, the "DRG model", which is what a lot of this proposed "reform" is based on, will be expanded to preclude any additional fees (fee-for-service) being billed to the patient for re-admission, secondary procedures. You see, the public believes that they should be able to come to the hospital and be "fixed", no matter what the ailment or how complex their co-morbidities are, the first time just like everyone else who's had the "same" ailment and admission before... why?

There is this belief, this "movement" if you will, lately in medicine that every patient and every clinical presentation should fit neatly into a protocol, and that any deviation from what's expected must be the fault (somehow) of the healthcare team treating the patient. MRSA? Always our fault. Other hospital-acquired infections? Always our fault. Failing to keep the patient at home once discharged? Always our fault. People are unwilling to tolerate, and therefore pay, for what they perceived to be any deficiency in care, whether it actually was or wasn't deficient care. And, at the same time, organizations like JCAHO are tying our hands and further increasing the bureacracy of medicine by distracting us away from individualized care and more into standardized care - at the expense of the patient who falls "outside the box", which happens often.

In many ways, we're victims of our own successes. And, the point is, people expect those successes in all instances. If you have a large longitudinal study that shows 80% of the people will do well given a certain clinical treatment pathway and set of circumstances, everyone wants to be in that 80%. They forget that another 20% of the people won't do well no matter what we do. But, Uncle Sam is only going to pay us for those 80% that should do well. The other 20%? We should eat it because, obviously, we should've done something differently or better to get them into that 80%.

You understand the madness here?

Americans want 100% certainty in everything. The mentality is that people are like automobiles, and that if you take them to the shop (in our case, the hospital) there should be a 100% guarantee that you can fix the problem... and within 30 days you should not have to pay for "additional" care.

So, where does that bring us? The DRG.

"Diagnosis-related group" charges are currently the way CMS operates. You get a set amount of money for a diagnosis, and it doesn't matter what actually happens to the patient. At the end of day-4 when the DRG money runs out, the patient is literally shoved out the door whether or not they're really better.

Now, here's the kicker...

If you get the patient better in 3 days (instead of 4 that the DRG pays) and you do that too many times, you're going to have a CMS auditor looking through your charts claiming fraud (i.e., that you "trumped up" the diagnosis to get more money from CMS, because every other hospital takes longer to get that patient better than you do). So, the current result? If CMS pays 4 days for an admission for "unspecified abdominal pain" with the co-requisite work-up, that patient is going to stay 4 days and get the tests whether or not they have that big bowel movement and get better within 24 hours. Otherwise, CMS won't pay.

Conversely, if you have too many patients that stay 6-7 days because they really are sick in spite of their diagnosis, then you lose money because you can't get fresh bodies into those hospital beds. So, the impetus is to kick the patient out whether or not they are acutally better.... or, at least this is what the policy wonks in Washington currently believe is the norm at largely CMS-funded hospitals.

So... here's the solution...

We pay for 30-days per diagnosis. Period. You get one lump-sum of money. Period.

How does this affect us?

Remember, we can't collectively bargain. Currently, private practices would have to, under this new model, negotiate for their share of the fee. Pretty soon, the hospital will start to realize, "Hey, if I can hire enough staff anesthetists (either -ologists or CRNAs), I won't have to negotiate with a PP group. I can just pay them a salary." And, that, my friends, is the end of the PP model in anesthesia.

"So what?" You say. "There is still private insurance. As long as there is a private insurance model, I have a job."

Well, remember that Uncle Obama wants to (ultimately) create a single payor system. Don't believe anyone who tells you otherwise. If and when this happens, the bulk of healthcare will be administered by the government. Sure, there may be some minimal supplemental private insurance, but most of you will be unable to make a living hoping for the additional money and patient selection coming from PP money. It will just, quite frankly, become far too expensive for the vast majority of the public to afford for any individual practitioner (in our field) to be able to expect to provide full income.

So, what does this mean? Why do I say diversify?

You will be competing for jobs within the ideal hospital systems that have high throughput and a good mix of private insurance patients. These jobs will pay better. The hospital hiring you will be more likely to want a candidate that can offer more services than what just the standard "general anesthesiologist" has to offer. This means strong regional, TEE, etc. You won't get paid extra for these services, though, because they will all be "bundled" into the charge.

Do I really think this is going to happen? I give it a high probability. Obama is a hard-charger, and I think he perceives this to be the best solution. We are going to end-up with something between the Canadian and English models of healthcare system. Most of the reimbursement money will come from Uncle Sam, and it will be a flat fee per diagnosis. Everyone will get the same amount in a given geographic region, and your ability (both as an individul practitioner as well as hospital system) will be tracked and monitored per patient outcome... remember thos National Provider Identification numbers we were issued a coupla of years ago... any coincidence that that number stays with you for life no matter where you go...

REMEMBER: Many of you guys voted for "change". Congratulations! You're going to get it.

Expect more competition for dream jobs, expect lower income, and expect to climb of your high horse (for those of you on it). You're not going to be expected to be a thinker. You're going to be expected to follow protocols and to have to explain every instance where you didn't have a perfect outcome. Your stress level is going to increase. Your lifestyle is going to go down.

Why anyone would want to go into medicine now, knowing what is about to happen, is beyond me. Thanks, Politicians, for muddling around in something that you really don't understand. You are going to ruin high-quality healthcare in the U.S.

I could go on and on, but I'll stop here.

-copro

 

[InfraMan]

Let me preface what I'm about to say with the following: if you are a prospective med student considering a career in medicine, don't. I would not get into the healthcare field right now. It's too uncertain. Heck, everything is uncertain right now, but in a couple of years the economy should rebound and things will get better in the business sector. If you want to get into healthcare, go into the management side.

Have to respectfully disagree. Healthcare is one of the few fields where you will be virtually guaranteed to have a job for life.

If you think healthcare is bad, you ought to try the real world. I did for years, and it's ugly. Layoffs, constant fear of layoffs, decreasing salary, being transferred by your company, office politics, and on and on.

Healthcare is a fantastic field with many rewards. If you go into it for just the money ( which is still better than just about any other field) then you aren't going to be happy no matter how much you are paid.

 

[2win]

To be clear, I didn't say it would be the death of our specialty. I said it will be the death of our specialty as we currently know and enjoy it.

In other words, all of you who voted for "change" this past November are going to get it, like it or not. The American people put an activist crusader into the White House, and now we're going to see sweeping "reform" of our healthcare system by consumers, not by the people who work within it day-to-day (because we're seen as too deeply immersed in and part of the problem).

Let me preface what I'm about to say with the following: if you are a prospective med student considering a career in medicine, don't. I would not get into the healthcare field right now. It's too uncertain. Heck, everything is uncertain right now, but in a couple of years the economy should rebound and things will get better in the business sector. If you want to get into healthcare, go into the management side.

For those of you who are already in the system, I feel that you should broaden your portfolio as widely as possible. This means picking up and specializing in as many skills as possible. The person who's going to make him/herself valued is someone who will be able to provide slick, cost-effective care in a timely manner.

For our field, this means knowing regional anesthesia like the back of your hand. It's being adept at outpatient-type anesthesia, where the patient has an anesthetic that doesn't (1) cost more to give than you can bill for (e.g., "using all the drugs in the drawer" type anesthetic), (2) leave the patient nauseous, in pain, and sitting in the PACU for 10 hours, and (3) slowing down turnover of the room. Efficiency is going to be key, because you're going to have to increase your volume to get your share... why?

Because, the "DRG model", which is what a lot of this proposed "reform" is based on, will be expanded to preclude any additional fees (fee-for-service) being billed to the patient for re-admission, secondary procedures. You see, the public believes that they should be able to come to the hospital and be "fixed", no matter what the ailment or how complex their co-morbidities are, the first time just like everyone else who's had the "same" ailment and admission before... why?

There is this belief, this "movement" if you will, lately in medicine that every patient and every clinical presentation should fit neatly into a protocol, and that any deviation from what's expected must be the fault (somehow) of the healthcare team treating the patient. MRSA? Always our fault. Other hospital-acquired infections? Always our fault. Failing to keep the patient at home once discharged? Always our fault. People are unwilling to tolerate, and therefore pay, for what they perceived to be any deficiency in care, whether it actually was or wasn't deficient care. And, at the same time, organizations like JCAHO are tying our hands and further increasing the bureacracy of medicine by distracting us away from individualized care and more into standardized care - at the expense of the patient who falls "outside the box", which happens often.

In many ways, we're victims of our own successes. And, the point is, people expect those successes in all instances. If you have a large longitudinal study that shows 80% of the people will do well given a certain clinical treatment pathway and set of circumstances, everyone wants to be in that 80%. They forget that another 20% of the people won't do well no matter what we do. But, Uncle Sam is only going to pay us for those 80% that should do well. The other 20%? We should eat it because, obviously, we should've done something differently or better to get them into that 80%.

You understand the madness here?

Americans want 100% certainty in everything. The mentality is that people are like automobiles, and that if you take them to the shop (in our case, the hospital) there should be a 100% guarantee that you can fix the problem... and within 30 days you should not have to pay for "additional" care.

So, where does that bring us? The DRG.

"Diagnosis-related group" charges are currently the way CMS operates. You get a set amount of money for a diagnosis, and it doesn't matter what actually happens to the patient. At the end of day-4 when the DRG money runs out, the patient is literally shoved out the door whether or not they're really better.

Now, here's the kicker...

If you get the patient better in 3 days (instead of 4 that the DRG pays) and you do that too many times, you're going to have a CMS auditor looking through your charts claiming fraud (i.e., that you "trumped up" the diagnosis to get more money from CMS, because every other hospital takes longer to get that patient better than you do). So, the current result? If CMS pays 4 days for an admission for "unspecified abdominal pain" with the co-requisite work-up, that patient is going to stay 4 days and get the tests whether or not they have that big bowel movement and get better within 24 hours. Otherwise, CMS won't pay.

Conversely, if you have too many patients that stay 6-7 days because they really are sick in spite of their diagnosis, then you lose money because you can't get fresh bodies into those hospital beds. So, the impetus is to kick the patient out whether or not they are acutally better.... or, at least this is what the policy wonks in Washington currently believe is the norm at largely CMS-funded hospitals.

So... here's the solution...

We pay for 30-days per diagnosis. Period. You get one lump-sum of money. Period.

How does this affect us?

Remember, we can't collectively bargain. Currently, private practices would have to, under this new model, negotiate for their share of the fee. Pretty soon, the hospital will start to realize, "Hey, if I can hire enough staff anesthetists (either -ologists or CRNAs), I won't have to negotiate with a PP group. I can just pay them a salary." And, that, my friends, is the end of the PP model in anesthesia.

"So what?" You say. "There is still private insurance. As long as there is a private insurance model, I have a job."

Well, remember that Uncle Obama wants to (ultimately) create a single payor system. Don't believe anyone who tells you otherwise. If and when this happens, the bulk of healthcare will be administered by the government. Sure, there may be some minimal supplemental private insurance, but most of you will be unable to make a living hoping for the additional money and patient selection coming from PP money. It will just, quite frankly, become far too expensive for the vast majority of the public to afford for any individual practitioner (in our field) to be able to expect to provide full income.

So, what does this mean? Why do I say diversify?

You will be competing for jobs within the ideal hospital systems that have high throughput and a good mix of private insurance patients. These jobs will pay better. The hospital hiring you will be more likely to want a candidate that can offer more services than what just the standard "general anesthesiologist" has to offer. This means strong regional, TEE, etc. You won't get paid extra for these services, though, because they will all be "bundled" into the charge.

Do I really think this is going to happen? I give it a high probability. Obama is a hard-charger, and I think he perceives this to be the best solution. We are going to end-up with something between the Canadian and English models of healthcare system. Most of the reimbursement money will come from Uncle Sam, and it will be a flat fee per diagnosis. Everyone will get the same amount in a given geographic region, and your ability (both as an individul practitioner as well as hospital system) will be tracked and monitored per patient outcome... remember thos National Provider Identification numbers we were issued a coupla of years ago... any coincidence that that number stays with you for life no matter where you go...

REMEMBER: Many of you guys voted for "change". Congratulations! You're going to get it.

Expect more competition for dream jobs, expect lower income, and expect to climb of your high horse (for those of you on it). You're not going to be expected to be a thinker. You're going to be expected to follow protocols and to have to explain every instance where you didn't have a perfect outcome. Your stress level is going to increase. Your lifestyle is going to go down.

Why anyone would want to go into medicine now, knowing what is about to happen, is beyond me. Thanks, Politicians, for muddling around in something that you really don't understand. You are going to ruin high-quality healthcare in the U.S.

I could go on and on, but I'll stop here.

-copro

👍👍👍👍👍👍
2win

 

[coprolalia]

Have to respectfully disagree. Healthcare is one of the few fields where you will be virtually guaranteed to have a job for life.

If you think healthcare is bad, you ought to try the real world. I did for years, and it's ugly. Layoffs, constant fear of layoffs, decreasing salary, being transferred by your company, office politics, and on and on.

Healthcare is a fantastic field with many rewards. If you go into it for just the money ( which is still better than just about any other field) then you aren't going to be happy no matter how much you are paid.

I also was in the real world for "years". I left a near six-figure income to pursue medicine, because I felt like I could "do more" as a physician. It was a gamble from ignorance and much advice from already-physicians that, in my hubris, I ignored because I thought they were just jaded.

What I gave up:

(1) Weekends off.

(2) Getting to spend every night in my own bed.

(3) Solace of knowing that some a-hole that I couldn't "please" wouldn't be able to possibly engage me in a frivolous lawsuit.

(4) Not being >$130,000 in school debt.

(5) A stable relationship for a string of "crashed" ones because I can't always be there and/or satisfy the full notion in some young ladies minds that it'd be really cool to date a doctor without the understanding that I'm a human being first and foremost and that I'm not always "on", especially when I come home from a 6-hour ruptured triple-A repair that went from 12:30 AM to 6:30 AM and the patient died anyway.

(6) Constant beration from subordinates with the expectation that I, as the one with the supposed "power", should just sit there and take it coupled with the constant strain that any slight deviation from what's expected and/or trivial and insignificant "mistake" is further proof that, in fact, all doctors are indeed *****s who don't know what they're doing and should be perfect all the time.

Again, I could go on and on... The rose-tinted glasses are off. The Pollyanna types I occassionally run into... I don't know how they keep their perspective. Most physicians I know are not as optimistic. It's not that they hate what they do (I don't either). It's just that the sacrifices are not always worth the rewards, contrary to what the public and the non-indoctrinated may believe.

-copro

 

[nightflight747]

Thanks, Politicians, for muddling around in something that you really don't understand. You are going to ruin high-quality healthcare in the U.S.

Are you kidding me, copro?? High-quality healthcare in the US? We spend SO much money on healthcare, much more than any of the other Western countries, and our health is not better but often worse, we don't live as long, have more chronic problems, and have been known to err on the side of OVER-spending on tests and treatments because in our society the fear of being sued is ever present. What is it now, 50 million people uninsured in our country?

The high-quality healthcare only exists for you when you either have an awesome private insurance, or are a young healthy person with an immediately identifiable, treatable condition. Otherwise you end up not getting ANY healthcare (except for your initial workup in a county ED), or you're put through a whole bunch of unnecessary tests w/o any result or change in your health/management, costing ridiculous amounts of money.

I agree with you, Anesthesiology will change as a specialty. Done are the days when a private practice gig was available for any motivated graduate and would pay for all you'd want in life. And you know what, maybe that's not the end of the world either. I'm getting tired of people complaining on this forum about how Obama is ruining their lifestyle. He is attempting to fix a messed up, badly broken system that has been sabotaged by multiple entities that only look out for their own good:

- a public that has a tendency to faint when the word socialized healthcare comes up (what the **** is wrong with that?? we take socialized firefighters and schools, yet socialized medicine would end our innate American freedom somehow) instead of engaging in a serious discussion about its risks and benefits.
- insurance companies that are trying to make money-- excuse me, but that is SO wrong. people get together, pay money into a pot to be covered should they become seriosuly sick. that's it, real simple idea. and this is exactly what i hope to get when a single payor system is finally created under the Obama administration. will it be perfect? NO. will it be better than this broken, f'ed up system we have now? YES.
- people going into medicine b/c the economy is bad --> seriously, we all know them and can do w/o them. medicine has been and will be a respected profession, you'll always have a job, you'll be able to have a car and travel and all that, but REALLY, don't do it for the sweet life.
- individuals who can make a choice b/w a flat screen TV or health insurance and go for the TV, and then end up costing the government programs loads of money when something happens. that's why i vote for mandatory insurance, to lessen the evil mpact of ppl who only want to pay for insurance when the insurance would have to PAY FOR THEM already! insurance is not for after-the-fact, gosh!
- the judicial system allowing everyone to sue everyone for all kinds of crap. this self-sustaining system of lawyers, courts, and experts should be banned b/c it has been evolving and outsmarting logic and reason in healthcare for too long now. i hope to see a regulation that limits lawsuits the way they are essentially limited now in the VAs.

The thing that sucks for the ones of us caught in this transition is having all these loans and going into a field that won't pay as much anymore. That blows. The way to change this in the long-run is to reduce the cost of medical education. I doubt that'll happen, b/c again, the public will be like "Why the f*** should we pay for some doctor's education?"

Last but not least, I agree w/ copro about diversification. Sitting around in the OR won't do the trick anymore. Fellowship is a must. Not gonna talk about midlevels, that has been done, and it sucks. It'll be up to us to lobby for our profession, defend our turf, beat down that unfortunate movement, but ultimately, the survival of our specialty will depend on our success of expanding into a multitude of other fields-- be it administration, the ICU, end-of-life, whatever. The one good thing about less money in healthcare is that less nurses will want to become CRNAs cause it won't make a whole lot of difference, compensation-wise, for them anymore.

 

[coprolalia]

Are you kidding me, copro?? High-quality healthcare in the US? We spend SO much money on healthcare, much more than any of the other Western countries, and our health is not better but often worse, we don't live as long, have more chronic problems, and have been known to err on the side of OVER-spending on tests and treatments because in our society the fear of being sued is ever present. What is it now, 50 million people uninsured in our country?

I think you've identified the problem, but the solution is not governmental healthcare.

The solution is a society (generally the fattest, unhealthiest probably in the world) takes individual responsibility for their own health. This means maintaining good preventive strategy (lose weight, stop smoking, etc.) and mandating affordable, private insurance.

You do away with the "for profit" model of private healthcare insurance. You require individual policies in lieu of negotiating and adding as a benefit employer-based group insurance. You allow people to write-off their insurance premiums on their annual taxes. This provides portability and maintenance of the policy if the person should lose their job, plus the added incentive of carrying insurance if they are separated from employment.

You get rid of the incentive of insurance companies to withold payment through reducing the profit incentive. You clearly publish and provide to the patient and the provider the anticipated cost of intended care before you provide the care, and you give the patient treatment options based upon what they can afford.

Creating a single payor system will result in delayed care, rationing, and lack of access. I don't see how having Uncle Sam administrate healthcare will possibly improve the situation. The problem is the private insurance lobby and the plaintiffs attorneys. Until we're ready, as a country, to seriously tackle those two issues, nothing meaningful will change regardless of whatever "solutions" are proposed and undertaken.

-copro

 

[coprolalia]

One more thing...

If they invoke a system here that punishes the providers and creates what is tantamount to a European-style healthcare system, I'll tell you what I'm going to do: I'm going to move to Europe and practice there. At least I won't have the continued constant threat of lawsuits, and the masses and culture are generally far more conducive to being happy (better food, better museums, better lifestyle, etc.). If they are going to punish me by removing any financial incentive to practice in the U.S., there's no reason for me to stay here.

Hey, if the current administration wants to jump in "full guns ablazing" to a socialized medicine system, they need to be prepared for the consequences... which they can't possibly fully foresee right now with the radical changes they are proposing.

-copro

 

[maceo]

I also was in the real world for "years". I left a near six-figure income to pursue medicine, because I felt like I could "do more" as a physician. It was a gamble from ignorance and much advice from already-physicians that, in my hubris, I ignored because I thought they were just jaded.

What I gave up:

(1) Weekends off.

(2) Getting to spend every night in my own bed.

(3) Solace of knowing that some a-hole that I couldn't "please" wouldn't be able to possibly engage me in a frivolous lawsuit.

(4) Not being >$130,000 in school debt.

(5) A stable relationship for a string of "crashed" ones because I can't always be there and/or satisfy the full notion in some young ladies minds that it'd be really cool to date a doctor without the understanding that I'm a human being first and foremost and that I'm not always "on", especially when I come home from a 6-hour ruptured triple-A repair that went from 12:30 AM to 6:30 AM and the patient died anyway.

(6) Constant beration from subordinates with the expectation that I, as the one with the supposed "power", should just sit there and take it coupled with the constant strain that any slight deviation from what's expected and/or trivial and insignificant "mistake" is further proof that, in fact, all doctors are indeed *****s who don't know what they're doing and should be perfect all the time.

Again, I could go on and on... The rose-tinted glasses are off. The Pollyanna types I occassionally run into... I don't know how they keep their perspective. Most physicians I know are not as optimistic. It's not that they hate what they do (I don't either). It's just that the sacrifices are not always worth the rewards, contrary to what the public and the non-indoctrinated may believe.

-copro

I agree with what you say. But, you have to agree that the system is broke. It ain't working. It costs too da mn much. Its unable to sustain itself. Hospitals are closing left and right. We have too many uninsured or underinsured folks in this country. SOmething has to be done. IF you were the president, would you turn a blind eye to this because you want to protect the interests of the powerful insurance lobby? Healthcare has to be affordable. Its is the back bone of our society. That and education.

THere are too many industries making a KILLING on medicine and guess what. it aint the doctors. The health insurance cos and HMOS. pharmaceutical industry, device manufacturers, its goes on and on and on..

My friend stayed one night in the hospital fractured ankle. Total bill. 27K.
CMON COPRO>> cmon..

what does it matter to you who pays you? insurance co or government? We are socilaized already dont you think . You cant charge what market forces dictate like plastic surgeons. The government tells you what you can charge already.

Medicine is an unappealing career choice and will not change. IT has been for a long while. People(pre meds) are still blinded by medical dramas on tv which glamorize medicine and the historic reputation of doctors having wednesdays off etc etc.

 

[nightflight747]

One more thing...

If they invoke a system here that punishes the providers and creates what is tantamount to a European-style healthcare system, I'll tell you what I'm going to do: I'm going to move to Europe and practice there. At least I won't have the continued constant threat of lawsuits, and the masses and culture are generally far more conducive to being happy (better food, better museums, better lifestyle, etc.). If they are going to punish me by removing any financial incentive to practice in the U.S., there's no reason for me to stay here.

Hey, if the current administration wants to jump in "full guns ablazing" to a socialized medicine system, they need to be prepared for the consequences... which they can't possibly fully foresee right now with the radical changes they are proposing.

-copro

Good idea, copro. Have been thinking about exactly that for a while... but despite the unification of Europe, each country still has its own rules and guidelines for accepting foreign MD degrees, plus if you're not a EU citizen you'll have a hard time getting in in the first place. And American doctors are not considered to be that great either, mainly b/c we don't function independently enough (relying on techs and ancillary staff too much). Plus the language barrier for most of Europe; although the Scandinavian countries have been draining doctors from the rest of the EU and are OK w/ English in the hospitals.

 

[coprolalia]

I agree with what you say. But, you have to agree that the system is broke. It ain't working. It costs too da mn much. Its unable to sustain itself. Hospitals are closing left and right. We have too many uninsured or underinsured folks in this country. SOmething has to be done. IF you were the president, would you turn a blind eye to this because you want to protect the interests of the powerful insurance lobby? Healthcare has to be affordable. Its is the back bone of our society. That and education.

THere are too many industries making a KILLING on medicine and guess what. it aint the doctors. The health insurance cos and HMOS. pharmaceutical industry, device manufacturers, its goes on and on and on..

My friend stayed one night in the hospital fractured ankle. Total bill. 27K.
CMON COPRO>> cmon..

what does it matter to you who pays you? insurance co or government? We are socilaized already dont you think . You cant charge what market forces dictate like plastic surgeons. The government tells you what you can charge already.

Medicine is an unappealing career choice and will not change. IT has been for a long while. People(pre meds) are still blinded by medical dramas on tv which glamorize medicine and the historic reputation of doctors having wednesdays off etc etc.

I don't agree that it's completely "broke", or we would not have a place to go to work on Monday morning. Unsustainable over the long run as currently operating? Definitely.

But, the solution is not radical reform to a single-payer, European style system. That will last about a year, if it happens, as most Americans (who hate to wait for anything) will revolt en masse.

Again, I've pointed out a few alternative steps above. The people in charge don't seem to want to seriously consider such alternatives. Next, you need to ask yourself "why" that's the case... And, it's got more to do with Obama being more of a "good ole boy" (not in the racist, but southern redneck sense) than many people who've drank the Koolaid realize.

-copro

 

[Taurus]

I agree with what you say. But, you have to agree that the system is broke. It ain't working. It costs too da mn much. Its unable to sustain itself. Hospitals are closing left and right. We have too many uninsured or underinsured folks in this country. SOmething has to be done. IF you were the president, would you turn a blind eye to this because you want to protect the interests of the powerful insurance lobby? Healthcare has to be affordable. Its is the back bone of our society. That and education.

THere are too many industries making a KILLING on medicine and guess what. it aint the doctors. The health insurance cos and HMOS. pharmaceutical industry, device manufacturers, its goes on and on and on..

My friend stayed one night in the hospital fractured ankle. Total bill. 27K.
CMON COPRO>> cmon..

what does it matter to you who pays you? insurance co or government? We are socilaized already dont you think . You cant charge what market forces dictate like plastic surgeons. The government tells you what you can charge already.

Medicine is an unappealing career choice and will not change. IT has been for a long while. People(pre meds) are still blinded by medical dramas on tv which glamorize medicine and the historic reputation of doctors having wednesdays off etc etc.

I agree that the status quo is not sustainable. Annual 10% health premium increases is not sustainable for individuals or businesses. That's what different today than 15 years ago. There's a concensus from businesses, individuals, government, hospitals, etc that the system needs fixing. I don't believe that the overhaul will be as drastic as Copro is predicting. Obama seems to be taking incremental changes. The Republicans would block any major changes like single payor system.

 

[badgas]

I don't agree that it's completely "broke", or we would not have a place to go to work on Monday morning. Unsustainable over the long run as currently operating? Definitely.

But, the solution is not radical reform to a single-payer, European style system. That will last about a year, if it happens, as most Americans (who hate to wait for anything) will revolt en masse. Again, I've pointed out a few alternative steps above. The people in charge don't seem to want to seriously consider such alternatives. Next, you need to ask yourself "why" that's the case... And, it's got more to do with Obama being more of a "good ole boy" (not in the racist, but southern redneck sense) than many people who've drank the Koolaid realize.

-copro

This will be exactly what prevents the US from a European style socialized medicine.

 

[maceo]

I agree that the status quo is not sustainable. Annual 10% health premium increases is not sustainable for individuals or businesses. That's what different today than 15 years ago. There's a concensus from businesses, individuals, government, hospitals, etc that the system needs fixing. I don't believe that the overhaul will be as drastic as Copro is predicting. Obama seems to be taking incremental changes. The Republicans would block any major changes like single payor system.

We are doing too many things to too many people. Everyone over age 50 gets a colonoscopy, everyone gets viagra paid for by the govt if they need it, every woman gets their baby delivered with afew days in the hospital, everyone who dies has to stay in the ICU for 3- 4 months. They get labs everyday a abg, chest film. 10 doctors come by everysingle day to say, "Hes ***** ing dying", they dialize, trach, culture etcetcetc.. all this cost money. The landscape has changed. Back in the day, people died and that was it. NO ventilator. the nurses watched them die in the regular room. On top of paying for all this.. the insurance company has to make at least a 30 percent profit. How can anybody be ok with it? IT was hidden beforre becuase it was affordable. Now even companies cant even afford to buy health insurance thats why they are moving their operations overseas. i say cut the middle man right out. I dont know how to do that, but i know thats what has to be done.

 

[ChrisA]

maceo

We might not agree politically but we absolutely agree on this. 👍

We are doing too many things to too many people. Everyone over age 50 gets a colonoscopy, everyone gets viagra paid for by the govt if they need it, every woman gets their baby delivered with afew days in the hospital, everyone who dies has to stay in the ICU for 3- 4 months. They get labs everyday a abg, chest film. 10 doctors come by everysingle day to say, "Hes ***** ing dying", they dialize, trach, culture etcetcetc.. all this cost money. The landscape has changed. Back in the day, people died and that was it. NO ventilator. the nurses watched them die in the regular room. On top of paying for all this.. the insurance company has to make at least a 30 percent profit. How can anybody be ok with it? IT was hidden beforre becuase it was affordable. Now even companies cant even afford to buy health insurance thats why they are moving their operations overseas. i say cut the middle man right out. I dont know how to do that, but i know thats what has to be done.

 

[UTSouthwestern]

This is spot on and can be summarized as defensive medicine with exercises in futility. Spending 1.7 million dollars on a 5 month pediatric ICU indigent patient that unfortunately fell into and floated in a pool for at least 15 min and is brain dead, because the parents are sure of a miracle happening even after fulminant fungal necrosis of the brain is just one example of an ABUSED system. The doctors all wanted to let the patient die months prior but the threat of legal action by grieving INDIGENT Catholic parents persuaded the hospital to acquiesce (along with state Medicaid funds).

You want to fix the system? Give physicians the mandate to make the tough decisions they already make without the threat of lawsuits to dissuade them from making the rightvand sensible choices.

Also punish those people that clearly take no PERSONAL responsibility for any aspect of their health. Why should taxpayers' have to pay for the healthcare of the 500 pound Burger King fiend? What incentive will be built into the system to promote healthy living? What punishment will be written in to ensure that the current money draining abusers don't continue their abusive patterns or even teach their family and friends how to continue to manipulate the system?

Universal care without universal responsibility will universally FAIL and drive the best minds away from health care.

We are doing too many things to too many people. Everyone over age 50 gets a colonoscopy, everyone gets viagra paid for by the govt if they need it, every woman gets their baby delivered with afew days in the hospital, everyone who dies has to stay in the ICU for 3- 4 months. They get labs everyday a abg, chest film. 10 doctors come by everysingle day to say, "Hes ***** ing dying", they dialize, trach, culture etcetcetc.. all this cost money. The landscape has changed. Back in the day, people died and that was it. NO ventilator. the nurses watched them die in the regular room. On top of paying for all this.. the insurance company has to make at least a 30 percent profit. How can anybody be ok with it? IT was hidden beforre becuase it was affordable. Now even companies cant even afford to buy health insurance thats why they are moving their operations overseas. i say cut the middle man right out. I dont know how to do that, but i know thats what has to be done.

 

[ChrisA]

This is spot on and can be summarized as defensive medicine with exercises in futility. Spending 1.7 million dollars on a 5 month pediatric ICU indigent patient that unfortunately fell into and floated in a pool for at least 15 min and is brain dead, because the parents are sure of a miracle happening even after fulminant fungal necrosis of the brain is just one example of an ABUSED system. The doctors all wanted to let the patient die months prior but the threat of legal action by grieving INDIGENT Catholic parents persuaded the hospital to acquiesce (along with state Medicaid funds).

You want to fix the system? Give physicians the mandate to make the tough decisions they already make without the threat of lawsuits to dissuade them from making the rightvand sensible choices.

Also punish those people that clearly take no PERSONAL responsibility for any aspect of their health. Why should taxpayers' have to pay for the healthcare of the 500 pound Burger King fiend? What incentive will be built into the system to promote healthy living? What punishment will be written in to ensure that the current money draining abusers don't continue their abusive patterns or even teach their family and friends how to continue to manipulate the system?

Universal care without universal responsibility will universally FAIL and drive the best minds away from health care.

 

[Muadib]

This is spot on and can be summarized as defensive medicine with exercises in futility. Spending 1.7 million dollars on a 5 month pediatric ICU indigent patient that unfortunately fell into and floated in a pool for at least 15 min and is brain dead, because the parents are sure of a miracle happening even after fulminant fungal necrosis of the brain is just one example of an ABUSED system. The doctors all wanted to let the patient die months prior but the threat of legal action by grieving INDIGENT Catholic parents persuaded the hospital to acquiesce (along with state Medicaid funds).

You want to fix the system? Give physicians the mandate to make the tough decisions they already make without the threat of lawsuits to dissuade them from making the rightvand sensible choices.

Also punish those people that clearly take no PERSONAL responsibility for any aspect of their health. Why should taxpayers' have to pay for the healthcare of the 500 pound Burger King fiend? What incentive will be built into the system to promote healthy living? What punishment will be written in to ensure that the current money draining abusers don't continue their abusive patterns or even teach their family and friends how to continue to manipulate the system?

Universal care without universal responsibility will universally FAIL and drive the best minds away from health care.

rite on ut!!! ppl def have to take some responsiblity for their own health. as a nation we've gotten so far away from personal responsiblity and culpability that everyone thinks that someone else will or should take care of it. whatever problem 'it' is. it's like those 20/20 specials on 'what would you do?' where so many ppl see horrific **** going down, but do nothing about it!!! we def need better efficiency, less defensive medicine - which just adds expense to the system and maybe even loan forgiveness for physicians. at $250000+ in student debt when u get out followed by several years in residency where you are just paying the interest t get by we're all screwed when we finally finish.

 

[coprolalia]

This is spot on and can be summarized as defensive medicine with exercises in futility. Spending 1.7 million dollars on a 5 month pediatric ICU indigent patient that unfortunately fell into and floated in a pool for at least 15 min and is brain dead, because the parents are sure of a miracle happening even after fulminant fungal necrosis of the brain is just one example of an ABUSED system. The doctors all wanted to let the patient die months prior but the threat of legal action by grieving INDIGENT Catholic parents persuaded the hospital to acquiesce (along with state Medicaid funds).

You want to fix the system? Give physicians the mandate to make the tough decisions they already make without the threat of lawsuits to dissuade them from making the rightvand sensible choices.

Also punish those people that clearly take no PERSONAL responsibility for any aspect of their health. Why should taxpayers' have to pay for the healthcare of the 500 pound Burger King fiend? What incentive will be built into the system to promote healthy living? What punishment will be written in to ensure that the current money draining abusers don't continue their abusive patterns or even teach their family and friends how to continue to manipulate the system?

Universal care without universal responsibility will universally FAIL and drive the best minds away from health care.

You just, in this one sentence, fully yet succinctly summarized the fundamental problem with the what-are-otherwise good intentions of the Left Wingers of this country.

-copro

 

[nightflight747]

Of course would universal responsibility of the people in our society make things easier, nobody argues with that. The problem is simply that WE DON'T LIVE IN A PERFECT WORLD. People are bad parents, fail in school and at their jobs, are bad examples as citizens and neighbors, and often just not that bright when it comes to taking care of their own health. NEVERTHELESS, they still have the right (yes, it is a right) to have their healthcare needs looked after. And the system isn't doing even a decent job at this time, that's why- sooner or later, during this 4yr administration or during the next one- universal health care will be implemented.

 

[badgas]

Of course would universal responsibility of the people in our society make things easier, nobody argues with that. The problem is simply that WE DON'T LIVE IN A PERFECT WORLD. People are bad parents, fail in school and at their jobs, are bad examples as citizens and neighbors, and often just not that bright when it comes to taking care of their own health. NEVERTHELESS, they still have the right (yes, it is a right) to have their healthcare needs looked after. And the system isn't doing even a decent job at this time, that's why- sooner or later, during this 4yr administration or during the next one- universal health care will be implemented.

Remind me why it is their right and not their privelage. I know that people have the right to persue happiness. I know that people have the right to life and liberty. I missed the part about free, unlimited health care. Why does the alcoholic have the right to come into the ICU for numerous issues 3+ times a month and not pay the bill or go to rehab? Why does the 400 lb diabetic have the right to 3+ ICU admissions per month for DKA when they will inevitibly be walking out the door with a big mac in hand ... and of course not pay their bill. I could go on and on for hours. Please explain why this is their RIGHT at the expense of everyone responsible. Then after you finish your internship, I want you to go ahead and answer that question again.

 

[ChrisA]

AS i understand it...

Healthcare is NOT a right in the USA.

 

[Consigliere]

Copro,

I think you might be a goddamn genius!

 

[nightflight747]

Remind me why it is their right and not their privelage. I know that people have the right to persue happiness. I know that people have the right to life and liberty. I missed the part about free, unlimited health care. Why does the alcoholic have the right to come into the ICU for numerous issues 3+ times a month and not pay the bill or go to rehab? Why does the 400 lb diabetic have the right to 3+ ICU admissions per month for DKA when they will inevitibly be walking out the door with a big mac in hand ... and of course not pay their bill. I could go on and on for hours. Please explain why this is their RIGHT at the expense of everyone responsible. Then after you finish your internship, I want you to go ahead and answer that question again.

Listen, we can all come up with examples that make the other side look ridiculous... You've made a few good ones about the alcoholic and the diabetic, now I could come up with some heartbreaking stories about people losing their insurance, getting cancer and being denied treatment. Look, you gotta be less emotional and more cerebral about this.

How on Earth can you pursue happiness, life and liberty if your health is not taken care of? How can you seriously live a life productive as a member of this society (and unlike your ridiculous examples of the alcoholic and 400lb diabetic, some lives ARE productive) if you have to worry about having one thing happen to you that can take it all away from you?

I suspect that you have been through internship and now have earned the right to be jaded and all. However, you've chosen a profession where SERVICE to the people is the main principal, and like it or not, you are in one line with teachers, nurses, firefighters, and other professions that universally make less money than you do. I agree with you, there are issues w/ money being thrown out the window for futile treatments, and you 400lb diabetic friend is one example of many.

However, and this is where I suspect we disagree, a society is a construct where individuals take care of each other. It means NOT looking the other way when something bad happens to your neighbor. And this is where one of the great paradoxes of the US becomes evident: Most, if not all, Americans would help out their neighbor next door if something bad was to happen, but when it comes to that abstract idea of a neighbor they cannot see, they become very selfish. -- You don't wanna help the 400lbs diabetic? Fine. I suspect your friend doesn't have insurance, no primary care doc around, and that's why (is it a she or he?) that diabetic comes visiting you in the ICU... I say we hook them up with health insurance, hook them up w/ a primary care doc, and try that for a while. You might be surprised.

 

[coprolalia]

Listen, we can all come up with examples that make the other side look ridiculous... You've made a few good ones about the alcoholic and the diabetic, now I could come up with some heartbreaking stories about people losing their insurance, getting cancer and being denied treatment. Look, you gotta be less emotional and more cerebral about this.

How on Earth can you pursue happiness, life and liberty if your health is not taken care of? How can you seriously live a life productive as a member of this society (and unlike your ridiculous examples of the alcoholic and 400lb diabetic, some lives ARE productive) if you have to worry about having one thing happen to you that can take it all away from you?

I suspect that you have been through internship and now have earned the right to be jaded and all. However, you've chosen a profession where SERVICE to the people is the main principal, and like it or not, you are in one line with teachers, nurses, firefighters, and other professions that universally make less money than you do. I agree with you, there are issues w/ money being thrown out the window for futile treatments, and you 400lb diabetic friend is one example of many.

However, and this is where I suspect we disagree, a society is a construct where individuals take care of each other. It means NOT looking the other way when something bad happens to your neighbor. And this is where one of the great paradoxes of the US becomes evident: Most, if not all, Americans would help out their neighbor next door if something bad was to happen, but when it comes to that abstract idea of a neighbor they cannot see, they become very selfish. -- You don't wanna help the 400lbs diabetic? Fine. I suspect your friend doesn't have insurance, no primary care doc around, and that's why (is it a she or he?) that diabetic comes visiting you in the ICU... I say we hook them up with health insurance, hook them up w/ a primary care doc, and try that for a while. You might be surprised.

And, this is the primary problem with students who have had no real-life experience yet. Your thinking is incredibly superficial, unsubstantiated, wishful, and serves only to reinforce your preconceived notions. You live in a world that really hasn't challenged you yet. You demonstrate so many different cognitive biases in this response, I don't even know where to start. So...

I challenge you to provide one - one - example, anywhere it can be found (web blog, media outlet, etc.) where someone in this country was denied treatment under the circumstances you state.

Let me give you some additional advice, to someone who is going to be on the wards soon: don't say **** you can't back up; you will have to be prepared to back-up all of your statements - people's lives are at stake.

When I'm rotating in any of the various ICU's in our hospital, I see the occassional hotshot med student who comes onto the wards with some preconceived notion about how gifted he/she is, and is going to prove to everyone how much smarter they are than the rest of the team. Usually, I've found that they just fudge and vamp, and when you start questioning them they fall apart. They often say what they believe to be going on with a particular patient, and - yes - occassionally they are correct. Many times they are not. But, the important thing is that when you start asking for details, they are only able to give you bits and pieces of studies they've heard about. It quickly becomes clear they haven't read them, or if they have they've gotten the important parts completely wrong. Likewise, they can't tell you the exact article, and often they've gotten the conclusions slightly skewed in whatever study they are attempting to quote.

And, issues about a particular patient they're managing? Inevitably, they don't have the labs handy or haven't reviewed the latest x-rays. Yet, they're likely to still tell you that they have. If you ask them what they think needs to be done, they may come up with some elaborate long-winded "stall" response that is vague and doesn't really do anything more than burn-up the oxygen in the room.

In the interim, let me help you here: you don't know what you're talking about. Okay? And, you just tried to bullsh*t some of the smartest people on the entire SDN forum. We see through it. The people on the wards that you are going to be dealing with will see through it to.

So, here's my advice:

(1) Don't make up details, stories, or vague recollections. You are going to be a doctor. Details are important. Know them. Be prepared to support and defend your statements.

(2) Don't quote studies or anecdotes that either (a) don't exist, or (b) do exist but you then go onto either get the conclusions completely wrong or you then misquote/misremember/misrepresent the data in the study. If you are going to quote a study or share an anecdote, actually read the study and bring a copy of it (or the article or weblink, if it's an anecdote) with you so your senior resident or attending can point out the important parts of it to you as well as describe to you how you got your initial intepretation completely wrong. Nothing drives me crazier than someone expecting me to listen to something they say and believe is important without the readiness and ability for me to independently corroborate it.

(3) Don't expect everyone to accept what you say at face value, especially if your reasoning is shaky, nebulous, and/or vague. You will meet someone like me, and I'm going to tear you apart and make you look stupid in front of your colleagues (who probably already aren't quite as impressed with you as you are with yourself).

Lastly, read this, take a deep breath, and realize that I'm trying to help you. You're not going to like what I say, but I promise you that the above is some stellar advice that you ignore at your own perile.

-copro

 

[Consigliere]

Copro,

See post #29.

 

[soupcan]

Copro,

That could be the best post I have seen on sdn to date. Well done, Sir.

-Soup

 

[badgas]

Listen, we can all come up with examples that make the other side look ridiculous... You've made a few good ones about the alcoholic and the diabetic, now I could come up with some heartbreaking stories about people losing their insurance, getting cancer and being denied treatment. Look, you gotta be less emotional and more cerebral about this.

How on Earth can you pursue happiness, life and liberty if your health is not taken care of? How can you seriously live a life productive as a member of this society (and unlike your ridiculous examples of the alcoholic and 400lb diabetic, some lives ARE productive) if you have to worry about having one thing happen to you that can take it all away from you?

I suspect that you have been through internship and now have earned the right to be jaded and all. However, you've chosen a profession where SERVICE to the people is the main principal, and like it or not, you are in one line with teachers, nurses, firefighters, and other professions that universally make less money than you do. I agree with you, there are issues w/ money being thrown out the window for futile treatments, and you 400lb diabetic friend is one example of many.

However, and this is where I suspect we disagree, a society is a construct where individuals take care of each other. It means NOT looking the other way when something bad happens to your neighbor. And this is where one of the great paradoxes of the US becomes evident: Most, if not all, Americans would help out their neighbor next door if something bad was to happen, but when it comes to that abstract idea of a neighbor they cannot see, they become very selfish. -- You don't wanna help the 400lbs diabetic? Fine. I suspect your friend doesn't have insurance, no primary care doc around, and that's why (is it a she or he?) that diabetic comes visiting you in the ICU... I say we hook them up with health insurance, hook them up w/ a primary care doc, and try that for a while. You might be surprised.

You are obviously a 1st or 2nd year med student. Any 3rd/4th year has gotten to know the frequent flier diabetics and alcoholics in most ICUs in the country. I used those examples because they are so common and not off the wall BS examples about cancer patients and refusal of treatment. I have seen ZERO instances of your hypothetical situation or anything like it.

The pursuit of life, liberty and happiness is just that... the right to PURSUE. It does not say the "governments duty to provide" life, liberty and happiness. If the diabetic wants better health for themself, then STOP eating the ho-ho's. At some point people have to take some responsibility for their actions.

Naive med students with your general attitude are a dime a dozen. We have all dealt with you over and over again. Do yourself a huge favor and reread the advice given to you in post above. When you are done, reread it. You have been given one of the biggest keys to success as a 3rd/4th year.

 

[RabbMD]

I would love for one, JUST ONE, politician be forced to work for 12 hours straight taking care of anyone who comes in the door, who does not follow the advise they are given and is just hoping and secretly praying that when you intubate them for their third BKA revision you knock up their last tooth hanging by a thread so they can sue you.

Seriously, you have not done hard work until you have done residency. Med school was a walk in the park comparatively, so was clearing Texas swamp land all day long. Until that time, you really can not understand. It is physically tough, but mainly it is emotionally tough. With the work hour rules is has gotten much better, so you will only get a toned down version.

People do not get a right to housing, if they destroy their section 8 apartment, they get kicked out eventually. However, they can destroy their body to no end. The number of people who "get denied cancer therapy" (funny you use that one, because cancer treatment is unquestionably the US system excels, despite the attempts to statistically prove its inefficiencies) pales compared to the number of severely demented alzheimers patients on dialysis that are in the ICU for 3 months that you take to the OR for left rotator cuff repairs.

Three are three problems of healthcare that non doctors never seem to talk about

1). Defensive medicine
2). Personal repsonsibility for health
3). The amazing propensity for the American people to consume enormous amounts of anything "free" when they do not see the bill for it.

 

[nightflight747]

lol...

Look, Copro, that was a bit of a rant, don't you think?

The poster I was referring to had brought up some examples that are on one extreme of the spectrum (the 400lbs diabetic w/ multiple ICU admits/month and the alcoholic w/ multiple ICU admits/month). They were, IMHO, meant to dramatically point out the concept of over-utilization of health care resources in some instances. The point here is DRAMATICALLY, because even though I admit that these people exist, they are not the norm. That is why I, in my youthful naiveness, brought up another hypothetical example on the other extreme of the spectrum (people being left OUTSIDE of the US health care system). Nothing to quote here or papers to print out for you... sorry.

Now, Copro, I don't know what kind of bad experiences you have had with medical students, but it seems like you just had to get that off your chest, didn't you? That stuff about hotshot med students who make up labs and all that really doesn't help with this discussion, but it was fun to read. Good to know you were a medical student as well just a few years ago and can empathize.

I'd love to say that you were being a good guy on a mission to somehow help others understand your viewpoint better, but your posts are just a touch too... how do you say it... aggressive? But thanks for trying to help, I'm glad there are sincere and SMART people out there looking out for some stranger's greater good on an anonymous internet forum. 🙂

 

[pgg]

Late to the thread ... agree with coprolalia in essentially every detail.

NEVERTHELESS, they still have the right (yes, it is a right) to have their healthcare needs looked after.

It is not a right. Life isn't fair, and government can't make life fair.

I support universal healthcare in a handful of specific circumstances:

• For everyone under age 18 (or perhaps 21) - after all, no child can be blamed or faulted for the circumstances of his birth and upbringing. Coverage should extend into adulthood for conditions which preclude an economically productive life. Society can afford this, and giving every kid a fair shot at life is a noble goal (even if the kid's parents ought to bear that burden).
• All conditions in all people which pose a public health risk - e.g., free treatment for tuberculosis, STDs.
• A free, lifetime supply of any person's preferred contraceptive.

No adult is entitled to comprehensive health care as some kind of inalienable human right; no adult is entitled to shelter; no adult is entitled to food; no adult is entitled to clothing. Adults are entitled to a fair shot at earning a living in a free society, nothing more.

badgas had it right when he said the pursuit of happiness doesn't imply a government obligation to make it happen.

 

[Gern Blansten]

lol...

Look, Copro, that was a bit of a rant, don't you think?

The poster I was referring to had brought up some examples that are on one extreme of the spectrum (the 400lbs diabetic w/ multiple ICU admits/month and the alcoholic w/ multiple ICU admits/month). They were, IMHO, meant to dramatically point out the concept of over-utilization of health care resources in some instances. The point here is DRAMATICALLY, because even though I admit that these people exist, they are not the norm. That is why I, in my youthful naiveness, brought up another hypothetical example on the other extreme of the spectrum (people being left OUTSIDE of the US health care system). Nothing to quote here or papers to print out for you... sorry.

Now, Copro, I don't know what kind of bad experiences you have had with medical students, but it seems like you just had to get that off your chest, didn't you? That stuff about hotshot med students who make up labs and all that really doesn't help with this discussion, but it was fun to read. Good to know you were a medical student as well just a few years ago and can empathize.

I'd love to say that you were being a good guy on a mission to somehow help others understand your viewpoint better, but your posts are just a touch too... how do you say it... aggressive? But thanks for trying to help, I'm glad there are sincere and SMART people out there looking out for some stranger's greater good on an anonymous internet forum. 🙂

One of his points was that everyone who needs care gets care. The person with cancer (or whatever) who comes in does not get turned away. They may get referred to a tertiary center or turfed to another hospital, but they do get cared for, no matter what their ability to pay is. The number of uninsured is dramatically overblown and includes mostly young healthy patients. The sick and uninsured are cared for by tertiary and teaching hospitals as well as free clinics etc. They get care. It may not be Cadillac care, but it is good care. Not always efficient, but still good care. These are the teaching hospitals where med students and residents are learning. It can be seen as a mutually beneficial trade off.

I suspect that the average "paying" citizen will expect a better and more efficient health care delivery system. It seems to me that the government wishes to model all health care delivery after the VA system. In other words, there will be no "paying" customers left. If you have ever worked in such a system, you know it will be a disaster. The inefficiencies and layers of bureaucracy will suffocate many physicians and steal their souls.

I admire your somewhat Pollyanna view of the world, but I think your views are quite naive. Copro's examples are much more realistic than yours. Everyone can give you many examples that fit with his two scenarios. I suspect there are only a handful of examples in the U.S. that would fit your scenario. I suspect that even the most jaded physicians would not turn away someone who truly needed their care no matter what the wallet biopsy showed. I concede that many would do the initial stabilizing and then transfer to a tertiary center, but that is not abandonment. Most hospitals provide a hefty percentage of "free" care. I happen to work in one that provides a great deal of it.

Needless to say, I agree with almost everything Copro and UTSW mentioned. The levels of waste and inefficiencies in our current system are horrendous. Until we fix the reasons that these exist (litigation, unreasonable patient/family expectations, poor patient compliance, unhealthy and risky behavior, and lack of self policing to rid the profession of the bad apples that make the legitimate litigation necessary etc), we won't be able to fix the system.

 

[coprolalia]

I would love for one, JUST ONE, politician be forced to work for 12 hours straight taking care of anyone who comes in the door, who does not follow the advise they are given and is just hoping and secretly praying that when you intubate them for their third BKA revision you knock up their last tooth hanging by a thread so they can sue you.

Seriously, you have not done hard work until you have done residency. Med school was a walk in the park comparatively, so was clearing Texas swamp land all day long. Until that time, you really can not understand. It is physically tough, but mainly it is emotionally tough. With the work hour rules is has gotten much better, so you will only get a toned down version.

People do not get a right to housing, if they destroy their section 8 apartment, they get kicked out eventually. However, they can destroy their body to no end. The number of people who "get denied cancer therapy" (funny you use that one, because cancer treatment is unquestionably the US system excels, despite the attempts to statistically prove its inefficiencies) pales compared to the number of severely demented alzheimers patients on dialysis that are in the ICU for 3 months that you take to the OR for left rotator cuff repairs.

Three are three problems of healthcare that non doctors never seem to talk about

1). Defensive medicine
2). Personal repsonsibility for health
3). The amazing propensity for the American people to consume enormous amounts of anything "free" when they do not see the bill for it.

👍

-copro

 

[coprolalia]

No adult is entitled to comprehensive health care as some kind of inalienable human right; no adult is entitled to shelter; no adult is entitled to food; no adult is entitled to clothing. Adults are entitled to a fair shot at earning a living in a free society, nothing more.

badgas had it right when he said the pursuit of happiness doesn't imply a government obligation to make it happen.

👍

-copro

 

[coprolalia]

lol...

Look, Copro, that was a bit of a rant, don't you think?

The poster I was referring to had brought up some examples that are on one extreme of the spectrum (the 400lbs diabetic w/ multiple ICU admits/month and the alcoholic w/ multiple ICU admits/month). They were, IMHO, meant to dramatically point out the concept of over-utilization of health care resources in some instances. The point here is DRAMATICALLY, because even though I admit that these people exist, they are not the norm. That is why I, in my youthful naiveness, brought up another hypothetical example on the other extreme of the spectrum (people being left OUTSIDE of the US health care system). Nothing to quote here or papers to print out for you... sorry.

Now, Copro, I don't know what kind of bad experiences you have had with medical students, but it seems like you just had to get that off your chest, didn't you? That stuff about hotshot med students who make up labs and all that really doesn't help with this discussion, but it was fun to read. Good to know you were a medical student as well just a few years ago and can empathize.

I'd love to say that you were being a good guy on a mission to somehow help others understand your viewpoint better, but your posts are just a touch too... how do you say it... aggressive? But thanks for trying to help, I'm glad there are sincere and SMART people out there looking out for some stranger's greater good on an anonymous internet forum. 🙂

👎

I know your type.

You're going to struggle in residency because people aren't going to fit your preconceived notion about how they should respond to the treatment you propose, to the advice you offer, to your clinical judgment, and to what you think they should do next.

Patients aren't really going to want your help or advice in making them a better person. The vast majority will only want you to fix their immediate problem so they can go out and continue engaging in the bad habits that got them there in the first place. The people you encounter in the hospital (patients and colleagues) will not be like your family and friends, and aren't always going to agree with you and think you're wonderful and kiss your feet. Get used to it.

You've still got a lot of learning to do, and I'm not talking about biochemistry and pathology.

-copro

 

[IMED4Life]

I would have to agree with coprolalia. Just a little background, as you can tell from my name, I WAS an internal medicine resident. I completed residency and am board certified in IM. I was set to start a GI fellowship, when during my third year I had a relevation. After almost three years in clinic, seeing the patients who I though I would appreciate my love for "continuity of care", they did very little to change there way of being. They were content to take their meds even if there was a possibility of getting off them because in order to achieve this they would have to perform lifestyle modifications they were not willing to partake. Suddenly I realized that all my hardwork would never really pay any dividends becuase people only want the path of least resistance (myself included). Thus, I decided to withdraw from my fellowship and pursue anesthesiology because what I wanted out of a career in medicine involved direct care and intervention. In anesthesia, I feel that I have a direct outcome in someone's care and that my hours of due diligence will payoff. In internal medicine, unfortunately, even your best attempts at providing preventative care are thwarted by a person's desire for the quick fix.

In summary, while I appreciate nightlife's view on life and healthcare (believe me, if we were all like you this world could be a better place), the reality is that this current system will continue to fail so long as people choose to wait until the signs of end organ failure (and believe me, you will also see people who will persist with their bad habits despite their horrific condition i.e. the end-stage COPDed who still has the 2 ppd habit) to fix their condition. Nightlife, wait until residency before you cast judgement on those that have gone before you. If my login name is to attest, sometimes life takes you to places you didn't plan on going (and yes that is from Thrash Unreal😀