biggest problem in US health care system?

[montessori2md]

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To get back to the initial question:

Yep, there are people who need care and don't get it. There are folks in the hills who can die from their heart attack because they are 50 miles from a hospital, and there are folks in the 'hood who can die because 300 other people decided to flood the ER on a full moon and it just took too long to get to them.

Yep, human error and covering your ass can waste $$$ and kill.

Yep, not having insurance can suck, and some people genuinely can't afford it (and some people choose not to pay for it or jump through the hoops to get it).

Yep, some people create their expensive health problems, or their children's, and exacerbate them by not bothering to get help in a timely fashion, and some people are just plain ignorant.

But IMHO, the big problem with medicine/healthcare/whatever you want to call it, is that it is still a toddler. Modern medicine was born in the 20th century, and there are still a lot of kinks to be worked out. We can whine all we want about $$$ and access and ignorance, but the truth of it is, 200 years ago, no one had real access to anything other than quacks and barbers, and we're all lucky that we're alive now, and not then.

It would be nice if that evil mandate applying to ERs providing free assessment to all applied to all MDs so that we could share the love (can't you just see it -going to the plastics guys for the free eval, c'mon) 😀

 

[mindquick]

isn't the biggest problem the fact that there are a lot of people without access to health care? which means health care too expensive and not enough doctors.

 

[jae9970]

Very well said. We need to act collectively, as the next generation of physicians, to stick up for ourselves. It seems that behind every criticism, suggestion, and political manuever is an effort to screw doctors. It is ridiculous. We deserve, based on years of dedication and the premium intellect should demand, to receive very high compensation. We should have the right to operate with the added bonus of profit. This should not be deemed as nefarious or heartless, but rather as an ADDITIONAL and DESERVED motivating factor.

Many of our politicians do not value the worth of a doctor, but we certainly should understand and espouse an accurate assessment of our value.

i think there should be some politicians who come from the medical field. Some doctors enter the administration, so why not the politics? 🙂

 

[jae9970]

People in this country don't want to work hard and...

It's a fact that American people are fatter (and maybe lazier) than the world average, but that doesn't mean they don't want to work hard..

i cant list the exact source, but i read an article a few days ago from some governmental department relating to labor, and it compared the US to other developed countries in terms of workers' average number of hours working per year

the result was, the US workers on average work a LOT more hours than European workers, and that's no surprise. Only some countries in Asia worked significantly higher numbers of hours per year than the US

Then the GDP or whatever, the national gross something per worker (not capita) was compared, and this number was divided by the # of hours worked to compare the general efficiency of the countries' working force.

The US had a very high GDP, thus, efficiency-wise, it was one of the top countries. In conclusion, the US is one of the hardest working country (judging by the number of hours workers work) and one of the most efficiently working nation.

May be pretty irrelevant to the whole discussion, but those who believe we are all fat lazy and don't wanna work.. have some pride in your country 😀

 

[TRAMD]

I didn't have time to read through everything so maybe these have been mentioned before.

Some of the things that I think hurt healthcare:

People are stupid and do things that are truly harmful to their health while being scared of something harmless they heard about on the news.

There is too much focus on fixing health problems and not enough on preventing them.

Lawyers.

Insurance companies.

 

[Gut Shot]

Second with socialized medicine your eliminating compition, you talk about how doctors are in it for the money and what not, sure this is true, so you take away the one thing that brings new people to wanting to become doctors and what do you get? A shortage of doctors.

From this 2003 release from the journal Health Affairs:

• The U.S. had fewer physicians per 1,000 population in 2000 and fewer physician visits per capita than the OECD median. There were 2.8 physicians per capita in the U.S., compared to an OECD median of 3.1 physicians.
• Germany and Switzerland have much higher hospital admissions per capita, average length-of-stay, and acute care beds per capita than the United States. Yet both countries spend far less than the U.S. per capita and as a percentage of GDP on hospital care than the U.S.
• The average U.S. expenditure per hospital day was $1,850 in 1999 - three times the OECD median.

 

[midn]

I just wanted to give everyone on the interview trail a recommendation to read this thread. I got asked this question and was probed in healthcare issues for the majority of my interviews (only 2 interviews at one school so far).

What I see the biggest problem in healthcare from my semi-naive pre-med perspective, is the lack of informed patients and how much they buy into direct-to-consumer advertising and the media overall.

Our consumer culture ingrains on the minds of all that you should get the bang for your buck without considering anything. Hell you pay so much money for insurance each month, why not demand every freaking diagnostic test from the menu? This focus on the individual allows a patient to easily forget how their expenditures are effecting the overall system. Mix in a very tired doctor who is just trying to turn over the patient so he or she can empty a bed for the next forty or fifty people who have been waiting in the ER for up to eight hours, and you have a lot of wasteful diagnostic tests being ordered.

The consensus amongst regular (those lacking knowledge in our medical system) persons these days is that the doctor and insurance company are trying to screw you. You need to be immediately on the defensive as soon as you step into a hospital/clinic making sure the doctor isn't cutting corners. I had a person argue with me that the triage system we have is crap because there is no way a nurse could properly assess a medical situation by him or herself. Instead, he proposed that the triage nurses should be replaced with doctors. I was rather stunned by the ignorance in his statements, but it clearly embodied how mistrustful people are of our system and how many ridiculous demands they are willing to make without having any idea of the costs of healthcare.

Lastly, direct-to-consumer advertising by drug companies is somewhat problematic. People come visit their doctors to demand these drugs and think it is their right to have them. From what I hear, most doctors don't have time to research drugs and thus go ahead and give the patients what they want if they fit some sort of criteria for the drugs given to them by the drug companies. Also, a doctor knows that if he or she denies the patient their drugs, the patient is highly likely to go to other clinics until they find one that will give into their demands. Thus, the doctor risks losing valuable insurance money to their clinic. It's not completely the drug companies fault either because they have to spend 15-20 years in developing a drug (due to tight government regulations) and have to turn a profit on their current approved medicine to continue research on other drugs.

Anyways, I digress. This is mostly all coming from books and a little bit from personal experience. If there was somehow a way to get people to start thinking more holistically again and not just for themselves, that could help to cut down the cost of health care by minimizing wasteful treatments. Given our strong independent culture, I do not see this happening.

 

[WantsThisBad]

Would it not go over so good if you wrote that the biggest problem was the way the practice of psychiatry has been and the over prescription of psychoactive drugs? If you asked everyone on the street and they were honest you would be amazed by how many people are on antidepressants and anti anxiety drugs. Does anyone else see this as a real problem that faces our society? Sometimes I feel like psychiatry is a pseudo-science. Any thoughts?

 

[Gut Shot]

What I see the biggest problem in healthcare from my semi-naive pre-med perspective, is the lack of informed patients and how much they buy into direct-to-consumer advertising and the media overall.

I hope your arguments went over better with your interviewers than they would have with me. DTC advertising is annoying, and I wish it would go away, but that's about it. Also, since when did patients have to be informed? That's our job. In any case, there are so many more crushing problems in healthcare today, you're picking crabgrass in an apple orchard.

Here, I'll toss out some concerning charts and graphs and you can do some brainstorming, if you like. Also, you should read The Moral Hazard Myth.

 

[Gut Shot]

Per capital health spending of OECD nations.

 

[Gut Shot]

From the White House!

 

[Gut Shot]

 

[jae9970]

thank you Gut Shot for these, but a couple of questions.

The second bar graph is unlabeled but i assume it's something like healthcare-related expenditure per capita for different nations ?

and the last graph, the administrators are health administrators in the hospital?

 

[armybound]

I talked with Gut Shot before about that health administrators graph, and I believe it's showing the growth of administrators in all aspects of health care, and is directly related to the growth of HMOs.

 

[Gut Shot]

Would it not go over so good if you wrote that the biggest problem was the way the practice of psychiatry has been and the over prescription of psychoactive drugs?

I'd shy away from anything the criticizes the decisions physicians make about treating or not treating with any modality. You may end up sounding presumptive, which is not good considering your lack of training.

If you asked everyone on the street and they were honest you would be amazed by how many people are on antidepressants and anti anxiety drugs. Does anyone else see this as a real problem that faces our society?

I do see it as a real problem, but more from the perspective that the number of depressed and anxiety-ridden people has been steadily increasing in this country.

Sometimes I feel like psychiatry is a pseudo-science. Any thoughts?

It's definitely softer in its underpinnings than most other branches of medicine, but calling it a pseudo-science is unwarranted. There are useful models of psychiatric illness, and there are useful therapeutic options available to psychiatrists. Tell you what, though, if you pull one of these with your interviewer I'll send you $20:

 

[Gut Shot]

The second bar graph is unlabeled but i assume it's something like healthcare-related expenditure per capita for different nations ?

Correct!

and the last graph, the administrators are health administrators in the hospital?

That graph was compiled with numbers from the Bureau of Labor Statistics. It reflects mainly an increase in insurance/HMO administrators, although there has been significant growth in hospital administration as well.

 

[jae9970]

so you constructed those graphs, huh?

i have to say, nice usage of colors.. the yellow, i feel compelled to feel shocked when i see your graphs 😀

 

[8744]

that's not the point. we have about 45 million people without health insurance and, without it, are severely limited in the health care they can receive. then you add the number of people with health insurance that are limited in their access to medical care because of various reasons like physical constraints, or are impeded because their health insurance sucks. the "access" mentioned is a broad term.

Whoa. Do the millions of 20-and-30 somethings who are counted among the ranks of the uninsured who don't feel they need to buy even an inexpensive major medical policy policy because they can always get free care at the Emergency Department count as those suffering from lack of healh care? How about the families with combined incomes over sixty grand who have better things to spend their money on than medical care? Do they count?

You need to stop believing the hype. "47 million without health insurance" is a catch phrase. A little cliche that you can spout automatically without thinking about it. Everybody over 65 has insurance. That takes care of the elderly. Every child from every home with an income of from twice to three times the federally defined povery level (depending on your state) either has or is eligable for medicaid. Of the "47 million without health insurance," if you subtract people who could either pay for their health care or insurance but don't because they have other priorities the number probably shrinks to about 10 million or so hard-core unreachable citizens. You know, like the ones living under bridges who, never-the-less, can get a heart cath or a cholecystecomy a lot quicker than you can in Greece, France, or any of the other Freeloader Kingdoms.

The point is that if you can afford medical insurance or even paying out-of-pocket for your routine health care and don't why is this a crisis? Sounds more like a crisis of personal responsibility which, once you make your first trip off of the fantasy planet where you currently reside, will become apparent.

 

[Gut Shot]

so you constructed those graphs, huh?

No, but the physicians/administrators one has been drifting around health policy circles for at least seven years (with some modifications).

 

[Gut Shot]

You need to stop believing the hype. "47 million without health insurance" is a catch phrase. A little cliche that you can spout automatically without thinking about it. Everybody over 65 has insurance. That takes care of the elderly. Every child from every home with an income of from twice to three times the federally defined povery level (depending on your state) either has or is eligable for medicaid. Of the "47 million without health insurance," if you subtract people who could either pay for their health care or insurance but don't because they have other priorities the number probably shrinks to about 10 million or so hard-core unreachable citizens.

Do you have any data to back this up, or are you just shooting from the hip?

According to KFF's 2005 data, only 6.8% of people with a family income over $40,000 are uninsured. In contrast, 36% of those with family incomes <$20,000 are uninsured.

A safer bet would be to say that a relatively small number of young, well earning individuals are uninsured, but the majority have significant barriers to obtaining affordable coverage (despite being employed). Also, just because you have insurance doesn't mean it's any good. If one could adequately quantify the number of underinsured I think the picture would become truly scary.

As for personal responsibility, you might enjoy this NEJM article Imposing Personal Responsibility for Health.

 

[TheRealMD]

Heh, I had this same question for my interview yesterday. I answered it that healthcare and insurance WILL change within the next 10 years because the status quo isn't going to be sticking around for much longer. Most importantly, any time of universal healthcare is going to provoke businesses to drop their plans and shuttle their employees to government programs, causing an increased spiral of spending, increase of taxes, and eventually the end of the world as we know it (a bit drastic, i know).

The real problem is that there's no adequate way to literally cover everyone without raising taxes not only on individuals but businesses as well. And with the power of lobbyists being paid by corporate dollars, there's NO way that's gonna happen any time soon.

 

[xpinchx]

I'm going to have to go through and read everything in this thread at some point. Just marking this post to come back to later.

 

[midn]

I hope your arguments went over better with your interviewers than they would have with me. DTC advertising is annoying, and I wish it would go away, but that's about it. Also, since when did patients have to be informed? That's our job. In any case, there are so many more crushing problems in healthcare today, you're picking crabgrass in an apple orchard.

From what I've seen, people come in the ER for very minute things that could be solved by a day of rest or just some bandages. As a doctor, don't you feel that your time could be better spent seeing less patients with more immediate concerns? Maybe it's just my belief that not every single person needs to be seen because the body does have some capacity to heal itself. Of course, if there are recurrent problems, then it is important to see a physician, but if it is a very isolated case, maybe one should wait a day or two to see how everything works out. By informed, I think people need to be better aware that for most minor cases, only symptoms are being treated and the eight hours they spend in the ER might be better used just relaxing and taking some over the counter medicine.

The points I brought up with DTC are minor,that I concede and it was not even addressed in my interviews. I just brought it up here for reasons I cannot remember now.

What I do still believe is that our consumer culture is inherent in the problem with our excess and lopsided healthcare expenditures. This view cannot be easily substantiated because it would require a much broader investigation, but my interviewers thus far did seem to agree somewhat with me (or they were just trying to hurry the conversation, but I wouldn't guess that since one of my interviewers opted to keep me 15 minutes longer than my alloted 30 minutes). This observation is rather futile even if true because it is incredibly difficult to control an entire culture, but I still state it because I am a very big-picture person. You may not agree with me, but I do not think you can say my statement is completely untrue.

Anyways, thanks for the link. The book I am reading ("The Truth About Healthcare) does seem rather bias against pharmaceutical spending and overly expensive medical advances that provide cost-ineffective improvements. I'll read the website you provided as soon as I catch up with my school work. I admit I am still very ignorant about the healthcare system, but I do not think any amount of reading will give me a correct insight since it takes first person experience as a medical professional (not a volunteer) to understand. Thus, the reasons for the poor health of our medical system will probably not be agreeable with all persons since it is largely a matter of perspective.

 

[armybound]

I just plan on telling them that the biggest problem is that I'm not a doctor yet.

Guaranteed acceptance.

 

[Gut Shot]

From what I've seen, people come in the ER for very minute things that could be solved by a day of rest or just some bandages. As a doctor, don't you feel that your time could be better spent seeing less patients with more immediate concerns?

I see these situations as normal and relatively unobtrusive. If you refer to the chart in post #110, 85% of the population consumes only 26.9% of health care expenditures. Toggling the minor complaints of that 85% either way is not going to significantly affect the overall picture. The far bigger concern is people who have definite, severe pathology yet do not present until late stage. Those are the patients who will consume time and resources (often to poor outcome).

I admit I am still very ignorant about the healthcare system, but I do not think any amount of reading will give me a correct insight since it takes first person experience as a medical professional (not a volunteer) to understand.

I appreciate your thoughtful approach to this issue (as you showed in your PM). Indeed, there are people who spend their entire professional lives studying health care, and they can't wrap their heads all the way around it. Despite being a physician and reading a lot on the topic I still chase my own tail on many policy concerns. I believe I've changed my mind about the best healthcare reforms in this country at least four times in the past few years.

As such, it is not my desire to convert you (or anyone) to my way of thinking, but we can all aspire to be better educated on this enormously complex topic. Here is a partial list of links that I've complied over the past year or so:

For starters, Dr. Thomas Bodenheimer wrote a four part series on various aspects of the health care system. If you read those you’ll know more than 99.8% of premeds (and about 80% of practicing physicians). The first three are here:

http://www.annals.org/cgi/content/full/142/10/847
http://www.annals.org/cgi/content/full/142/11/932
http://www.annals.org/cgi/content/full/142/12_Part_1/996

The birth of Medicare (many parts):
http://www.medicarerights.org/maincontenthistory.html

The system explained (many parts):
http://www.yourdoctorinthefamily.com/grandtheory/index.html

Slate has some interesting left-leaning pieces:
http://www.slate.com/id/2161736/
http://www.slate.com/id/2114554/
http://www.slate.com/id/2099036/

For the free marketeeers:
http://www.marketmed.org/fmm.asp?fmmfont=fontsml

 

[Daydreamer2008]

I just plan on telling them that the biggest problem is that I'm not a doctor yet.

Guaranteed acceptance.

LOL!

 

[futuremd1517]

so on an interview invite, would the best response to the biggest problem facing healthcare be cost because it then includes access as well? i'm still not sure how i should answer this question. i was thinking if i said cost then i could discuss prevention/treatment, the uninsured, etc...but then i wasn't sure if it was better to say the biggest problem is access and go from there. ahh! i'm nervous...my first interviews are this week and i feel unprepared in this area....

 

[baylormed]

Whoa. Do the millions of 20-and-30 somethings who are counted among the ranks of the uninsured who don't feel they need to buy even an inexpensive major medical policy policy because they can always get free care at the Emergency Department count as those suffering from lack of health care? How about the families with combined incomes over sixty grand who have better things to spend their money on than medical care? Do they count?

Do you mind telling me at which ER I can get free care ? Most of the ones I know will eventually send me a bill by mail.


And how about those "inexpensive" insurance policies that you talk about, that truly cover nothing and are thereby pretty useless?

 

[8744]

Do you mind telling me at which ER I can get free care ? Most of the ones I know will eventually send me a bill by mail.


And how about those "inexpensive" insurance policies that you talk about, that truly cover nothing and are thereby pretty useless?

Every one where I have ever worked. Do you really think that anybody ever pays the bill sent to them by the hospital? Not hardly. Most of the time it's not even worth the cost of collection.

Take a hospital like LSU. What percentage of the patients do you think either worry about or even intend to pay their bill? Practically none.

As for inexpensive insurance policies, they are called major medical or "high deductible policies" which cover nothing but, well, major medical expenses. In other words, routine and semi-routine medical care that most people can or could afford is not covered. The idea is that most people will not be bankrupted by common medical complaints but only by something catastrophic. People don't buy these because everybody expects that if they really get sick or seriously injured they will get free care through the Emergency Department. Thus, it is only suckers who pay for health inurance nowadays and EMTALA enables this kind of thinking.

See, you buy into the notion that health insurance should cover every little thing which is your major disconnect.

Many, many patients, particularly the young and otherwise healthy use the ED as primary care. I had a run of young ladies with various vaginal complaints last night, several of whom could probably have afforded paying out of pocket for a visit to an OB-Gyn or a Family Physician at least judging by the clothes, the expensive accessories, and the objective evidence of a few expensive vices. They don't because ED care is free, quick, and relatively convenient. Vaginal itching is not, by the way, a medical emergency.

You guys think that people don't have money and while it is true that most people are not rich, even most of my indigent patients have no trouble scraping together the money for expensive vices. (Smoking, drinking, gambling, etc.) It's a question of priorities. Why pay eighty bucks to see a doctor when you can see one for free in the ED where the only cost is a little bit of your otherwise worthless time? Many of my patients blow that much every month on their cell-phones. And a pack of cigarettes, as it costs close to five bucks around here, sets the typical smoker back two hundred a month, money that could be used for blood pressure medications, a little glucophage, and a few other cheap drugs to control their relatively benign health problems that will only later explode into expensive ICU visits.

I also want to point out that every poor child in the country is covered under medicaid so you can go ahead and take them out of the picture. I get plenty of medicaid mothers who are too lazy and cheap to buy even a bottle of tylenol for their babies and will bring them in to get a free bottle.

 

[Gut Shot]

Every one where I have ever worked. Do you really think that anybody ever pays the bill sent to them by the hospital? Not hardly. Most of the time it's not even worth the cost of collection.

Then you should amend you statement, limiting "free" care to only those who don't care about being pursued by collection agencies, having their credit ruined, or being pushed into bankruptcy. Hospitals have widely different policies on eating costs. Some will do nothing if the bill is less than $500, others will have men with baseball bats waiting at your house, particularly if your bill is over a few thousand dollars.

 

[midn]

so on an interview invite, would the best response to the biggest problem facing healthcare be cost because it then includes access as well? i'm still not sure how i should answer this question. i was thinking if i said cost then i could discuss prevention/treatment, the uninsured, etc...but then i wasn't sure if it was better to say the biggest problem is access and go from there. ahh! i'm nervous...my first interviews are this week and i feel unprepared in this area....

That's kind of how I answered, but I left out the access part. The interviewer went ahead and started talking about access anyways, so I think it maybe a general consensus that access is the biggest problem. I would make sure to mention it.

I would suggest that you just relax and not try to answer what you think they want to hear. Say whatever you can legitimately back up. The interviewer isn't interested in hearing you regurgitate public health policy. Chances are you'll make a mistake anyways, so best talk about something you feel passionate about.

 

[8744]

Then you should amend you statement, limiting "free" care to only those who don't care about being pursued by collection agencies, having their credit ruined, or being pushed into bankruptcy. Hospitals have widely different policies on eating costs. Some will do nothing if the bill is less than $500, others will have men with baseball bats waiting at your house, particularly if your bill is over a few thousand dollars.

It is practically impossible for hospitals to collect on unpaid bills. And it is against the law in every state to harrass debtors, even to the point that they cannot be called at work and not after a certain hour of the evening, in my state 7:00 PM.

Let's take the typical crack ***** who gets a 6000 dollar heart cath added to a 4000 dollar hospital stay. The bill, even if it got to the right person, is a work of fantasy and has no relation to what the hospital would collect even if the patient had insurance. Almost everybody understands this and the big charity centers don't even bother trying to collect or even to involve the credit bureaus. You cannot get blood from a stone and the effort to collect is rarely even worth the postage.

I spent my intern year at Duke and, for example, half of my OB patients were Spanish speaking, straight from Meso-America with their skirts still soiled by Rio Grande water and the thought that they would have to pay a dime was inconceivable.

That's the reality. I have plenty of poor, uninsured patients and not a one of them has ever left AMA for fear of the cost nor have we ever turned anyone away.

The point is that most people could afford primary care easily if they made it a priority above beer, cigarrettes, and cable TV. The big things nobody can afford but these things are generally freely available if you live in a city large enough to have a major medical center. The Emergency Department is the backdoor to free health care...but not a secret back door, rather it is the friendly, inviting backdoor that everybody uses rather than going in through the formal entrance.

 

[Gut Shot]

That's the reality.

The reality seems to be that extrapolate your anecdotal experiences, however numerous and vivid, well beyond where you should. We all do it (it has been called the availability heuristic), but it's not a good way to perform an accurate analysis.

Any study of this problem will have its limitations, but why not refer to, say, the Commonwealth Fund's biennial health insurance survey?

- One-fifth (21%) of working-age adults, both insured and uninsured, currently have medical debt they are paying off over time and more than two of five (44%) of these individuals are carrying $2,000 or more in debt.

- More than one-third (34%) of adults ages 19 to 64 either had medical bill problems in the past year or were paying off accrued medical debt. Problems include not being able to pay bills, being contacted by a collection agency about unpaid medical bills, or having to change way of life to pay bills.

- Three of five (62%) of all adults with medical bills or debt problems said they or their family member were insured at the time the debt was incurred.

- More than half (51%) of uninsured adults reported medical debt or bill problems. Of those, nearly half (49%) used up all their savings to pay their bills. Two of five were unable to pay for basic necessities like food, heat, or rent because of medical bills.

- Rates of medical bill problems and debt were high among people in both lower-income and higher-income households who experienced a time uninsured. Indeed, rates were highest among those with higher incomes. Nearly three of five (59%) adults with incomes of $40,000 or more reported difficulties with medical bills or accrued debt. Forty-six percent of adults with higher incomes were paying off unpaid medical bills over time, with over half (54%) of these individuals carrying $2,000 or more in medical debt.

 

[baylormed]

It is practically impossible for hospitals to collect on unpaid bills. And it is against the law in every state to harrass debtors, even to the point that they cannot be called at work and not after a certain hour of the evening, in my state 7:00 PM.

Let's take the typical crack ***** who gets a 6000 dollar heart cath added to a 4000 dollar hospital stay. The bill, even if it got to the right person, is a work of fantasy and has no relation to what the hospital would collect even if the patient had insurance. Almost everybody understands this and the big charity centers don't even bother trying to collect or even to involve the credit bureaus. You cannot get blood from a stone and the effort to collect is rarely even worth the postage.

I spent my intern year at Duke and, for example, half of my OB patients were Spanish speaking, straight from Meso-America with their skirts still soiled by Rio Grande water and the thought that they would have to pay a dime was inconceivable.

That's the reality. I have plenty of poor, uninsured patients and not a one of them has ever left AMA for fear of the cost nor have we ever turned anyone away.

The point is that most people could afford primary care easily if they made it a priority above beer, cigarrettes, and cable TV. The big things nobody can afford but these things are generally freely available if you live in a city large enough to have a major medical center. The Emergency Department is the backdoor to free health care...but not a secret back door, rather it is the friendly, inviting backdoor that everybody uses rather than going in through the formal entrance.

While it might hold true for some people, I think a lot of poor people would beg to disagree.

 

[Femme Fatale]

*

 

[8744]

While it might hold true for some people, I think a lot of poor people would beg to disagree.

My internist (who is my PCP) charges around $150 for my 20-minute visit (but is reimbursed 80 by my inurance oddly enough). I suppose I could probably go in twice a year (but I don't you understand because I'm a guy). This is not an obnoxioulsy large amount of money for most people to pay once or twice a year considering the other things that most people spend far more money on. People may beg to disagree but that's because primary care is a low priority item to most people, ranking well below cigarettes, booze, cable TV, video games, personal electronics, online music, personal watercraft, stamp collecting, hunting, fishing, and any number of leisure activities and luxuries upon which people, including the poor and the middle class, spend their money.

Many of my lower-middle-class uninsured redneck friends buy a new four-wheeler every few years and a hunting rifle or two not to mention all of the hunting paraphenalia, paying for these items far more than the cost of a few measly doctor's visits. Their children are covered under medicaid, you understand, freeing even more money for luxuries.

Many of my poor patients have 20-dollar a day weed habits.

This is not a difficult concept to get a hold of. If you refuse to pay for primary care because it would cut into your hunting or blunt money, by definition you value these things more than you do primary care.

 

[pittnative]

"The leading cause of personal bankruptcy in the United States is unpaid medical bills. "

From:
http://www.gladwell.com/2005/2005_08_29_a_hazard.html

Is this true?

 

[Gut Shot]

"The leading cause of personal bankruptcy in the United States is unpaid medical bills. "

From:
http://www.gladwell.com/2005/2005_08_29_a_hazard.html

Is this true?

That statement is likely based on a Harvard study that came out back in 2005, attributing about half of bankruptcies to medical bills as the major cause. You can read the news release here: "Illness and Medical Bills Cause Half of All Bankruptcies - 2 Million Americans Financially Ruined Each Year - Harvard Study Finds 2200% Increase Since 1981 - Most of Those Bankrupted by Illness Were Middle Class and Had Insurance."

The study later took some flak for some of the conditions that were characterized as medical, such as compulsive gambling. I have yet to see anyone release a revised figure, however, including the critics of the study.

 

[yaniv34]

mental health care system. i wrote about that on my stony brook secondary.

 

[Gut Shot]

This is not a difficult concept to get a hold of. If you refuse to pay for primary care because it would cut into your hunting or blunt money, by definition you value these things more than you do primary care.

Forget about your redneck friends and crack ***** patients, for a moment, and consider this. Today it was announced that health care premiums rose 6.1% this year, far outpacing inflation. The average family now costs $12,000 a year in premiums for employer-sponsored insurance, a quarter of which is covered by employers. Not surprisingly, the number of uninsured has climbed from 44.8 million in 2005 to 47 million this year.

Where do you suppose all this is heading?

 

[baylormed]

My internist (who is my PCP) charges around $150 for my 20-minute visit (but is reimbursed 80 by my inurance oddly enough). I suppose I could probably go in twice a year (but I don't you understand because I'm a guy). This is not an obnoxioulsy large amount of money for most people to pay once or twice a year considering the other things that most people spend far more money on. People may beg to disagree but that's because primary care is a low priority item to most people, ranking well below cigarettes, booze, cable TV, video games, personal electronics, online music, personal watercraft, stamp collecting, hunting, fishing, and any number of leisure activities and luxuries upon which people, including the poor and the middle class, spend their money.

Many of my lower-middle-class uninsured redneck friends buy a new four-wheeler every few years and a hunting rifle or two not to mention all of the hunting paraphenalia, paying for these items far more than the cost of a few measly doctor's visits. Their children are covered under medicaid, you understand, freeing even more money for luxuries.

Many of my poor patients have 20-dollar a day weed habits.

This is not a difficult concept to get a hold of. If you refuse to pay for primary care because it would cut into your hunting or blunt money, by definition you value these things more than you do primary care.

Well, I'm glad you know so many lower-middle class uninsured redneck people to support your example, but it doesn't mean that that is the case for everyone. If they can afford to buy a new four-wheeler every few years and hunting paraphenalia, chances are they are not really that poor.

Let me tell you why I don't think so. 5-6 years ago when my family moved here to the US, we had to start from zero. Zilch, nada. We spent all our savings on the USHS citizenship/PR applications and on the moving costs. There were no assets (again, all savings gone), no income other than my parents' jobs. Since my parents' university degrees were worth nothing here, they were pulling maybe ~12,000/year at the most.

That is what you would get on a salary of $5-6/hour for 40 hours a week for 52 weeks a year. Only my dad worked, because as you might or might not know, PR applications take a while to process, so for the first year or two my mom was unable to work (not without doing it illegally and risking her application approval, something that would be very stupid to do). There was a window of time when my dad had 3 jobs, since sometimes full-time positions were difficult to come by in our town.

12,000 year (that's ~1,000/month) minus food, rent, and bills leaves practically nothing, for a family of 4. We had one car, a small sedan (gas saver) that we had had for a few years and was paid for. We didn't live in a fancy house, and our rent was certainly on the very low end of the spectrum. I don't remember even once going out to eat to...anywhere. We didn't buy any new clothes unless it was an absolute necessity, and even then they were cheap clothes. My parents didn't have any debt, so no credit cards or loans to pay off. At the end of the month I know my parents had maybe 2 or 3 dollars on their checking account, if not negative balances. We didn't take vacations, or trips, or even any kind of outing that required money (movie theater, plays, museums, etc).

Do you really think that we could afford health insurance, or even occassional doctor visits, back then? What should we have given up? Food? Potable water? Maybe we should have lived in our car, you know, maybe renting a small house was too much of a luxury.

Is that so hard to understand? I don't care how many "poor" rednecks you know, or how many heroin addicts come through your ER, just because you see that more often it doesn't mean that all poor people are lazy bums who, if only they were more careful with their money, could afford basic health care.

This is not a difficult concept to get a hold of.

 

[pittnative]

So I just read the Moral Hazard Myth article and the harvard release on Medical Bills and Bankruptcies.

I don't know very much about any of these issues, but it seems sort of obvious that as a medical professional you would argue in favor of like a "social insurance" where the healthy may help foot the bill for the sick and keep insurance costs more even keel. Just from a morals standpoint this makes the most sense to me.

Say you're asked this question and you get into high cost, and lack of insurance leading to lack of access to healthcare. You might get into current insurance systems, and my question is whether most healthcare professionals are in favor of the social system (like Medicare) or an actuarial system (like car insurance, the sick pay more and healthy pay less)? Both seem to have benefits and limitations. To me, .When you view patients, I feel everyone is viewed in the same way. Some obviously in need of more intensive care than others, though they are all essentially equals in my eyes with the right to whatever care they would need. This is what social insurance advocates as I understand it.
.

 

[8744]

Forget about your redneck friends and crack ***** patients, for a moment, and consider this. Today it was announced that health care premiums rose 6.1% this year, far outpacing inflation. The average family now costs $12,000 a year in premiums for employer-sponsored insurance, a quarter of which is covered by employers. Not surprisingly, the number of uninsured has climbed from 44.8 million in 2005 to 47 million this year.

Where do you suppose all this is heading?

The real question is, would most people rather have the 15 grand that my familiy cost to insure when I was at Duke (according to Duke, of which I paid about a third) or the insurance. As there is no way that my family used even close to 15 grand worth of health care per year we would probably have preferred the money, paying for our health care out-of-pocket. Alas, we were not given this option, or even the option of just paying for a major medical policy and pocketing the rest.

Health insurance is expensive for two reasons. First because people expect to be covered for everything, including routine expenses, and second because a lot of your premium goes to cover people who are not even paying into the system.

Who knows where it will end? Certainly not well because there is no convincing most of the people most of the time that money spent on medical care is not wasted.

 

[8744]

Well, I'm glad you know so many lower-middle class uninsured redneck people to support your example, but it doesn't mean that that is the case for everyone. If they can afford to buy a new four-wheeler every few years and hunting paraphenalia, chances are they are not really that poor.

Let me tell you why I don't think so. 5-6 years ago when my family moved here to the US, we had to start from zero. Zilch, nada. We spent all our savings on the USHS citizenship/PR applications and on the moving costs. There were no assets (again, all savings gone), no income other than my parents' jobs. Since my parents' university degrees were worth nothing here, they were pulling maybe ~12,000/year at the most.

That is what you would get on a salary of $5-6/hour for 40 hours a week for 52 weeks a year. Only my dad worked, because as you might or might not know, PR applications take a while to process, so for the first year or two my mom was unable to work (not without doing it illegally and risking her application approval, something that would be very stupid to do). There was a window of time when my dad had 3 jobs, since sometimes full-time positions were difficult to come by in our town.

12,000 year (that's ~1,000/month) minus food, rent, and bills leaves practically nothing, for a family of 4. We had one car, a small sedan (gas saver) that we had had for a few years and was paid for. We didn't live in a fancy house, and our rent was certainly on the very low end of the spectrum. I don't remember even once going out to eat to...anywhere. We didn't buy any new clothes unless it was an absolute necessity, and even then they were cheap clothes. My parents didn't have any debt, so no credit cards or loans to pay off. At the end of the month I know my parents had maybe 2 or 3 dollars on their checking account, if not negative balances. We didn't take vacations, or trips, or even any kind of outing that required money (movie theater, plays, museums, etc).

Do you really think that we could afford health insurance, or even occassional doctor visits, back then? What should we have given up? Food? Potable water? Maybe we should have lived in our car, you know, maybe renting a small house was too much of a luxury.

Is that so hard to understand? I don't care how many "poor" rednecks you know, or how many heroin addicts come through your ER, just because you see that more often it doesn't mean that all poor people are lazy bums who, if only they were more careful with their money, could afford basic health care.

This is not a difficult concept to get a hold of.

When you were a child, if you were a US citizen you qualified for free health insurance under your state's medicaid system. If your mother got pregnant she also would qualify for medicaid while pregant and for a year after.

This is no-cost health insurance, by the way. No copay or deductible which is why there is no disincentive for the polybabydadic mothers to bring their brood in for free tylenol.

Why non-citizens should qualify for free health care in our country is another debate.

 

[cleothecat]

Pre-meds?

 

[Gut Shot]

The real question is, would most people rather have the 15 grand that my familiy cost to insure when I was at Duke (according to Duke, of which I paid about a third) or the insurance. As there is no way that my family used even close to 15 grand worth of health care per year

Yes, that's why they call it insurance. You probably won't come close to using 15 grand per year, but that could be chump change if a family member develops a chronic illness.

we would probably have preferred the money, paying for our health care out-of-pocket. Alas, we were not given this option, or even the option of just paying for a major medical policy and pocketing the rest.

Health insurance is expensive for two reasons. First because people expect to be covered for everything, including routine expenses,

Oh, come now. Health insurance is expensive for more than just two reasons. I posted these earlier, but you really should read Bodenheimer's pieces (here here and here). You've left out the glaring facts that 1.) health care is very expensive to administer, and 2.) there is insurance company overhead, which is rather high.

and second because a lot of your premium goes to cover people who are not even paying into the system.

Above you were dismissive of the uninsured problem since they can always get "free" care at Emergency Centers, but now they're jacking our premiums. It's the catch-22 of insurance. Let the market run it and you suck up the costs for other people. Make everyone pay into the system and they still bitch.

Who knows where it will end? Certainly not well because there is no convincing most of the people most of the time that money spent on medical care is not wasted.

Given the distribution of health care expenditure consumption in this country, I doubt many people feel that way. We either consume so little health care that it's not of huge concern (except the premiums), or we consume so much that we have no choice.

Here's my model for the short-term:
1. Premiums increase
2. People can't afford coverage
3. Number of uninsured rise
4. Amount of "free" care sought increases
5. Costs passed to hospital
6. Some costs passed to insurance
7. Premiums increase
8. Return to 2.

 

[DocWalken]

From the White House!

If this graph and other figures that cite rising costs in healthcare over the last few decades are accurate then how can physicians' salaries be considered by the public as a reason for the rising cost? Weren't physicians being paid a lot more back in the 60's and 70's? If the cost of healthcare keeps increasing despite physicians' salaries declining, do you think the public will see that we should look elsewhere to fix the problem of rising healthcare costs?

I think it is easy for people to have a lack of sympathy for doctors as they are stereotypically known to be filthy rich and unfriendly. However, I think that they will understand they may not get the same quality of care and may have to wait in even longer lines if they do not want to provide good incentives for people to undergo medical training.

The nation needs to look to other factors to explain these rising costs. How about 12 million people who don't pay taxes, yet get free healthcare and clog up emergency rooms, and who never even expected/ever had decent healthcare in the first place?!

Or how about lets cut spending in this wasteful war taking place in the middle east?

 

[apricotattack]

The biggest problem is access.

There are 50 million people in this country with inadequate access to healthcare. But you'll never hear about that on SDN because there are so many CHILDREN here that are concerned about making as much money as possible. I love reading the stuff about socialized medicine, etc. Nobody is talking about what is best for patients. Its frightening.

Amen

 

[Beau Geste]

biggest problem? pre-meds

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