Do psychiatrists provide psychotherapy?

[fairtrade]

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Just to supply a little more information for our field, I am a prescribing psychologist and our codes are very similar to psychiatrists. The way it works is you can bill from three separate E/M codes that you use for medication management: 99213 (low complexity), 99214 [moderate complexity (most commonly used)] and 99214 (high complexity). These are element-based, not time-based. You can then add one of three time-based psychotherapy codes, 90833 (16- 37 minutes), 90838 (38 - 52 minutes) and 90836 (53 + minutes).

The New Mexico Medicaid rates are pretty low but it is the most common insurance I see. The most common combination we use is 99214 + 90832 which pays around $130. We usually see 2-3 an hour. Psychiatrists also use the same codes; however, the reimbursement rates are quite a bit higher for them.

Evaluations are not time-based: a 90792 when we discuss medication and pay $140 and a regular psychological evaluation (90791) pays $109

Here are the rates

https://www.hsd.state.nm.us/uploads/FileLinks/e7cfb008157f422597cccdc11d2034f0/CPT_Codes_24.pdf

 

[beginner2011]

Just to supply a little more information for our field, I am a prescribing psychologist and our codes are very similar to psychiatrists. The way it works is you can bill from three separate E/M codes that you use for medication management: 99213 (low complexity), 99214 [moderate complexity (most commonly used)] and 99214 (high complexity). These are element-based, not time-based. You can then add one of three time-based psychotherapy codes, 90833 (16- 37 minutes), 90838 (38 - 52 minutes) and 90836 (53 + minutes).

The New Mexico Medicaid rates are pretty low but it is the most common insurance I see. The most common combination we use is 99214 + 90832 which pays around $130. We usually see 2-3 an hour. Psychiatrists also use the same codes; however, the reimbursement rates are quite a bit higher for them.

Evaluations are not time-based: a 90792 when we discuss medication and pay $140 and a regular psychological evaluation (90791) pays $109

Just to be clear: you're doing 2 or 3 $130 sessions per hour? = $260-$390 hourly rate from Medicaid?

 

[WisNeuro]

Just to be clear: you're doing 2 or 3 $130 sessions per hour? = $260-$390 hourly rate from Medicaid?

Just remember, billing and collections are not always the same number.

 

[fairtrade]

Just to be clear: you're doing 2 or 3 $130 sessions per hour? = $260-$390 hourly rate from Medicaid?

It is around $245 if you see two an hour However, I had to complete two more years of school and pass a pretty difficult test the American Psychological Association administers, so it isn't like I just stumbled into this pay increase

 

[Sanman]

It is around $245 if you see two an hour

Now compare that to the average psychologist bills $107 for a 90834 for an hour and we do not have an E/M code to bill for paperwork.

An enterprising psychologist can make $160-$240/hr using the same method (2 to 3 90832 sessions per hour)

 

[fairtrade]

Now compare that to the average psychologist bills $107 for a 90834 for an hour and we do not have an E/M code to bill for paperwork.

An enterprising psychologist can make $160-$240/hr using the same method (2 to 3 90832 sessions per hour)

Yes, there always many paths to a better salary. I worked at the V.A. for 2 years after fellowship and did not like the glacial speed at which pay increased. I also did not like having the same job description as a social worker or counselor. I could see the writing on the wall for psychology so immediately after passing the EPPP, I started the post-doctoral master's in psychopharmacology at NMSU.

There are pros and cons to medication management. The pros are the demand for persons who can prescribe seems to be MUCH greater than those who do therapy. Additionally, the no-show rate is almost zero for patient receiving medication management. The cons are I do miss doing psychotherapy as, in a lot of ways, it is more rewarding that medication management. Also, medication management is much more draining than conducting therapy as there are a lot more variables to juggle in your mind when you are dealing with medical variables.

However, doing the extra heavy lifting to obtain my prescriptive authority was the best move I ever made. At least in this area of the country, there is a much higher demand for my services, my pay increased 4 x more than it did when I was a GS-13 at the V.A., and, although I may have been cynical about the future of clinical psychology (and still am), I feel like I have a much greater degree of job security

 

[Sanman]

Yes, there always many paths to a better salary. I worked at the V.A. for 2 years after fellowship and did not like the glacial speed at which pay increased. I also did not like having the same job description as a social worker or counselor. I could see the writing on the wall for psychology so immediately after passing the EPPP, I started the post-doctoral master's in psychopharmacology at NMSU.

There are pros and cons to medication management. The pros are the demand for persons who can prescribe seems to be MUCH greater than those who do therapy. Additionally, the no-show rate is almost zero for patient receiving medication management. The cons are I do miss doing psychotherapy as, in a lot of ways, it is more rewarding that medication management. Also, medication management is much more draining than conducting therapy as there are a lot more variables to juggle in your mind when you are dealing with medical variables.

However, doing the extra heavy lifting to obtain my prescriptive authority was the best move I ever made. At least in this area of the country, there is a much higher demand for my services, my pay increased 4 x more than it did when I was a GS-13 at the V.A., and, although I may have been cynical about the future of clinical psychology (and still am), I feel like I have a much greater degree of job security

GS-13 looks like around 100k in NM. 4x pay increase? I would have assumed 2-3x.

 

[deleted343839]

There’s got to be more than that, though. I’ve retained APA membership for several years, but haven’t been much involved at all. Aren’t there workgroups or something more focused?

In the recent past APA has advocated for psychologists to be added to the group of providers who can bill E&M (which includes chiropractors, podiatrists, etc.). This proposal showed up in several bills introduced to Congress in the 2010s. If APA was on your radar during the past 10 years, you might have seen emails asking for calls to your legislators to support those bills. To the best of my recollection the legislation was stuck in committee and never reached the House floor before the end of session. Also, APA lost a key congressional ally, Tim Murphy (a psychologist), for reasons that you are welcome to Google.

I predict that this issue will circle back around, though I don't know whether there is any pending legislation or a dedicated workgroup. It's on the radar but not on top of the advocacy agenda at the moment given everything else going on right now.

 

[fairtrade]

GS-13 looks like around 100k in NM. 4x pay increase? I would have assumed 2-3x.

I also run a testing lab, do medical cannabis evaluations to make extra

 

[Sanman]

In the recent past APA has advocated for psychologists to be added to the group of providers who can bill E&M (which includes chiropractors, podiatrists, etc.). This proposal showed up in several bills introduced to Congress in the 2010s. If APA was on your radar during the past 10 years, you might have seen emails asking for calls to your legislators to support those bills. To the best of my recollection the legislation was stuck in committee and never reached the House floor before the end of session. Also, APA lost a key congressional ally, Tim Murphy (a psychologist), for reasons that you are welcome to Google.

I predict that this issue will circle back around, though I don't know whether there is any pending legislation or a dedicated workgroup. It's on the radar but not on top of the advocacy agenda at the moment given everything else going on right now.

Lets not forget that we are slated to take a 7% cut in CMS rates in 2021 and E/M codes are being redone to drop 99201 and 99211 and make 99202/99212 the lowest level visit. They were able to keep 99205/99215 after some negotiations.

 

[Fan_of_Meehl]

Lets not forget that we are slated to take a 7% cut in CMS rates in 2021 and E/M codes are being redone to drop 99201 and 99211 and make 99202/99212 the lowest level visit. They were able to keep 99205/99215 after some negotiations.

Man...that's depressing.

 

[Sanman]

Man...that's depressing.

Yup, this is what finally changed my stance on 'Medicare for all' and why I will not vote for any candidate that is for it.

 

[tr]

Yup, this is what finally changed my stance on 'Medicare for all' and why I will not vote for any candidate that is for it.

Private insurance companies are able to reimburse better than Medicare because they can cherry-pick the young, healthy, cheap patients while Medicare shoulders all of the old, sick ones.

All the money that private insurance companies don't have to spend taking care of sick people goes right into shareholder pockets. The largest insurance companies combined made a total of $35 billion last year. Meaning they collected $35bn *more* in premiums than they paid out in health care and administrative costs. That's despite spending grotesque amounts of money on paying actuaries and claims reviewers to figure out how not to pay claims, resulting in administrative costs that are 10x that of Medicare.

Medicare for All isn't the same as Medicare for seniors. Think about what could be done with an extra $35 billion going to the actual provision of health care rather than into the pockets of the insurance companies. I don't think shaving the CPT codes would need to be a priority.

 

[beginner2011]

As a profession, we really need to start thinking bigger picture and longer-term. I think this sort of, "as long as I get mine," attitude has left psychologists vulnerable and essentially boxed into a corner in terms of fees.

 

[Sanman]

Private insurance companies are able to reimburse better than Medicare because they can cherry-pick the young, healthy, cheap patients while Medicare shoulders all of the old, sick ones.

All the money that private insurance companies don't have to spend taking care of sick people goes right into shareholder pockets. The largest insurance companies combined made a total of $35 billion last year. Meaning they collected $35bn *more* in premiums than they paid out in health care and administrative costs. That's despite spending grotesque amounts of money on paying actuaries and claims reviewers to figure out how not to pay claims, resulting in administrative costs that are 10x that of Medicare.

Medicare for All isn't the same as Medicare for seniors. Think about what could be done with an extra $35 billion going to the actual provision of health care rather than into the pockets of the insurance companies. I don't think shaving the CPT codes would need to be a priority.

Medicare has consistently cut rates for psychotherapy over the past 20 years while increasing rates for certain physician services. An extra $35 bilion would not change the people making the decisions. It also would not change the increase is mandated paperwork and push to audit providers. Why vote to box myself into a bigger corner? At least now we have the option of higher reimbursement in the form private insurance and some fee for service. If proposals showed psychologists getting a fair shake and a seat at the table in a 'Medicare for all' scenario, I would again consider it. However, as long as medicare continues to prove time and again that they do not value psychologists, I can't be for removing alternatives that can lead to a viable living.

This doesn't even get into the enormous number of jobs in this country tied to the healthcare system that would be lost with no plan for how to replace them.

 

[fairtrade]

Medicare has consistently cut rates for psychotherapy over the past 20 years while increasing rates for certain physician services. An extra $35 bilion would not change the people making the decisions. It also would not change the increase is mandated paperwork and push to audit providers. Why vote to box myself into a bigger corner? At least now we have the option of higher reimbursement in the form private insurance and some fee for service. If proposals showed psychologists getting a fair shake and a seat at the table in a 'Medicare for all' scenario, I would again consider it. However, as long as medicare continues to prove time and again that they do not value psychologists, I can't be for removing alternatives that can lead to a viable living.

This doesn't even get into the enormous number of jobs in this country tied to the healthcare system that would be lost with no plan for how to replace them.

Yes, Medicare doesn't even look at psychologists as independent providers. Government run healthcare is all about lowering costs at all expense. There is no doubt that if Medicare for all were enacted, psychology would be even more supplanted in favor of less expensive providers.

Also, look at how the V.A. is run -- why would we ever want the government to run a national healthcare system when it cannot even manage the V.A. ?Furthermore, look at how government run healthcare systems perform in other countries. Just in the UK, there were over 8 million people on wait lists at the end of September and 25 percent of cancer patients had to wait more than two months to start treatment.

Hospital waiting times at worst-ever level

Record numbers in England are on hospital waiting lists, while A&E delays highest since target introduced.

www.bbc.com

When I did my internship in Detroit and my fellowship in Seattle, I would routinely see patients from cancer coming to the hospital where I worked because they could not get care in Canada.

 

[WisNeuro]

When I did my internship in Detroit and my fellowship in Seattle, I would routinely see patients from cancer coming to the hospital where I worked because they could not get care in Canada.

We could trade anecdotes all day on the Canada thing. I lived on the border of the US and Canada for 18 years, and have several very good friends who I talk to weekly who are Canadian, not too mention one who works in healthcare as a psychologist. Exactly zero of them want US healthcare. One has a couple chronic health conditions and receives very timely care.

 

[beginner2011]

Yes, Medicare doesn't even look at psychologists as independent providers. Government run healthcare is all about lowering costs at all expense. There is no doubt that if Medicare for all were enacted, psychology would be even more supplanted in favor of less expensive providers.

Also, look at how the V.A. is run -- why would we ever want the government to run a national healthcare system when it cannot even manage the V.A. ?Furthermore, look at how government run healthcare systems perform in other countries. Just in the UK, there were over 8 million people on wait lists at the end of September and 25 percent of cancer patients had to wait more than two months to start treatment.

Hospital waiting times at worst-ever level

Record numbers in England are on hospital waiting lists, while A&E delays highest since target introduced.

www.bbc.com

When I did my internship in Detroit and my fellowship in Seattle, I would routinely see patients from cancer coming to the hospital where I worked because they could not get care in Canada.

Got any citations for your claims about wait times?

I did a cursory look and I don't see a lot of strong research on the topic. I do hear/see a lot of axe-grinding about VA service, which I believed until I actually worked in the VA and discovered the care in this system is actually pretty exceptional. For example, you can get in to our outpatient mental health clinic within two weeks of contact, we have a walk-in triage clinic, and you'll see an individual therapist in under 30 days (in most cases) following intake for specialty services. By comparison, you'd be lucky to find a therapist with an opening in the next 2 months in the community. Most psychologists don't even keep wait lists. Patients basically call around for months until they hit on someone who happens to have an opening in the future. I did intake screening for our departmental clinic as a grad student and I would frequently get horror stories about the months-long wait times in the community. It sucked.

The only data I found on relative wait times by country that wasn't anecdotal or led to a dead-end is this:

Adults in most comparable countries have quicker access to a doctor or nurse when they need care


To me, the important take away from this conversation is that we need to take responsibility for our professional reputation and rights. We're going to have to advocate for our profession in contexts where it matters, or this kind of stuff is going to continue to be the norm in 10, 20, 50 years. This mealy-mouthed attitude that it isn't fair so we're not going to try just won't cut it.

 

[fairtrade]

Got any citations for your claims about wait times?

I did a cursory look and I don't see a lot of strong research on the topic. I do hear/see a lot of axe-grinding about VA service, which I believed until I actually worked in the VA and discovered the care in this system is actually pretty exceptional. For example, you can get in to our outpatient mental health clinic within two weeks of contact, we have a walk-in triage clinic, and you'll see an individual therapist in under 30 days (in most cases) following intake for specialty services. By comparison, you'd be lucky to find a therapist with an opening in the next 2 months in the community. Most psychologists don't even keep wait lists. Patients basically call around for months until they hit on someone who happens to have an opening in the future. I did intake screening for our departmental clinic as a grad student and I would frequently get horror stories about the months-long wait times in the community. It sucked.

The only data I found on relative wait times by country that wasn't anecdotal or led to a dead-end is this:

Adults in most comparable countries have quicker access to a doctor or nurse when they need care


To me, the important take away from this conversation is that we need to take responsibility for our professional reputation and rights. We're going to have to advocate for our profession in contexts where it matters, or this kind of stuff is going to continue to be the norm in 10, 20, 50 years. This mealy-mouthed attitude that it isn't fair so we're not going to try just won't cut it.

Canada’s health-care wait times eclipsed 20 weeks in 2019; second-longest wait ever recorded

VANCOUVER, British Columbia, Dec. 10, 2019 (GLOBE NEWSWIRE) -- The median wait time for medically necessary treatment in Canada this year was 20.9 weeks,...

www.globenewswire.com

 

[clausewitz2]

Private insurance companies are able to reimburse better than Medicare because they can cherry-pick the young, healthy, cheap patients while Medicare shoulders all of the old, sick ones.

All the money that private insurance companies don't have to spend taking care of sick people goes right into shareholder pockets. The largest insurance companies combined made a total of $35 billion last year. Meaning they collected $35bn *more* in premiums than they paid out in health care and administrative costs. That's despite spending grotesque amounts of money on paying actuaries and claims reviewers to figure out how not to pay claims, resulting in administrative costs that are 10x that of Medicare.

Medicare for All isn't the same as Medicare for seniors. Think about what could be done with an extra $35 billion going to the actual provision of health care rather than into the pockets of the insurance companies. I don't think shaving the CPT codes would need to be a priority.

I am not someone interested in defending the current US healthcare system in...any way, but insurance companies achieve these big net revenues by taking a small piece of an enormous pie.

US healthcare spending last year was $3.6 trillion. this means insurance company profits are less than than one tenth of one percent of total healthcare spending. It could disappear tomorrow and barely make a dent on overall spending. Cut it up equally and it is about 116 extra dollars of healthcare spending per person per year. Not nothing, but...not going to revolutionize anything.

 

[beginner2011]

Canada’s health-care wait times eclipsed 20 weeks in 2019; second-longest wait ever recorded

VANCOUVER, British Columbia, Dec. 10, 2019 (GLOBE NEWSWIRE) -- The median wait time for medically necessary treatment in Canada this year was 20.9 weeks,...

www.globenewswire.com

"The Fraser Institute" sounds very science-y. Have you looked into it at all?

The Fraser Institute is a Canadian public policy think tank and registered charity. It has been described as politically conservative[1][2][3] and libertarian.[4][5]

https://www.cbc.ca/news/health/fraser-institute-wait-time-survey-critique-1.3867927

"The Fraser Institute methodology is — and I use the word carefully — an abomination," Lewis said, adding that there's a better way: use real data.

Not a good look. I'm gonna go ahead and say I'll need an actual source to take your claims seriously.



This is another interesting take, essentially concluding that there isn't adequate data to compare at the between-country level:

A majority of the studied countries measure waiting times and they have some type of national care guarantee. The establishment of such a guarantee suggests that healthcare availability is or has been an issue of concern. Current national waiting time statistics are of limited use for comparing health care availability among the various countries due to the differences in measurements and data collection. Different methodological issues must be taken into account when making such cross-country comparisons.

International comparisons of waiting times in health care – Limitations and prospects

Yes, Medicare doesn't even look at psychologists as independent providers. Government run healthcare is all about lowering costs at all expense. There is no doubt that if Medicare for all were enacted, psychology would be even more supplanted in favor of less expensive providers.

What makes you think the private health insurance industry isn't, "all about lowering costs at all expense?"

The reason our value to the healthcare system isn't being recognized is because our value-add isn't being represented at the table. As @PsyDr mentioned, if APA isn't at the table then no one is going to advocate for psychologists. The issue isn't that administrators want the system to be cost-efficient, the issue is that no one has adequately communicated that bringing psychologists into the system will increase cost-efficiency.

 

[WisNeuro]

Also, we have to take into account that views on healthcare and actual issues of access in the US vary quite differently on your SES. Someone with means of course can access treatment and services quickly, someone without insurance, or medicaid.....meh..not so much. So yes, the rich would probably see longer wait times, while a majority of our country would likely see greatly increased access and lower wait times in a Canada like system.

 

[Fan_of_Meehl]

Got any citations for your claims about wait times?

I did a cursory look and I don't see a lot of strong research on the topic. I do hear/see a lot of axe-grinding about VA service, which I believed until I actually worked in the VA and discovered the care in this system is actually pretty exceptional. For example, you can get in to our outpatient mental health clinic within two weeks of contact, we have a walk-in triage clinic, and you'll see an individual therapist in under 30 days (in most cases) following intake for specialty services. By comparison, you'd be lucky to find a therapist with an opening in the next 2 months in the community. Most psychologists don't even keep wait lists. Patients basically call around for months until they hit on someone who happens to have an opening in the future. I did intake screening for our departmental clinic as a grad student and I would frequently get horror stories about the months-long wait times in the community. It sucked.

The only data I found on relative wait times by country that wasn't anecdotal or led to a dead-end is this:

Adults in most comparable countries have quicker access to a doctor or nurse when they need care


To me, the important take away from this conversation is that we need to take responsibility for our professional reputation and rights. We're going to have to advocate for our profession in contexts where it matters, or this kind of stuff is going to continue to be the norm in 10, 20, 50 years. This mealy-mouthed attitude that it isn't fair so we're not going to try just won't cut it.

The VA mental health care offered (especially psychotherapy) IS indeed exceptional.

And the administration is exceptionally bad and bloated. A big part of that is having an essentially unlimited budget.

 

[deleted343839]

Also, look at how the V.A. is run -- why would we ever want the government to run a national healthcare system when it cannot even manage the V.A. ?Furthermore, look at how government run healthcare systems perform in other countries. Just in the UK, there were over 8 million people on wait lists at the end of September and 25 percent of cancer patients had to wait more than two months to start treatment.

As far as I know, no serious proposals for a US national healthcare system would have us going the way of the UK NHS. "Medicare for all" more closely approximates the Canadian system. Obamacare/ACA edges a little closer to the model in many western European health systems where private not-for-profit payers play a central role.

One peculiarity about the US is that our private payers are allowed to turn a profit on even fundamental healthcare coverage, but if you think that's incompatible with "lowering costs at all expense" then I'm not sure what to tell you. It's easier in my community (major US city) to find a psychologist who takes Medicare than one who takes Molina or Humana, and if you don't think that's about containing costs then, again, I'm at a loss.

 

[tr]

I am not someone interested in defending the current US healthcare system in...any way, but insurance companies achieve these big net revenues by taking a small piece of an enormous pie.

US healthcare spending last year was $3.6 trillion. this means insurance company profits are less than than one tenth of one percent of total healthcare spending. It could disappear tomorrow and barely make a dent on overall spending. Cut it up equally and it is about 116 extra dollars of healthcare spending per person per year. Not nothing, but...not going to revolutionize anything.

About 30% of that spending is waste, fraud, and abuse, by comparison with OECD nations. How does health spending in the U.S. compare to other countries? - Peterson-KFF Health System Tracker

This doesn't even get into the enormous number of jobs in this country tied to the healthcare system that would be lost with no plan for how to replace them.

You mean the actuaries and claims deniers? They're parasites. Let's teach them to do something useful. Pramila Jayapal's proposal included substantial funds for retraining health insurance bureaucrats to do something positive for society.

 

[clausewitz2]

About 30% of that spending is waste, fraud, and abuse, by comparison with OECD nations. How does health spending in the U.S. compare to other countries? - Peterson-KFF Health System Tracker



You mean the actuaries and claims deniers? They're parasites. Let's teach them to do something useful. Pramila Jayapal's proposal included substantial funds for retraining health insurance bureaucrats to do something positive for society.

Like I said, fully recognize that current us healthcare expenditure is unsustainable, inequitable, and in desperate need of reform. No argument here, we are on the same page.

My point is that health insurance company profits are not a big driver of this. The link you provided does not appear to mention "waste, fraud, and abuse" anywhere, and for good reason. There is not a magical pot of money of meaningful size in relation to the scope of the problem that we could easily tap without anything important being affected. This is wishful thinking.

We for sure spend more proportionally and absolutely than any other country on healthcare. Clearly something is wrong and our results are underwhelming for the price tag. Reform is desperately, urgently needed and it's going to hurt. We may legitimately decide that some services or provisions of our healthcare system are things that are unnecessary or aren't worth the cost. But we should not pretend services and wages are going to be unaffected, it is frankly mendacious.

One major country with a fee for service model is France. Gets good outcomes at reasonable expense. Average physician salary there is about 40% less than their UD counterparts. Not the only difference on the money side, mind you, but a significant one.

 

[tr]

Like I said, fully recognize that current us healthcare expenditure is unsustainable, inequitable, and in desperate need of reform. No argument here, we are on the same page.

My point is that health insurance company profits are not a big driver of this. The link you provided does not appear to mention "waste, fraud, and abuse" anywhere, and for good reason. There is not a magical pot of money of meaningful size in relation to the scope of the problem that we could easily tap without anything important being affected. This is wishful thinking.

Fine, I admit that I repurpose the 'waste, fraud, and abuse' tagline from Republican campaigns promising to 'drain the swamp.' I just think it's funny.

But we spend a lot of money that we don't need to be spending. Health insurance profit is some of it. Health insurance companies paying people to do jobs that shouldn't need to be done is part of it. Hospitals taking advantage of the gross opacity of care pricing to charge $200 for a pill of Tylenol is part of it. There's more, but a universal health insurance plan and some transparency in pricing would take care of a very large chunk of the problem.

One major country with a fee for service model is France. Gets good outcomes at reasonable expense. Average physician salary there is about 40% less than their UD counterparts. Not the only difference on the money side, mind you, but a significant one.

Their doctors may make less money but their medical school is free. Would you not take that tradeoff?

Also, from a personal perspective, the salaries of bottom feeders like psych, family medicine, and peds are not *that* far off between US and EU nations.
It's really more that the high-rolling procedural specialties can't pull in like $1M+ per year doing luxury Botox and Lasik at high volume.

 

[clausewitz2]

Fine, I admit that I repurpose the 'waste, fraud, and abuse' tagline from Republican campaigns promising to 'drain the swamp.' I just think it's funny.

But we spend a lot of money that we don't need to be spending. Health insurance profit is some of it. Health insurance companies paying people to do jobs that shouldn't need to be done is part of it. Hospitals taking advantage of the gross opacity of care pricing to charge $200 for a pill of Tylenol is part of it. There's more, but a universal health insurance plan and some transparency in pricing would take care of a very large chunk of the problem.



Their doctors may make less money but their medical school is free. Would you not take that tradeoff?

Also, from a personal perspective, the salaries of bottom feeders like psych, family medicine, and peds are not *that* far off between US and EU nations.
It's really more that the high-rolling procedural specialties can't pull in like $1M+ per year doing luxury Botox and Lasik at high volume.

What do you mean bottomfeeders psych is the new feel you can make a bijillionty dollars working 80 hours a week and I can't even keep pretending those threads don't give me a migraine.

I would love for medical school to be free and it would be a fine tradeoff over a wide range of possible salaries. But man, if you are going to try and tackle healthcare reform AND higher ed reform simultaneously...good luck, I guess, but I am not sure you are gearing up for success.

I am all about price transparency and think hospitals have a disgusting amount of monopsony power. I tend to prefer multiple insurer solutions a la the Germanophone countries but competing in the same way utility companies compete. This also seems to require a backdrop public insurer typically. We are waaaaaay off topic though so I will leave it at that.

 

[Sanman]

About 30% of that spending is waste, fraud, and abuse, by comparison with OECD nations. How does health spending in the U.S. compare to other countries? - Peterson-KFF Health System Tracker



You mean the actuaries and claims deniers? They're parasites. Let's teach them to do something useful. Pramila Jayapal's proposal included substantial funds for retraining health insurance bureaucrats to do something positive for society.

Everyone wants to look at the waste a single rich bogeyman. The truth is that most of the waste is us, the dutiful U.S. citizen. Yes actuaries and claims deniers. Also medical billers and coders, administrative assistants that handle calls to insurance companies, medical scribes (would you need them without the paperwork nightmare?), paymeny processors, all the people working in insurance and insurance adjacent jobs. The truth is that while the system needs an overhaul and is a nightmare in many ways, that waste is what we built a large part of the economy on. Streamlining healthcare also means reducing the number of jobs. Will we even need every single front-line healthcare worker if competition in hospitals ceases and you could you streamline care under a nationalized healthcare system? What happens to all the 'extra' healthcare workers with six-figure student loan debt? Retrain them with additional loans?

 

[WisNeuro]

I am all about price transparency and think hospitals have a disgusting amount of monopsony power. I tend to prefer multiple insurer solutions a la the Germanophone countries but competing in the same way utility companies compete. This also seems to require a backdrop public insurer typically. We are waaaaaay off topic though so I will leave it at that.

Yeah, you guys are risking getting this thrown into the blackhole of the political forums. We could always open a new thread, and as long as we kept the healthcare reform discussion broadly focused on mental health, it could stay here, rather than where intelligent discourse goes to die.

 

[WisNeuro]

Everyone wants to look at the waste a single rich bogeyman. The truth is that most of the waste is us, the dutiful U.S. citizen. Yes actuaries and claims deniers. Also medical billers and coders, administrative assistants that handle calls to insurance companies, medical scribes (would you need them without the paperwork nightmare?), paymeny processors, all the people working in insurance and insurance adjacent jobs. The truth is that while the system needs an overhaul and is a nightmare in many ways, that waste is what we built a large part of the economy on. Streamlining healthcare also means reducing the number of jobs. Will we even need every single front-line healthcare worker if competition in hospitals ceases and you could you streamline care under a nationalized healthcare system? What happens to all the 'extra' healthcare workers with six-figure student loan debt? Retrain them with additional loans?

If the option is a possible one-time, painful, labor intensive fix, rather than kicking the can down the road at exponentially greater cost. I'll choose the fix right now.

 

[Sanman]

Their doctors may make less money but their medical school is free. Would you not take that tradeoff?

Also, from a personal perspective, the salaries of bottom feeders like psych, family medicine, and peds are not *that* far off between US and EU nations.
It's really more that the high-rolling procedural specialties can't pull in like $1M+ per year doing luxury Botox and Lasik at high volume.

What makes you think universal healthcare and possible salary reductions will be accompanied by educational cost reforms in this country? Have you seen it introduced in any bills for universal healthcare?

 

[Sanman]

If the option is a possible one-time, painful, labor intensive fix, rather than kicking the can down the road at exponentially greater cost. I'll choose the fix right now.

I don't think it is a one-time fix, but it will cause many people to be financially further behind the 8 ball. As someone who has family working in just about every aspect of healthcare (from medical billers, to providers, medical financing, to even the evil insurance companies) it would devastate pretty much everyone I know. You are welcome to that opinion,but I am very much opposed to that kind of pain inflicted on me and my loved ones.

 

[WisNeuro]

I don't think it is a one-time fix, but it will cause many people to be financially further behind the 8 ball. As someone who has family working in just about every aspect of healthcare (from medical billers, to providers, medical financing, to even the evil insurance companies) it would devastate pretty much everyone I know. You are welcome to that opinion,but I am very much opposed to that kind of pain inflicted on me and my loved ones.

I respect that opinion, but I'll trade off short-term financial pain for some (though I believe the solution includes retraining funds) for the long term pain of inadequate healthcare for most, with the financial hardship of exorbitant, life-shattering medical costs that some face. I'd love it if some of my elderly patients didn't feel the need to ration their insulin, or to be able to get a sleep apnea evaluation that would significantly improve their QOL and reduce stroke risk, or get those hearing aids and also reduce likelihood and speed of cognitive decline. The cost of not fixing things far outweighs the cost of fixing things.

 

[Sanman]

I respect that opinion, but I'll trade off short-term financial pain for some (though I believe the solution includes retraining funds) for the long term pain of inadequate healthcare for most, with the financial hardship of exorbitant, life-shattering medical costs that some face. I'd love it if some of my elderly patients didn't feel the need to ration their insulin, or to be able to get a sleep apnea evaluation that would significantly improve their QOL and reduce stroke risk, or get those hearing aids and also reduce likelihood and speed of cognitive decline. The cost of not fixing things far outweighs the cost of fixing things.

I am curious as to how much of that will actually be fixed though. The elderly patients are already on medicare. There are reforms to medication pricing and in other areas that need to take place. I am for a public option that will afford people the right to choose and force private competition to be less greedy and more creative. Will that lead to the same outcome over a longer time period? Probably, the bleeding may just not be as severe.

 

[WisNeuro]

I am curious as to how much of that will actually be fixed though. The elderly patients are already on medicare. There are reforms to medication pricing and in other areas that need to take place. I am for a public option that will afford people the right to choose and force private competition to be less greedy and more creative. Will that lead to the same outcome over a longer time period? Probably, the bleeding may just not be as severe.

I doubt that public option is viable without a sea change of the bloated infrastructure. I'm sorry for all of the people hired into healthcare jobs that simply exist to create unnecessary roadblocks in accessing healthcare, but sometimes things change and jobs are phased out because they are unnecessary. We don't need gas lamplighters anymore, just as soon automation and irrelevance has killed many manufacturing jobs. The answer is not to pay for expensive and unnecessary workers, the answer is to have them do something else, and help make the system more efficient. Hell, give them UBI, probably still cheaper than keeping that useless bureacratic nightmare in place.

 

[cara susanna]

I just want to add that this thread is about mental healthcare, and the VA does that exceptionally well. I believe that even the people who want to privatize or shut down the VA acknowledge that.

Also, honestly, I feel like a lot of people bash the VA without acknowledging that the same problems exist--or are even worse--in private healthcare. For instance, in the community here right now it's a several month wait for a psychiatrist. Here in our clinic you can get in within a few weeks.

 

[WisNeuro]

I just want to add that this thread is about mental healthcare, and the VA does that exceptionally well. I believe that even the people who want to privatize or shut down the VA acknowledge that.

Also, honestly, I feel like a lot of people bash the VA without acknowledging that the same problems exist--or are even worse--in private healthcare. For instance, in the community here right now it's a several month wait for a psychiatrist. Here in our clinic you can get in within a few weeks.

Prior to COVID shutdowns, VA wait list for neuropsych evals in my metro? 2 weeks. Outside of the VA, my artificially low 3 month wait list was one of the shortest in the area.

 

[Fan_of_Meehl]

I just want to add that this thread is about mental healthcare, and the VA does that exceptionally well. I believe that even the people who want to privatize or shut down the VA acknowledge that.

Also, honestly, I feel like a lot of people bash the VA without acknowledging that the same problems exist--or are even worse--in private healthcare. For instance, in the community here right now it's a several month wait for a psychiatrist. Here in our clinic you can get in within a few weeks.

And where else--but the VA--do you get UNLIMITED LIFETIME FREE psychotherapy (at my VA 90% by doctoral providers) at absolutely no cost (vast majority) without any co-pay or any fees for no-shows or cancellations and --all the while--getting monthly disability payments as income for even having the MH condition in the first place?

 

[cara susanna]

And where else--but the VA--do you get UNLIMITED LIFETIME FREE psychotherapy (at my VA 90% by doctoral providers) at absolutely no cost (vast majority) without any co-pay or any fees for no-shows or cancellations and --all the while--getting monthly disability payments as income for even having the MH condition in the first place?

Seriously. I've seen people on here say that they almost want the VA to privatize so people see for themselves what private healthcare systems will and won't put up with.

 

[Sanman]

I doubt that public option is viable without a sea change of the bloated infrastructure. I'm sorry for all of the people hired into healthcare jobs that simply exist to create unnecessary roadblocks in accessing healthcare, but sometimes things change and jobs are phased out because they are unnecessary. We don't need gas lamplighters anymore, just as soon automation and irrelevance has killed many manufacturing jobs. The answer is not to pay for expensive and unnecessary workers, the answer is to have them do something else, and help make the system more efficient. Hell, give them UBI, probably still cheaper than keeping that useless bureacratic nightmare in place.

I don't want to get to far astray from the topic at hand, but the larger issue here is that most plans don't go far enough in ensuring that workers are taken care of properly in the event of such a transition. I am not saying that they need to have unnecessary jobs. However, the history of successful major governmental reforms have included comprehensive jobs programs. FDR created jobs following the great depression for just such a reason. There does not need to be an "I'm sorry" and "too bad" attitude towards workers. Not doing this will simply create a different bureaucratic nightmare.

 

[Sanman]

And where else--but the VA--do you get UNLIMITED LIFETIME FREE psychotherapy (at my VA 90% by doctoral providers) at absolutely no cost (vast majority) without any co-pay or any fees for no-shows or cancellations and --all the while--getting monthly disability payments as income for even having the MH condition in the first place?

It is good job security though.

 

[tr]

I am curious as to how much of that will actually be fixed though. The elderly patients are already on medicare. There are reforms to medication pricing and in other areas that need to take place. I am for a public option that will afford people the right to choose and force private competition to be less greedy and more creative. Will that lead to the same outcome over a longer time period? Probably, the bleeding may just not be as severe.

The public option isn't a fiscal possibility without intense regulatory checks on the private options.

If the private options are allowed to continue to cherry-pick young healthy enrollees, lemon-drop old sick ones, and charge articifially low premiums for false-front plans that don't actually cover any care, the public option, with no ability to pick and choose its enrollees, will sink under the costs. (That's the 'death spiral'.)
The 'public option' can only cover its costs if it includes the healthy people who pay more into the system than they take out of it. If it's 'optional' then it can't actually be an option.

You can try to rein in the private insurers like Obamacare did, banning the pre-existing condition exceptions, putting a ceiling on total profit, and requiring that health care insurance plans actually provide coverage for medical needs. But that requires a ton of regulatory oversight, and Trump has also rolled back a lot of those protections.

It might work. But it would be simpler and cheaper to expand something that we already have, that is working pretty well.

There does not need to be an "I'm sorry" and "too bad" attitude towards workers.

Nobody is saying that. We are saying they should be put to better use (or even, as Wisneuro said, provided with UBI). The Jayapal plan has a provision for retraining. It's not an issue that's being ignored.

What makes you think universal healthcare and possible salary reductions will be accompanied by educational cost reforms in this country? Have you seen it introduced in any bills for universal healthcare?

Bernie had a plan for free community college to start with. It was a good idea to start with. NYU was able to make their med school free just with donor money. Other med schools, faced with a new level of competition, are also finding ways to decrease the financial burden for students who can't pay. Obviously there isn't going to be total higher ed reform in one fell swoop, combined with health care reform. And it's too late for everyone who already paid their debt under the old system. But you have to start somewhere.

 

[Sanman]

The public option isn't a fiscal possibility without intense regulatory checks on the private options.

If the private options are allowed to continue to cherry-pick young healthy enrollees, lemon-drop old sick ones, and charge articifially low premiums for false-front plans that don't actually cover any care, the public option, with no ability to pick and choose its enrollees, will sink under the costs. (That's the 'death spiral'.)
The 'public option' can only cover its costs if it includes the healthy people who pay more into the system than they take out of it. If it's 'optional' then it can't actually be an option.

You can try to rein in the private insurers like Obamacare did, banning the pre-existing condition exceptions, putting a ceiling on total profit, and requiring that health care insurance plans actually provide coverage for medical needs. But that requires a ton of regulatory oversight, and Trump has also rolled back a lot of those protections.

It might work. But it would be simpler and cheaper to expand something that we already have, that is working pretty well.

While this is true, the "death spiral" expenditures can be covered in other ways. If you can't rein them in, what makes you think you can successfully get the votes to get rid of them altogether? This is a multi-billion dollar industry that will not go away without a fight.

Nobody is saying that. We are saying they should be put to better use (or even, as Wisneuro said, provided with UBI). The Jayapal plan has a provision for retraining. It's not an issue that's being ignored.

To my knowledge, the retraining provisions are nothing more than some funds and this has proven to end poorly in the past. You need a WPA for the healthcare industry where government will employ these people and retrain them into good jobs. Otherwise, the money is useless without an industry to retrain them into. We can't all be stock brokers and private equity guys. A nation full of fast food workers is just as depressing.

Bernie had a plan for free community college to start with. It was a good idea to start with. NYU was able to make their med school free just with donor money. Other med schools, faced with a new level of competition, are also finding ways to decrease the financial burden for students who can't pay. Obviously there isn't going to be total higher ed reform in one fell swoop, combined with health care reform. And it's too late for everyone who already paid their debt under the old system. But you have to start somewhere.

There should be a total higher ed reform otherwise saddling workers with huge student loans and lower pay doesn't work. Either put forth a type of all encompassing "New Deal" or patch it and move on. You can't cherry pick one area of a huge system and change it without touching the other dominoes. This is how we ended up with the student loan crisis in the first place.

 

[Sanman]

Seriously. I've seen people on here say that they almost want the VA to privatize so people see for themselves what private healthcare systems will and won't put up with.

It is not even that they will not put up with it (they won't). It is that the market will not exist. That the reason why a number of positions at the VA exist that have little to no equivalent in the private sector. How much money do you think will be spent to train trauma psychologists when the need is diffusely spread throughout communities rather than centralized in the VA system?