Repeal of the ACA, HCAHPS, Press-ganey, reimbursements.. etc

Discussion in 'Emergency Medicine' started by throckmortonDO, Jan 15, 2017.

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  1. throckmortonDO

    throckmortonDO 2+ Year Member

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    Now that we have seen the initial repealment steps of the ACA, what does this mean for HCAHPS, press ganey/patient satisfation, and similar related issues from an EM standpoint, and what predictions do you have going forward for EM reimbursement/value based reimbursment, MACRA, bundled payments, the continued trend of corporate consolidations etc?
     
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  3. chessknt87

    chessknt87 ASA Member 7+ Year Member

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    Nobody has any idea because ths Republicans don't even have a hypothesis of what they want to replace it with before they tear it down. We know that an orthopedic surgeon married to an anesthesiologist who has never had to e/m code in his life will be at the forefront of that effort though.
     
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  4. NinerNiner999

    NinerNiner999 Senior Member 10+ Year Member

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    Maybe we should tell him we need to be paid more in his plan, or we will call for every tiny sprain and every "difficult" airway...

    None of this matters to us in the big picture financially unless CMS begins to negatively change the RVU rate for our speciality or anchors private insurers to the medicaid reimbursement rate, which really can't happen due to antitrust issues and fair trade. Heck, if they repeal the quality portion of reimbursement and remove some of the PQRS holdbacks, we could actually do quite well...
     
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  5. canigetawhatwhat

    canigetawhatwhat

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    Dont understand why we would call a less qualified physician for a difficult away....;)
     
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  6. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    So you're saying that we'll move away from procedure-based reimbursements?
     
  7. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    Zero impact on our business. HCAP, Press-Ganey etc won't be affected by ACA repeal. On the good side we will finally be able to purchase good health insurance again.
     
  8. turkeyjerky

    turkeyjerky 7+ Year Member

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    As long as you don't have a preexisting condition...
     
  9. Psai

    Psai Account on Hold 2+ Year Member

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    Hahaha they're going to repeal aca but leave hcap and press-ganey? There's no point to repeal for doctors then.
     
  10. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    Well there is. Theoretically it would remove some small payroll tax increases. Also if you are paid 1099 and buy your own insurance, the ACA coverage plans are vastly inferior to what we used to get on the individual market.
     
  11. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    .
     
    Last edited: Jan 15, 2017
  12. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    I agree with this point. There is no reason to expect that any repeal will get rid of satisfaction measures.
     
    Last edited: Jan 15, 2017
  13. throckmortonDO

    throckmortonDO 2+ Year Member

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    I think hospitals and healthcare systems are entrenched with the notion of 'customer satisfaction' unfortunately, and it is likely that this won't go away with the repeal, but on the other hand, I wonder if some of it would, seeing as it essentially originated with the ACA. maybe things will go back to FFS model?
     
  14. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    Pretty sure I was hearing about PG long before the ACA. But please correct me if I'm wrong.
     
  15. throckmortonDO

    throckmortonDO 2+ Year Member

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    I should have phrased that better, 'wasn't linked to reimbursement prior to the ACA' would have probably been more appropriate. HCAHPS began implementation in 2006, but the ties with PQRS and Value based reimbursement came later. The patient satisfaction requirements date back to Oct. 2012 (the start of federal fiscal year 2013) when, under the Affordable Care Act, 1 percent of total hospital Medicare reimbursement was cut. But hospitals could get pay restored if they had high patient satisfaction scores, meeting certain "care standards". It was a trend but not a requirement for reimbursement prior to the ACA.

    https://www.acep.org/patientsatisfaction/
    http://healthjournalism.org/blog/2015/05/the-aca-and-patient-satisfaction-does-it-improve-care/
     
  16. chessknt87

    chessknt87 ASA Member 7+ Year Member

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    Oh wait some details: https://www.washingtonpost.com/poli...3375f271c9c_story.html?utm_term=.d86382686de0

    So this is great news since nobody will be uninsured and they'll have great coverage that is easy to collect and our taxes will be lower! He figured this out in just a few weeks even though he hasn't figured out grammar on Twitter.

    We have a demented delusional septuagenarian taking control of our nuclear arsenal on Friday, we're so ****ed.
     
  17. sum dude

    sum dude MD 7+ Year Member

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    Everyone is confusing the ACA with MACRA. The ACA led to MACRA, which replaced the SGR, but it is not going away. MACRA brings with it quality measures, MIPS, PG, etc. repealing the ACA will effect the insurances from the patients we see, and reimbursement, but not the pain in the arse measures that we have to do more and more of (since MACRA was a bi-partisan passed measure that will not be repealed any time soon)

    http://www.healthcareitnews.com/new...savings-and-cms-cmmi-more-complicated-experts
     
  18. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    I prefer #MAGA to MACRA
     
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  19. VA Hopeful Dr

    VA Hopeful Dr Senior Member 10+ Year Member

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    Actually Price has a plan for that. Haven't seen details of Paul Ryan's plan but he claims there is something in there about that too.
     
  20. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner SDN Moderator 10+ Year Member

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    So there's this awesome conference in DC every year called the ACEP LAC. It's where you get to learn about all of these things, and spend the nights destroying your liver in Adams Morgan.
    But yeah, if you've got concerns, this is the best way to get face time with the staffers of your representatives. Or, if you're an assclown like me, and "accidentally" ride the senator's elevator, you can stand right next to your senator. Who is decidedly not pleased to say hi to his constituents in the metal box on the way to the underground subway.
     
  21. turkeyjerky

    turkeyjerky 7+ Year Member

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    Hmm...we'll see. My guess is that the "Plan" is state administered high risk pools, which in all likelihood will end up being both prohibitively epensive to join as well as extremely restrictive. (As an aside, I love it that just saying that they have a plan is considered an acceptable retort. I mean, FEMA had a plan for Katrina too)

    Repeal of the ACA, for me, will result is far less job mobility, a lower salary, and no change to the pounding headache I have by the end of every shift.
     
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  22. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    Insurance is not something that should cover "pre-existing conditions" as it is no longer insurance. When you cover an event that has already happened, you are essentially paying the cost of that event. Does that suck for those people? Yes it does. Is there any way to give them free healthcare that won't cost trillions? No.

    My suggestion is that we separate the uninsurable from the market altogether. We do that by making healthcare spending 100% tax deductible on a sliding scale for means. At that point individual states should develop plans based upon their own populations of how they want to deal with it. We need to put limits though on what kind of care is provided. I'm all in favor of rationing if the public purse is paying.

    If we stopped providing futile care for old people, we could probably pay for the care of everyone in the country if we wanted to go the socialist route. The 85 year-old demented bedbound patient with recent PEG tube, on Xarelto with GI bleeding I saw last night is going to now consume $1 million in care for the remainder of his short life. All because his son said "do everything". Blood transfusion? Sure do it! Central line, pressors? Why not! Critical care transport to hospital with GI capabilities? Save my Dad! Until Americans develop realistic expectations about end-of-life care, and doctors are allowed to veto unlimited care for uninformed patients, we will continue down the healthcare bankruptcy hole. No Liberal, or Conservative alternatives or plans are going to slow this plummet.
     
  23. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    I agree with all of this, except for the preexisting conditions part. I will grant your point about what insurance is, but I do not think health care coverage can be treated like other parts of the free market. If you don't want to pay auto insurance, you can decide to walk, bike or take the bus. But nobody can reasonably be expected to forego treatment of their inflammatory bowel disease. When purchases stop being discretionary, the free market forces stop functioning (hence, utilities).
     
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  24. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    So who pays then?
     
  25. bravotwozero

    bravotwozero Chronically ambitious 10+ Year Member

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    We do, unless we're okay with letting people just die in the streets. Maybe that's ok with your morals, it's not with mine.


    Sent from my iPhone using Tapatalk
     
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  26. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    We all pay, but we don't pay for futile care.

    Like you said, "If we stopped providing futile care for old people, we could probably pay for the care of everyone in the country" - and, I'll add - without increasing healthcare expenditures.
     
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  27. Psai

    Psai Account on Hold 2+ Year Member

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    Feel free to back your morals up with your pocketbook, not mine.
     
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  28. bravotwozero

    bravotwozero Chronically ambitious 10+ Year Member

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    Lol troll...


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  29. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    I'm against giving people stuff for free. That being said there is a consensus in society (that I disagree with) that we should help people even if they don't participate in their own welfare. I think there is a happy medium somewhere between "letting people die" and providing unlimited free (and mostly futile) care.
     
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  30. bravotwozero

    bravotwozero Chronically ambitious 10+ Year Member

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    You do realize that people with pre existing conditions weren't 'getting stuff for free' right? They were paying, and willing to pay premiums just like everyone else?


    Sent from my iPhone using Tapatalk
     
  31. chessknt87

    chessknt87 ASA Member 7+ Year Member

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    The bigger problem is that some pre-existing conditions are associated with poor prognosis and astronomical costs of care that are ultimately absorbed by everyone else on the insurance plan since everyone pays the same premium without any adjustments for high utilization. Like cirrhosis in an unlistable alcoholic or cystic fibrosis in a failed transplant from med noncompliance. These people can easily use many times the resources of other people their age and when we grow up and realize everyone can't get everything we need to think about how to best allocate public resources.
     
  32. goodoldalky

    goodoldalky Member 10+ Year Member

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    The way we fix the outrageous spending in healthcare is really easy, but 95% of people in this country don't like the answer: stop wasting money.

    No more futile care hospital admissions and expensive procedures for a 95 year old unlikely to realize any benefit.

    Trach PEG dementia and 89 years old? No more dialysis for your ESRD.

    No more spending triple to have a brand name combination antihypertensive when the generic individual scripts are a fraction of the cost.

    No more CT scans and defensive medicine when real tort reform provides comprehensive protection.

    No more malingery psychiatric complaint for the tenth time this week seeking inpatient psychiatric placement, and tort reform protection for appropriately discharging this patient immediately.

    You did cocaine... again, and now you have chest pain, again, and an ugly ekg, like usual. No more admissions, no more troponins, here's an aspirin and the door, you're not a candidate for a stent anyway.

    Homicidal ideation? Sorry, this is a go to jail problem, not a go to hospital problem. All yours, officer.

    Commercials on television to the lay public advertising expensive placebos like Tamiflu? No more.

    I am all for providing coverage for someone's pre existing diabetes. Refusing to cover that results in paying for their non pre existing strokes and MIs later. But we should be covering insulin and metformin, not invokana and other more expensive non value add therapies.

    If you have a million dollars and you want to keep your great great grandmother chugging along with the dialysis and tube feeds, be my guest, feel free to pay cash. That'll be $20,000 M-W-F. But the collective public/taxpayer/etc should not be expected to spend money in this way.
     
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  33. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    I'm concerned that you're sneaking in value judgements ("cirrhosis in an unlistable alcoholic or cystic fibrosis in a failed transplant from med noncompliance") so that you can argue that those who can't afford care don't deserve care.
     
  34. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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  35. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    I liked your post. I also fixed it for you.
     
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  36. chessknt87

    chessknt87 ASA Member 7+ Year Member

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    Those aren't judgement those are real people I saw last week. If you want to split them in to a different class fine but right now they fall in the same category as a breast cancer or ra patient despite having drastically different prognosis.
     
  37. njac

    njac Senior Member 10+ Year Member

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    Are the benevolent overlords of the Aetna/BCBS/etc really going to improve their offerings now that they've gotten away with selling these worse plans they've had available the last few years?


    Sent from my iPhone using SDN mobile app
     
  38. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    No they are not benevolent, but there is more profit to be made by offering plans people want to buy. Right now people are forced at gunpoint to buy ****ty plans with coverage they don't want. Remove the mandate, and people won't buy those plans. In order to make money they will have to go back to offering a-la-carte individual plans that people will actually buy.
     
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  39. VA Hopeful Dr

    VA Hopeful Dr Senior Member 10+ Year Member

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    Your guess would be wrong.

    http://www.forbes.com/sites/theapot...ng-condition-exclusions-sort-of/#32f9869e68a1

    "The basic idea of Empowering Patients is to say that so long as you stay insured, insurers can't impose either pre-existing condition exclusions or raise your premiums because you have expensive medical conditions. There's no individual mandate -- the government isn't going to tax or penalize you if you don't have insurance. But under section 221 of Empowering Patients, if you haven't kept up your health insurance purchases for the requisite amount of time, an insurer is free to impose pre-existing condition exclusions for up to 18 months when you do want coverage. And it's also free to raise your premiums up to 50% for up to three years."

    Basically, his plan tries to encourage healthy people to buy insurance "If you get insurance now, you can't be discriminated against in the future" where the ACA tried to force healthy people to buy "Do it or we'll fine you".
     
  40. DoctwoB

    DoctwoB 7+ Year Member

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    This is one way to approach that problem, but it carries with it major flaws. First of all, people that don't have insurance currently get screwed, as it requires you to have coverage for a sufficient period to avoid rating or denial for pre-existing conditions. People who would also get screwed are those who lose their jobs and thus insurance and/or lack health literacy to know that they need insurance now to prevent getting denied or rated in the future. I don't know about the patient population you see, but either a majority or significant minority of my patients would lack the wherewithal to manage this system and end up without insurance or with unaffordable insurance that excludes their health conditions. While it is true that it would be their own fault in some way, I personally don't want a system that screws the people that don't understand it.

    As the article points out, there is also the hazard that a smart healthy person would buy the minimum policy that qualifies as "insurance" now to prevent issues in the future. That means that the people buying comprehensive policies will be the sick ones, and prices will skyrocket. It's the same problem as having the ACA without the individual mandate and subsidies. If you don't lower the risk pool by pushing healthier people in, the average cost goes way up. This policy would allow healthy people to essentially be outside the risk pool by having such bare bones insurance it barely qualifies.
     
  41. VA Hopeful Dr

    VA Hopeful Dr Senior Member 10+ Year Member

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    If you lose your job, you COBRA and then find an individual policy.

    As for people not understanding it - well a) its a fairly simple concept - you want to keep insurance or you run the risk of increased premiums/exclusions b) you could make it so that if someone goes off of their employer-sponsored insurance the insurance company has to offer them an individual policy immediately to prevent lapses in coverage. Beyond that, at some point people need to take responsibility for their own lives. I have no objection to putting a mechanism in place to help keep people from losing coverage and not getting new coverage but at some point you are responsible for you.

    As for healthy people buying minimum coverage - what do you think ACA bronze/silver plans are? Better to have a lot of people buying cheap plans now and not using them than few people buying expensive plans that they do use. Even the small amount of money that bare bones plans cost is better than no money coming in at all.
     
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  42. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    I shudder to think how expensive COBRA plans are now. I paid for my then-girlfriend (now wife)'s plan for awhile. It was pricey back then. Has to be even more and more now after the ACA.
     
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  43. xaelia

    xaelia neenlet 10+ Year Member

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    Sounds like a lot of folks here advocating for Death Panels.

    But – yes, there is a lot of low-yield, highly unaffordable care ... that makes for great headlines. How many times have we seen massive media backlash after a family publicized an insurance company denying coverage for some $20,000 cancer drug? America is not culturally ready to do the mature and prudent thing – evidenced by their magical thinking in so many aspects of society, even beyond healthcare.

    That said, there is another argument that says the federal government need not concern itself with these matters – which is another debate entirely.
     
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  44. alpinism

    alpinism Give Em' the Jet Fuel 5+ Year Member

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    One of the biggest differences between the US healthcare system and those of other developed countries is the insane amount of money we spend on futile end of life care. Unfortunately at my current hospital our most common MICU patient is an 85 year old severely demented nursing home resident with absolutely no meaningful quality of life.
    In most other developed countries these patients aren't allowed anywhere near a MICU and are usually allowed to die peacefully in a regular hospital bed.
     
  45. VA Hopeful Dr

    VA Hopeful Dr Senior Member 10+ Year Member

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    Right, so if we lose the ACA and Price's plan (or some variant of) comes about then prices should fall.

    Plus, COBRA is supposed to be 1-2 months max. Its not designed for long-term use.
     
  46. TrumpetDoc

    TrumpetDoc 7+ Year Member

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    And the huge amount we spend in defensive medicine. Without this holy grail non of these things can realistically happen.
    I love to hear about defensive medicine deniers. There is no one here that has not practiced it! It is really impossible to study accurately. It's also hard to "find" as any of us can document in a way that any test can look justified.
    Those who site TX for example always site health care costs and not utilization delta data.

    But despite whatever we as docs do to lower "healthcare costs" the population will continue to be more unhealthy and insurance co will still want their money. And once they are accustomed to x-amount of profits does anyone really think they will settle for any less???
     
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  47. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    The problem here is hospital CEOs. I don't order extra tests/studies to protect myself legally. I do a good H&P and chart everything. I order extra tests/studies to prevent patient complaints, which could result in my termination even if the medicine and tests ordered were appropriate.
     
  48. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    I 100% advocate for Death Panels.
     
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  49. alpinism

    alpinism Give Em' the Jet Fuel 5+ Year Member

    Joined:
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    Location:
    Chris Hani Baragwanath Academic Hospital
    Agreed.

    If there is a hell I’m going to end up there trach’d and peg’d before being restrained to a bed and examined by a never ending line of medical students.
     
    Gomertose, njac and WilcoWorld like this.
  50. bravotwozero

    bravotwozero Chronically ambitious 10+ Year Member

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    Location:
    Houston
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    Attending Physician
    Have there been any actual studies that have looked at how much is spent on 'futile' care? I don't doubt it's a high figure, but would be nice to have actual numbers ...


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  51. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    Verified
    Physician
    80% of medicare spending is during the last 30 days of a recipient's life. How much of that is "futile" is up for debate, but I'm sure it makes up a majority.
     

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