Socialist nightmare - "Thousands of suicidal children turned away by over-stretched NHS clinics"

[lymphocyte]

depends on the scenario(so yes there is grey).....if it's one of those babies with a 3 month survival max, then spending 3 million dollars to give them another month or two is wrong. If it's a scenario where there is evidence for an intervention with a very strong evidence base and clear outcome measures that are likely to result in a very marked difference in quality of life(decades and decades of potential high quality living), then sure...that's a different case. And that's why they are done.

In the specific case I responded to(30k wilderness camps for disturbed teens)....that's not even close to the same thing as a baby being born with TOF(in most TOF cases). The evidence base isn't the same. The outcome measures aren't the same. It's not even close.

Pardon, you do realise that contradicts what you said with such a mighty rhetorical flourish:

That is wrong. That is immoral. That is theft. Period.

?

Now you're nuancing your answer with outcome measures, cost, etc. You know who else does that? The NHS!

What about delivering a 28-weeker? You gonna let that baby die on mom's chest or try to resuscitate it with 50:50 of meaningful survival? Wait till the check clears? Okay, it survived but now has HIE, CP, chronic lung disease, and ROP. Now what? Lots of expensive interventions we might do there have a similar evidence-base to what exists in psychiatry.

What you're doing is objecting to a standard of care that almost nobody is expecting, almost nobody is asking for, and nowhere close to what we could reasonably hope to achieve and then using that example to argue against providing more equitable care. In philosophy, we call that a strawman.

---

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[MLT2MT2DO]

Yes, and these people are called I-M-B-E-C-I-L-E-S. A 'good philosophical and ethical question' is whether all of us have some right to a minimum standard of basic health care. I would say no, but that's just my opinion. Anyone who thinks all people should have access to 'all treatments regardless of expense' is likely selfish and tends to rationalize theft/stealing at their core.

I feel dirty that I somewhat agree with you, but considering this appears to be a less than popular opinion I feel I should post my agreeance.

Also, coming from a a low socioeconomic family and not being given handouts, I don't understand the entitlement I've seen.

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[vistaril]

Pardon, you do realise that contradicts what you said with such a mighty rhetorical flourish: ?

Now you're nuancing your answer with outcome measures, etc. You know who else does that? The NHS!

What about delivering a 28-weeker? You gonna let that baby die on mom's chest or try to resuscitate it with not great odds of meaningful survival? Wait till the check clears? Okay, it survived but now has HIE, CP, chronic lung disease, and ROP. Now what? Lots of expensive interventions we might do there have a similar evidence-base to what exists in psychiatry.

I don't agree with this at all. In the specific example I responded to(30k wilderness camps), I'd bet the entire decent evidence base for that whole shebang wouldn't fill up a large manilla envelope.

 

[lymphocyte]

I don't agree with this at all. In the specific example I responded to(30k wilderness camps), I'd bet the entire decent evidence base for that whole shebang wouldn't fill up a large manilla envelope.

Did you miss the part about the strawman? Or are you just specifically against wilderness camps? What a strong position.

@vistaril, taking an impassioned, cost-conscious, evidence-based stance against wilderness camps since 2016!

 

[WisNeuro]

@vistaril, taking an impassioned, cost-conscious, evidence-based stance against wilderness camps since 2016!

I heard that wilderness camps cause autism, fibromyalgia, and affinity for Nickelback.

 

[notdeadyet]

Vistaril may be Donald Trump.

Unlikely, but the syntax, rhythm, and "debate" style are remarkably similar.

 

[deleted736562]

ummm no. This is the argument of an idiot. First off to make a blanket statement like the govt is 'responsible' for all of these things is a matter of opinion. But more importantly, how you get a bull**** phrase like 'the average person suffering from health conditions' to equate to what we were talking about above is absurd.

The reality is that if superduper expensive high quality care(and yes I know cost and quality aren't always 1:1) is given to someone who doesn't have a pot to piss in, that care is only given by reaching into the wallets of others and taking their resources to pay for it. That is wrong. That is immoral. That is theft. Period.

We "reach out into the wallet of others and take their resources to pay for" public schools, for the army, to maintain the security of the community and basic amenities. Yet somehow when we use those same resources to provide for one of the most essential commodities to a life of dignity, it's "wrong", "theft" and "immoral"? Where is the difference in principle? That can be either hypocrisy, ignorance or both. I just find all those "theoretical" and "ethical" arguments on this issue truly outlandish.

 

[WisNeuro]

Vistaril may be Donald Trump.

Unlikely, but the syntax, rhythm, and "debate" style are remarkably similar.

What about "hand" size?

 

[notdeadyet]

I suspect that that hand size and the enthusiasm with which one endorses strip clubs are inversely proportional.

 

[smalltownpsych]

I don't agree with this at all. In the specific example I responded to(30k wilderness camps), I'd bet the entire decent evidence base for that whole shebang wouldn't fill up a large manilla envelope.

There is evidence to show that they are effective, but unfortunately we can't randomly assign kids to a wilderness program verses a psychiatric hospital to truly test for efficacy. If we could, I would bet on a program like Second Nature over the average psych hospital any day of the week.

 

[vistaril]

Did you miss the part about the strawman? Or are you just specifically against wilderness camps? What a strong position.

@vistaril, taking an impassioned, cost-conscious, evidence-based stance against wilderness camps since 2016!

You are the one who jumped in to a statement I made responding *directly* to a statement by another poster about wilderness camps....so STFU.

 

[smalltownpsych]

Here's an article our APA did a couple years back if anyone is interested in learning more about these programs.
http://www.apa.org/monitor/2013/09/therapy-wild.aspx

 

[vistaril]

We "reach out into the wallet of others and take their resources to pay for" public schools, for the army, to maintain the security of the community and basic amenities. Yet somehow when we use those same resources to provide for one of the most essential commodities to a life of dignity, it's "wrong", "theft" and "immoral"? Where is the difference in principle? That can be either hypocrisy, ignorance or both. I just find all those "theoretical" and "ethical" arguments on this issue truly outlandish.

are you actually this stupid? The concept behind paying for the army is to provide security for the whole country. Theoretically everyone benefits from this security.

 

[deleted736562]

are you actually this stupid? The concept behind paying for the army is to provide security for the whole country. Theoretically everyone benefits from this security.

Really? Have you ever heard of private security firms? The same thing applies to every other commodity that the government chooses to sponsor. By the same logic, everyone would also benefit from universal healthcare.

 

[WisNeuro]

are you actually this stupid? The concept behind paying for the army is to provide security for the whole country. Theoretically everyone benefits from this security.

Particularly defense contractors, and subsequently the congressman that they donate to.

 

[vistaril]

Really? Have you ever heard of private security firms? The same thing applies to every other commodity that the government chooses to sponsor. By the same logic, everyone would also benefit from universal healthcare.

Private security firms, although they have their place, can only function to fill in small gaps in specific areas here and there. A strong national defense will always be needed to provide for our security as a country, and we all benefit from it. That's unique from many of these other things you have mentioned.

 

[MLT2MT2DO]

We "reach out into the wallet of others and take their resources to pay for" public schools, for the army, to maintain the security of the community and basic amenities. Yet somehow when we use those same resources to provide for one of the most essential commodities to a life of dignity, it's "wrong", "theft" and "immoral"? Where is the difference in principle? That can be either hypocrisy, ignorance or both. I just find all those "theoretical" and "ethical" arguments on this issue truly outlandish.

I'm fine with public schools, of course once someone hits 21 they are no longer able to attend these. So how about once people of sound mind and ability hit 21 they pay for their own healthcare?

This is a crazy deep conversation that I feel both you and Vistaril are superficially throwing around shock value comments.

Please don't get me wrong, I love piling on vistaril as much as the next guy...

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[deleted736562]

Private security firms, although they have their place, can only function to fill in small gaps in specific areas here and there. A strong national defense will always be needed to provide for our security as a country, and we all benefit from it. That's unique from many of these other things you have mentioned.

The only reason private security firms don't play a larger role is because the government prevents them from doing that. There's no other reason why they wouldn't be able to secure whoever is funding them, and essentially the army, like every other state institution, gets it money by digging into the pockets of "everyone else". It's funny that you need to identify security as a "national concern" but not healthcare. That's precisely the issue here, and pretending it's "theft" for one and not for the other, is either hypocrisy, ignorance or both.

Recall that the point was that military spending is off the charts and goes much beyond basic security.

Anyways, I don't really intend to continue this back and forth, so have your fun.

 

[Shikima]

The only reason private security firms don't play a larger role is because the government prevents them from doing that. There's no other reason why they wouldn't be able to secure whoever is funding them, and essentially the army, like every other state institution, gets it money by digging into the pockets of "everyone else". It's funny that you need to identify security as a "national concern" but not healthcare. That's precisely the issue here, and pretending it's "theft" for one and not for the other, is either hypocrisy, ignorance or both.

Recall that the point was that military spending is off the charts and goes much beyond basic security.

Anyways, I don't really intend to continue this back and forth, so have your fun.

A large PMC is unsustainable from a budget standpoint.

 

[FlowRate]

The only reason private security firms don't play a larger role is because the government prevents them from doing that. There's no other reason why they wouldn't be able to secure whoever is funding them, and essentially the army, like every other state institution, gets it money by digging into the pockets of "everyone else". It's funny that you need to identify security as a "national concern" but not healthcare. That's precisely the issue here, and pretending it's "theft" for one and not for the other, is either hypocrisy, ignorance or both.

Recall that the point was that military spending is off the charts and goes much beyond basic security.

Anyways, I don't really intend to continue this back and forth, so have your fun.

Hey, at least someone recognizes private security firms as a possible alternative. Next stop, free market law.

---

We already have socialist healthcare, just like every other government-managed entitlement (housing, food, income, transportation, education). They all have the same problems--lack of true market reactivity, the general failure of central planning, layers of bureaucrats (some of them hilariously unionized!), and the special interest problem of a representative democracy.

I think that we should decide that X thing is an entitlement, the government can afford to spend Y amount on entitlement, and Z people are entitled to that entitlement, so each of those Z people get Y/Z to spend at least a portion of on X. Cut out all the bureaucrats, confusing government programs/applications, and inefficiencies.

The argument that universal healthcare would be cost saving because people wouldn't have to hire a billing department/insurance wouldn't make a profit/reduce the number of people working for insurance companies seems silly: people still need help billing medicare, the current method of FFS is largely entrenched in the government's involvement in the industry, and the government loves to grow, hire people who are difficult to fire and thus work less efficiently, and has a long history of diverting money from profitable programs into other programs.

 

[vistaril]

The only reason private security firms don't play a larger role is because the government prevents them from doing that. There's no other reason why they wouldn't be able to secure whoever is funding them, and essentially the army, like every other state institution, gets it money by digging into the pockets of "everyone else". It's funny that you need to identify security as a "national concern" but not healthcare. That's precisely the issue here, and pretending it's "theft" for one and not for the other, is either hypocrisy, ignorance or both.

Recall that the point was that military spending is off the charts and goes much beyond basic security.

Anyways, I don't really intend to continue this back and forth, so have your fun.

Me and you both have an interest in a nuclear bomb not detonating in the US.

Me and you both don't have an interest in whether or not *I* can afford/get treatment for hepC should I contract it.

The idea that you don't get that difference is alarming.

 

[FlowRate]

Me and you both have an interest in a nuclear bomb not detonating in the US.

Me and you both don't have an interest in whether or not *I* can afford/get treatment for hepC should I contract it.

The idea that you don't get that difference is alarming.

What you should be saying is that you are OK with theft by the government as long as it is used to do things that you think would be impossible without the government and which seem to serve a positive role in the lives of all citizens. Then your second assertion is that healthcare does not meet that criteria.

 

[lymphocyte]

Me and you both have an interest in a nuclear bomb not detonating in the US.

Me and you both don't have an interest in whether or not *I* can afford/get treatment for hepC should I contract it.

The idea that you don't get that difference is alarming.

You have the best words. I love your words.

EMTALA, Medicare, PACA, and SCHIP say otherwise. We're already shouldering most of the costs because we've decided, as a society, that in fact compassion is a key social interest (plus the fear that illness could happen to you and your loved ones); so with half-steps already taken toward introducing some kind of public system, why not go all the way for the sake of cost, efficiency, and reducing morbidity and mortality?

Australia has a great compromise between public and private, and I suspect it's where America will end up in 20 years, with Medicare for all plus private insurance for those who can afford it.

 

[Giovanotto]

Me and you both have an interest in a nuclear bomb not detonating in the US.

Me and you both don't have an interest in whether or not *I* can afford/get treatment for hepC should I contract it.

The idea that you don't get that difference is alarming.

Wait, what? Of course I have an interest in the bolded. Hep C is a highly transmissible infectious disease. Are you seriously a resident and think that way? Good lord, good freaking lord.

 

[Ceke2002]

compassion is a key social interest

This statement right here is one reason I find it incredibly bemusing that people who don't support systems of universal healthcare often seem to do so from the stance that those who do are just interested in dipping their hands into other people's pockets out of their own sense of entitlement. The idea that people could be willing to pay into a universal health care system out of a sense of community responsibility and compassion doesn't ever seem to occur to them.

If some special health fairy flew down tomorrow and told me I would never need to access the healthcare system, for any reason, for the remainder of my entire life, and then gave me the option of no longer paying taxes to support the universal healthcare system we have in place, my response would be immediate - of course I'm still going to pay my fair share so that others might benefit. To do otherwise, to me at least, is the equivalent of finding someone bleeding to death in the street and stepping over them without a second thought.

 

[FlowRate]

community responsibility and compassion

Except they are members of the community and feel it's not their responsibility. In fact, they may feel wronged by being forced to pay for something they don't even get to use. [Not saying that's my view, just that there's a reasonable counterpoint using the same logic.]

The other key point is that government "charity" is not charity. It's taxes. Forced giving. There's nothing charitable about it. If you want to make the argument that something is so important to the community good that everyone in the community should be logically and morally compelled to pay for that thing anyway, then why don't people do these things voluntarily? There's nothing stopping a city full of people from pooling their money to start a local universal healthcare system. If I remember correctly, I think there was a city in CO that managed to do this without government.

 

[Shikima]

If some special health fairy flew down tomorrow and told me I would never need to access the healthcare system, for any reason, for the remainder of my entire life, and then gave me the option of no longer paying taxes to support the universal healthcare system we have in place, my response would be immediate - of course I'm still going to pay my fair share so that others might benefit. To do otherwise, to me at least, is the equivalent of finding someone bleeding to death in the street and stepping over them without a second thought.

Then it begs the question - what is 'fair share'?

 

[smalltownpsych]

I pretty much support some type of universal care system as I agree that a healthier population is in the common interest and I am also compassionate. The question is still about implementation and cost. It also brings into question the concept of personal liberty. When one person is compelled to pay for others healthcare, then that person has a vested interest in controlling the others unhealthy choices.

 

[VA Hopeful Dr]

Wait, what? Of course I have an interest in the bolded. Hep C is a highly transmissible infectious disease. Are you seriously a resident and think that way? Good lord, good freaking lord.

A) Nicely done on Burnett's Law there Hoss
B) 1.8% transmission rate from hollow-bore needle is not "highly transmissible"

Carry on with the hysteria...

 

[Shikima]

A) Nicely done on Burnett's Law there Hoss
B) 1.8% transmission rate from hollow-bore needle is not "highly transmissible"

Carry on with the hysteria...

At risk of derailment, it was Brannigan's Law.

 

[MLT2MT2DO]

A) Nicely done on Burnett's Law there Hoss
B) 1.8% transmission rate from hollow-bore needle is not "highly transmissible"

Carry on with the hysteria...

But....but...Harvoni is a god given right that only man taketh away.

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[smalltownpsych]

But....but...Harvoni is a god given right that only man taketh away.

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Expensive treatment for a disease that is generally transmitted through substance abuse is a great example of the complexity of these issues and how intertwined health care and personal choices are. I have a close family member who contracted Hep C from IV drug use. They were diagnosed at about 5 years clean and sober. Since they had become a self-supporting and contributing member of society, they had insurance to pay for part of the cost of treatment and an employer willing to help with the remainder as a loan. This was when they were still doing the interferon and ribovarin combo treatment and it wasn't cheap. Almost 20 years later, they are still sober and viral load still undetectable. During the past 20 years, I have seen very few people take the course that this individual did. They are a huge advocate for personal responsibility and since they have worked so hard to get where they are to turn their life around, they have very little sympathy for those who won't.

 

[Shikima]

Expensive treatment for a disease that is generally transmitted through substance abuse is a great example of the complexity of these issues and how intertwined health care and personal choices are. I have a close family member who contracted Hep C from IV drug use. They were diagnosed at about 5 years clean and sober. Since they had become a self-supporting and contributing member of society, they had insurance to pay for part of the cost of treatment and an employer willing to help with the remainder as a loan. This was when they were still doing the interferon and ribovarin combo treatment and it wasn't cheap. Almost 20 years later, they are still sober and viral load still undetectable. During the past 20 years, I have seen very few people take the course that this individual did. They are a huge advocate for personal responsibility and since they have worked so hard to get where they are to turn their life around, they have very little sympathy for those who won't.

That's part of the equation. Far too frequently we equate sympathy with good medical care. The two ideas are intertwined so heavily that it leaves little room for anything else.

 

[Seattle Mariners Fan]

I pretty much support some type of universal care system as I agree that a healthier population is in the common interest and I am also compassionate. The question is still about implementation and cost. It also brings into question the concept of personal liberty. When one person is compelled to pay for others healthcare, then that person has a vested interest in controlling the others unhealthy choices.

European outcomes are very clearly preferable to US outcomes. They're providing universal for less than half the cost.

http://www-tc.pbs.org/prod-media/ne...h_than_what_might_be_expected_1_slideshow.jpg

I agree that the obesity epidemic in America is a cofounding factor, but single payer with forced reduced demand for frivolous services appears to be the most efficient model.

 

[VA Hopeful Dr]

At risk of derailment, it was Brannigan's Law.

What, equating an opinion you disagree with as meaning you'll be a bad doctor?

 

[smalltownpsych]

European outcomes are very clearly preferable to US outcomes. They're providing universal for less than half the cost.

http://www-tc.pbs.org/prod-media/ne...h_than_what_might_be_expected_1_slideshow.jpg

I agree that the obesity epidemic in America is a cofounding factor, but single payer with forced reduced demand for frivolous services appears to be the most efficient model.

How do we keep the people out of the ED? That seems to be a big driver of cost. Most of the people that are going there day in and day out are impoverished, uneducated, addicted, mentally ill, or some combination of all of the above and they all have some type of coverage. They just seem to like hanging out in the ED for some reason that I have yet to really figure out. No one I know does that so it is sort of a mystery to me.

 

[WisNeuro]

How do we keep the people out of the ED?

We make it so that people don't think of the ED as a replacement for primary or urgent care, and we focus on actually preventing medical problems rather than only worrying about them once they become an emergency health issue.

 

[smalltownpsych]

We make it so that people don't think of the ED as a replacement for primary or urgent care, and we focus on actually preventing medical problems rather than only worrying about them once they become an emergency health issue.

Here at our hospital they completely have that option and also do show up at the clinics regularly, but they also come to the ED all day long with pains, fever, cough, sore throat, even mosquito bite was one today. We get 100 patients a day through there and very few are actually urgent. It is sort of amazing to see when I am on call.

 

[WisNeuro]

Here at our hospital they completely have that option and also do show up at the clinics regularly, but they also come to the ED all day long with pains, fever, cough, sore throat, even mosquito bite was one today. We get 100 patients a day through there and very few are actually urgent. It is sort of amazing to see when I am on call.

Well, if some historically didn't have any insurance and only interacted with the medical system through the ED, are you surprised that they are simply doing what they have always done?

 

[smalltownpsych]

Well, if some historically didn't have any insurance and only interacted with the medical system through the ED, are you surprised that they are simply doing what they have always done?

That is one perfectly reasonable hypothesis as to why they are there, but there are definitely other factors at play. I do think we need to have a better grasp on what is going on with the "high utilizers" of medical care and why we don't come up with better ways to address it.

 

[sunlioness]

How do we keep the people out of the ED? That seems to be a big driver of cost. Most of the people that are going there day in and day out are impoverished, uneducated, addicted, mentally ill, or some combination of all of the above and they all have some type of coverage. They just seem to like hanging out in the ED for some reason that I have yet to really figure out. No one I know does that so it is sort of a mystery to me.

The turkey sandwiches are just that good.

I actually had a patient present to a local psych ED because her insurance denied Adderall. She wanted to be admitted for this. They called me.

 

[Blitz2006]

How do we keep the people out of the ED? That seems to be a big driver of cost. Most of the people that are going there day in and day out are impoverished, uneducated, addicted, mentally ill, or some combination of all of the above and they all have some type of coverage. They just seem to like hanging out in the ED for some reason that I have yet to really figure out. No one I know does that so it is sort of a mystery to me.

Simple. Increase resources/funding towards primary care. Pay family doctors more $$, therefore allowing more medical students to go into primary care.

This is how it works in the UK. Family Docs (GPs) in the UK earn very well, and can earn more than most specialists. The NHS figured out a long time ago that in the long run, its much cheaper to pay GPs to help prevent diabetes/CAD than to pay for a CABG.

I've worked here as a resident in primary care clinics. Its amazing how beyond HTN/Cholesterol/Diabetes, the primary care docs here just refer everything else to specialists, therefore skyrocketing healthcare costs.

 

[lymphocyte]

How do we keep the people out of the ED? That seems to be a big driver of cost.

The biggest drivers of cost are that we intervene more, consult more, and simply pay more. CT scans cost more per unit in the U.S. than in other developed countries. A study from Harvard Kennedy found that salaried physicians performed fewer procedures than those paid by fee-for-service (adjusting for all the appropriate covariates), and yet we're still very much entrenched in the fee-for-service model. There's no price transparency for even the most common procedures and Medicare by law is not allowed to negotiate prices with pharmaceutical companies, so competition is essentially nil.

Also, the ED has become America's de facto triage centre for social services. In Australia, it's the GP, who is free for anybody to visit.

@splik already posted one of best articles on this topic.

http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum

Simple. Increase resources/funding towards primary care. Pay family doctors more $$ [...]
I've worked here as a resident in primary care clinics. Its amazing how beyond HTN/Cholesterol/Diabetes, the primary care docs here just refer everything else to specialists, therefore skyrocketing healthcare costs.

Bingo.

That's why doctor-led ACO models like Geisinger and Kaiser--where the insurance company, the doctors, and the hospital are all in it together--produce great outcomes at high efficiency. Once you've done some healthcare consulting, you start to appreciate why ACOs are so quick to adopt e-mail consultations, phone-in advice nurses, excellent remuneration for their primary care doctors, incentives for lower Hb1Ac or BMI in risk-adjusted patient panels, etc.

 

[Blitz2006]

The biggest drivers of cost are that we intervene more, consult more, and simply pay more. CT scans cost more per unit in the U.S. than in other developed countries. A study from Harvard Kennedy found that salaried physicians performed fewer procedures than those paid by fee-for-service (adjusting for all the appropriate covariates), and yet we're still very much entrenched in the fee-for-service model. There's no price transparency for even the most common procedures and Medicare by law is not allowed to negotiate prices with pharmaceutical companies, so competition is essentially nil.

Also, the ED has become America's de facto triage centre for social services. In Australia, it's basically the GP, who is free to visit for anybody.

@splik already posted one of best articles on this topic.

http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum



Bingo.

That's why doctor-led ACO models like Geisinger and Kaiser--where the insurance company, the doctors, and the hospital are all in it together--produce great outcomes at high efficiency. Once you've done some healthcare consulting, you start to appreciate why they were so quick to adopt e-mail consultations, phone-in advice nurses, excellent remuneration for their primary care doctors, incentives for lower Hb1Ac or BMI in risk-adjusted patient panels, etc.

But remember, don't knock down fee for service.

Canada is 100% Universal Health Care (Private is ILLEGAL), but they still have fee for service, yet costs are not exorbitant like in the U.S.

The difference?

Insurance Companies!

 

[lymphocyte]

But remember, don't knock down fee for service.

Canada is 100% Universal Health Care (Private is ILLEGAL), but they still have fee for service, yet costs are not exorbitant like in the U.S.

The difference?

Insurance Companies!

It's a little more nuanced than that. Canada has fee-for-service, capitation, salary and blended systems (though, yes, about 65% of primary care remuneration comes through fee-for-service). And even the transparent and tightly regulated fee-for-service system is a topic of active debate: http://www.theglobeandmail.com/opin...ensions-not-fees-for-service/article24903968/

Canada pays less for care because it literally pays less for care. Cost per CT, blood tests, pharmaceuticals, etc. They just won't pay as much as we do in the US. Once you throw in the integration, absence of insurance paperwork, strong emphasis on primary care, less reliance on consultations... the savings really pile up.

But working in Canada is problematic. I prefer public/private systems like the UK, Australia, and Germany that preserve patient and doctor autonomy while guaranteeing a basic provision of care. If you want to skip the queue or receive "better" care, than you can pay for it.

The US tried to move toward the German model but didn't offer a public option to incentivise competition among insurance companies. The German model is one in which insurance companies play a beneficial role and also one of the only models that could gain political traction in the US (i.e. without bankrupting an entire industry and hitting the reset button on 50 years worth of provision-of-care infrastructure).

I honestly think Australia is where we'll end up, by extending Medicare for all and then requiring higher-income earners to pony up for private insurance (that competes with Medicare). Again, we've already taken half-steps in this direction with EMTALA, etc. Might as well go the whole way and save some money and lives.

 

[MLT2MT2DO]

The biggest drivers of cost are that we intervene more, consult more, and simply pay more. CT scans cost more per unit in the U.S. than in other developed countries. A study from Harvard Kennedy found that salaried physicians performed fewer procedures than those paid by fee-for-service (adjusting for all the appropriate covariates), and yet we're still very much entrenched in the fee-for-service model. There's no price transparency for even the most common procedures and Medicare by law is not allowed to negotiate prices with pharmaceutical companies, so competition is essentially nil.

Also, the ED has become America's de facto triage centre for social services. In Australia, it's the GP, who is free for anybody to visit.

@splik already posted one of best articles on this topic.

http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum



Bingo.

That's why doctor-led ACO models like Geisinger and Kaiser--where the insurance company, the doctors, and the hospital are all in it together--produce great outcomes at high efficiency. Once you've done some healthcare consulting, you start to appreciate why ACOs are so quick to adopt e-mail consultations, phone-in advice nurses, excellent remuneration for their primary care doctors, incentives for lower Hb1Ac or BMI in risk-adjusted patient panels, etc.

I don't think it's fair to point out our countries intensive workups and interventions and not mentioning our litigious society.



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[VA Hopeful Dr]

Simple. Increase resources/funding towards primary care. Pay family doctors more $$, therefore allowing more medical students to go into primary care.

This is how it works in the UK. Family Docs (GPs) in the UK earn very well, and can earn more than most specialists. The NHS figured out a long time ago that in the long run, its much cheaper to pay GPs to help prevent diabetes/CAD than to pay for a CABG.

I've worked here as a resident in primary care clinics. Its amazing how beyond HTN/Cholesterol/Diabetes, the primary care docs here just refer everything else to specialists, therefore skyrocketing healthcare costs.

I'm going to have to disagree with you on this one.

https://www.bma.org.uk/advice/employment/pay/general-practitioners-pay

Salaried GP salary range in England 2016-2017

Minimum £ Maximum £
55,965 84,453

That maximum ends up being $122,325.10 based on today's exchange rate.

I don't know a single US full-time family doctor making so little.

 

[smalltownpsych]

I don't know nuances, but would giving ER providers the authority to deny treatment for those who present at the ER for non life-threatening emergencies and who are unable to pay assist in cutting costs?

I briefly volunteered in the ER and 19/20 of the patients were there for petty/nonexistent/psychological reasons. A lot of what was left certainly could have waited until monday at 10:00.

Also, when these patients show up at the PCP without an appointment, they are sent packing. Often to the ED. Some of the PCPs are booked for two months out and they double book to makeup for the no shows. It's a messy system. That's for sure. I might like the idea of a two tiered system for the same reason that I try not to shop at Walmart. I'd rather pay more for better service. So if I need the ED (about once every 20 years or so, so far in my life), I don't have to wait. Of course, I haven't waited the other times because I was bleeding enough when I showed up.

 

[whopper]

I've worked in both systems. Each have their problems. E.g. a guy with diabetes in the US that cannot get treatment for it, this rarely happens in the UK to the point where it is hardly ever to be seen if at all.

Compare that to the US. Guy works more than a full-time job, still cannot afford health insurance and cannot see a doctor despite having diabetes.
A problem with healthcare and this is in any system is that the free-market doesn't work well in it and while it does have some benefits, those benefits aren't being exploited.
From a pure money model in the US this doesn't make sense because the guy's lack of diabetes treatment will in the long run end up costing society a heck of a lot more when he eventually gets DKA and now will be entitled to government assistance. Had he got treatment in the first place it would've been cheaper and he could've continued working and thus pay taxes.

Capitalism can be introduced into the healthcare system but it cannot be done by being entirely free-market. Healthcare is not like other services or products like hot dogs or window washing where the free market works well. It also isn't being used in a manner where it would benefit the system.

E.g. if the free market were to prevail psychiatrists would make more money and there likely would not be a shortage of them cause the money would be so good. Our pay hasn't gone up because the free-market forces are being locked up by the insurance companies.

Capitalism isn't he removal government interference and the Right and Libertarians often times misleadingly state. Capitalism is an economy based on competing forces fighting by offering the better product/service at better prices. Government IS SUPPOSED TO INTERVENE if this is not happening hence it is supposed to break up monopolies and prevent "Too Big to Fail." Adam Smith, the founder of capitalism,wrote chapters in his book The Wealth of Nations where he specifically stated it is supposed to intervene at times.

Specifically it should intervene if one business is sabotaging another business (E.g. one restaurant vandalizes another to reduce the other's business). It's supposed to regulate things that the consumer is unaware such as feces in meat, etc.

The very definition of capitalism has been lost among the masses who now believe it simply means no government interference whatsoever.

In short capitalism can work but it won't work the way the pundits are spinning it and it would only work in very limited methods. Socialism would also be needed in public health issues such as vaccination because the benefits of it are increased when everyone gets it. Neither model is perfect for healthcare. IMHO the best strategy is to specify what works best in each situation and rebuild the system from there but that ain't going to happen.

 

[MLT2MT2DO]

I've worked in both systems. Each have their problems. E.g. a guy with diabetes in the US that cannot get treatment for it, this rarely happens in the UK to the point where it is hardly ever to be seen if at all.

Compare that to the US. Guy works more than a full-time job, still cannot afford health insurance and cannot see a doctor despite having diabetes.
A problem with healthcare and this is in any system is that the free-market doesn't work well in it and while it does have some benefits, those benefits aren't being exploited.
From a pure money model in the US this doesn't make sense because the guy's lack of diabetes treatment will in the long run end up costing society a heck of a lot more when he eventually gets DKA and now will be entitled to government assistance. Had he got treatment in the first place it would've been cheaper and he could've continued working and thus pay taxes.

Capitalism can be introduced into the healthcare system but it cannot be done by being entirely free-market. Healthcare is not like other services or products like hot dogs or window washing where the free market works well. It also isn't being used in a manner where it would benefit the system.

E.g. if the free market were to prevail psychiatrists would make more money and there likely would not be a shortage of them cause the money would be so good. Our pay hasn't gone up because the free-market forces are being locked up by the insurance companies.

Capitalism isn't he removal government interference and the Right and Libertarians often times misleadingly state. Capitalism is an economy based on competing forces fighting by offering the better product/service at better prices. Government IS SUPPOSED TO INTERVENE if this is not happening hence it is supposed to break up monopolies and prevent "Too Big to Fail." Adam Smith, the founder of capitalism,wrote chapters in his book The Wealth of Nations where he specifically stated it is supposed to intervene at times.

Specifically it should intervene if one business is sabotaging another business (E.g. one restaurant vandalizes another to reduce the other's business). It's supposed to regulate things that the consumer is unaware such as feces in meat, etc.

The very definition of capitalism has been lost among the masses who now believe it simply means no government interference whatsoever.

In short capitalism can work but it won't work the way the pundits are spinning it and it would only work in very limited methods. Socialism would also be needed in public health issues such as vaccination because the benefits of it are increased when everyone gets it. Neither model is perfect for healthcare. IMHO the best strategy is to specify what works best in each situation and rebuild the system from there but that ain't going to happen.

To be fair Communism is a great idea and concept until man intervenes and redefines the original concept. There are too many confounding factors at this point in society for either socialism or communism to actually work, with most of these issues arising from the greed of man.

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