Watching Medicine Bleed by Politicians

[medlaw06]

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Hey all....ok, so I do not wanna make this into some sort of crusade (well...actually I do, but I know it won't happen) or something, but I was talking to one of the docs while on rotation, and he had no clue about all these things going on (below), which is why I am stating this in hopes that others who may not know what's going on will....

This all got started on one of the threads on this forum (something to do w/ turf wars) and it kinda rolled on from there....

BACKGROUND
so, as many of you may or may not know, the bill that was supposed to block the recent medicare physician reimbursement cuts was not able to do so, which means that as of 1/1/06, medicare reimbursement is cut by 4.4%. The thing that many physicians are not seeing (or maybe arent' concerned about) is that this is just a mere part of the whole process, which aims to cut approximately 25% of medicare reimbursement within the next 5-7 years or so. So, when all you residents, interns, graduating med students have your blinders on in terms of whats going on with your own field, realize that whatever you will get from medicare will be reduced by 1/4 in the next few years (GERIATRICS, are you listening!!)


But here is the main thrust of what I wanted to say....it is absolutely AMAZING how the politicians were able to spin this to put physicians against their patients and vice versa. I'm not a big conspiracy theory guy, but this is way too logical to not make any sense. You see, America is getting older and older as we all know. Social Security is pretty much about to topple over and drugs are getting more and more expensive...what's a dirty politician to do (and still keep his millions)....AHA!!! Let's put the patient against the doc and let them fight it out while the politicians and pharm industry can sit there behind their mahogany desks and laugh at all of us.....here's how it works

imagine if you are the person in charge of lowering drug prices for seniors(while the population of seniors sky rockets)...I NEED to get $$$ from somewhere....why not take it from the physicians....they have always been either too complacent to do anytihng, have no backbone to say anything, or too greedy to give a s**t about anything else than their own practice....so, if I can skim off the top from physicians and in turn convert that $$ to the elderly. Now, the elderly will love it since it saves them $$$. The average American already pretty much resents docs as is, since their (mis)conception is that docs sit there leeching $$$ off their patients and going home to their 1 million house driving their 745i BMW. The average idiot american will love to see docs fall as is for their jealousy towards docs, when in reality they have no idea what physicians have sacrificied to get there....

anyways....so, it is a prefect plan to take $$ from docs and move it over to the average americian while the politicians are still looting in their millions....the average american will vote in favor of it since it saves them money and docs are filthy rich anyways....on the other hand, the doc is either too weak to say anything OR if thay do fight back, then the slimy politician (usuallly an ex-lawyer like that a*****e from NC, John Edwards) will sit there and blame physicians for not caring for their patients and only their precious $$$ (while once again, not realizing what it takes to become a doc)


I think you get the picture....I may have not exactly said itr in the most politically correct fashion, but this stuff REALLY pisses me off, and my fellow so called physician "colleagues" are apparently impotent to do a damn thing about this.....


LET THE BLEEDING BEGIN!!!! (and will continue to do so UNLESS we fight back!!!)

 

[Poety]

wow, good points medlaw - personally (as the greedy little one that I will be) I'm glad I'm going into psych - hmm child psych is looking better and better

Ok, so joking aside- what do you pose physicians do? And btw John Edwards - is filthy rich - you'll notice there isn't one politician thats not absolutely loaded - so ofcourse it would behoove him to put down physicians now, he's got money anyway, what does he care?

So, I'm listening - what do you propose?

 

[GoPistons]

don't forget that congress votes to increase their own salary every year... by about 4%

 

[Clue]

The sad thing is that Republicans are supposed to be more sympathetic towards doctors and they are thy ones who are cutting medicare payments. Wonder what happens when Hillery gets in.

 

[medlaw06]

wow, good points medlaw - personally (as the greedy little one that I will be) I'm glad I'm going into psych - hmm child psych is looking better and better

Ok, so joking aside- what do you pose physicians do? And btw John Edwards - is filthy rich - you'll notice there isn't one politician thats not absolutely loaded - so ofcourse it would behoove him to put down physicians now, he's got money anyway, what does he care?

So, I'm listening - what do you propose?

Hey Poety...just PM'd you...

Anyways, interesting you bring up the proposal things. Something WAS proposed, but due to lack of physician involvement, it was shot down! The retaliatory bill to the medicare cut was the Protecting Patients Access to Physiciians Act, which people had placed messages on this forum. But I contacted Sen. Rob Andrews here in NJ (he's the hubby of Dean Camille Andrews- my law school Dean of Admissions) stated that there wasn't enough concern shown by docs in NJ. Whether or not he is telling the truth, I don't know. However, things WERE proposed and it was shot down!

My proposal is something that I have seen NEVER has worked: I propose that WE AS PHYSICIANS UNITE to fight this so called war. However, I REALLY do not (and have not) seen that happen.

Maybe unioization is a solution? Who knows. But, the truth of the matter is that we all need to unite somehow and fight back agianst RNs, PAs, CRNAs, etc.

More later....

 

[Poety]

Got the PM hon, thanks - you know, speaking on unionization - I thought I read somewhere (maybe here) that physicians CANNOT unionize - is this true? Had to do with the patients right to medical care - causes a monopoly?? anyone?

 

[docB]

Got the PM hon, thanks - you know, speaking on unionization - I thought I read somewhere (maybe here) that physicians CANNOT unionize - is this true? Had to do with the patients right to medical care - causes a monopoly?? anyone?

There are some big legal hurdles to overcome before docs could unionize. The government basically sees docs as more like corporations than workers. Workers can unionize and collectively bargain with thier labor. Corporations can not band together and set prices. That is collusion and price fixing and is illegal. It has been argued (and threatened) that the government might use RICO laws against unionized docs. Unless docs take up this might on a massive and dedicated scale it won't happen. Now that being said lets remember that by unionizing American workers destroyed almost all manufacturing in this country and lost thier jobs. Unionizing is not necessarily the best or only solution for this.

 

[Poety]

Thanks DocB that is exactly what I read before - what is RICO? I knew there was a reason why they couldn't actually do it - but I do think there can be something done to prevent all the cuts isn't there? With all those MBA's out there someone should come up with something 😛

 

[Hurricane]

Thanks DocB that is exactly what I read before - what is RICO? I knew there was a reason why they couldn't actually do it - but I do think there can be something done to prevent all the cuts isn't there? With all those MBA's out there someone should come up with something 😛

The Racketeer Influenced and Corrupt Organizations Act. It's what they use to prosecute mobsters. From watching Law & Order reruns, it seems like it applies to any sort of organized crime or conspiracy, mob related or not.

I don't know squat about the pros and cons of physcian unions, but I wonder... if we ended up with some sort of national heath care plan, then would it be legal to unionize? Since we'd all be getting paid by one entity.

 

[Orange Julius]

My proposal is something that I have seen NEVER has worked: I propose that WE AS PHYSICIANS UNITE to fight this so called war. However, I REALLY do not (and have not) seen that happen.

Maybe unioization is a solution? Who knows. But, the truth of the matter is that we all need to unite somehow and fight back agianst RNs, PAs, CRNAs, etc.

It's not so much a "unions" that we need so much as sophisticated, media-savvy, well funded lobby groups active on both state and federal levels. These have been slowly evolving over the last few years in the specialty I'm going into, to deal with issues like tort reform. Rather than re-inventing the wheel, it might be better to get involved in efforts that are already underway.


Note: the word "union" is best avoided. 😉

 

[futuredo32]

Aren't the AMA and AOA supposed to lobby for us?

 

[toofache32]

The sad thing is that Republicans are supposed to be more sympathetic towards doctors and they are thy ones who are cutting medicare payments. Wonder what happens when Hillery gets in.

You mean before or after I slit my wrists?

 

[zinjanthropus]

The Racketeer Influenced and Corrupt Organizations Act. It's what they use to prosecute mobsters. From watching Law & Order reruns, it seems like it applies to any sort of organized crime or conspiracy, mob related or not.

I don't know squat about the pros and cons of physcian unions, but I wonder... if we ended up with some sort of national heath care plan, then would it be legal to unionize? Since we'd all be getting paid by one entity.

A "national" health care plan does not exclusively or necessarily suggest a single-payer system.

 

[medlaw06]

Aren't the AMA and AOA supposed to lobby for us?

this is another thing that pisses me off.....i thought the same thing as well....i tried to get involved w/ the AOA for a legislative position, but unfotunately, the person who got the position has ties within the organization (so in some ways, we are like the "dirty politicians"). So much for my blooming political career, but in all seriousness, it is still somethimg that I wanna keep in the back of my mind....

As someone had mentioned earlies, the BEST way to change things is via lobbying. I guess in some bizarre way, this is my lobbying to you guys to get an idea of how we, as physicians, are being used by others.

The point of my original post was to possibly shed some light to people on this forum to be more aware of what is going on around you. I realize that everyone id busy taking care of their own stuff. I, too, am busy in the interview trail for residency. HOWEVER, that does not mean that I will play ostrich to what is going on around me. What happened w/ the Protecting Patients Access to Physicians Act is hopefully just a anomaly in hopes that future actions will illicit more of a response from my colleagues. The nurses, PAs, chiropractors and other mid-levels were somehow able to get more and more autonomy because they became more cohesive AS A PROFESSION. I can only hope the same from us in the future.

And keep posted on what is going on w/ the medicare cuts. While it is PROPOSED to cut by 26% in the next few years, it still doesn't mean that we can't stop it from getting any worse than the current 4.4% cut. And, there is some news (I am still vague on this as of now, but will look more in the future) that the legislature will re-visit these issues once they get back from their winter vacation....I mean...when legislative session resumes once again....wouldn't wanna disturb them while they are skiing off tax payers $$$ in Aspen with some blond bimbo on 1 side and a suit case full of lobbyist money on the other.

 

[PublicHealth]

Main Entry: cap·i·tal·ism
Pronunciation: 'ka-p&-t&l-"iz-&m, 'kap-t&l-, British also k&-'pi-t&l-
Function: noun
: an economic system characterized by private or corporate ownership of capital goods, by investments that are determined by private decision, and by prices, production, and the distribution of goods that are determined mainly by competition in a free market.

Source: http://www.m-w.com/dictionary/capitalism

 

[medlaw06]

Main Entry: cap·i·tal·ism
Pronunciation: 'ka-p&-t&l-"iz-&m, 'kap-t&l-, British also k&-'pi-t&l-
Function: noun
: an economic system characterized by private or corporate ownership of capital goods, by investments that are determined by private decision, and by prices, production, and the distribution of goods that are determined mainly by competition in a free market.

Source: http://www.m-w.com/dictionary/capitalism

main entry: LEECH
Kingdom: Dirty
Phylum: Bloodsuckers
Class: Lawyers and Politicians
Subclass: None
Function: noun
- people who are vehemenently opposed to the cause of financial independence and freedom from debt and loans pursued by physicians, due to their inherent defecits in self-confidence, lack of moral values pursuant to money laundering, smoke screening, and glutton for personal wealth while contributing little to society, AND strong feelings of jealousy and inadequacy.

Source: my own mind

Have a nice day! 🙂

 

[PublicHealth]

main entry: LEECH
Kingdom: Dirty
Phylum: Bloodsuckers
Class: Lawyers and Politicians
Subclass: None
Function: noun
- people who are vehemenently opposed to the cause of financial independence and freedom from debt and loans pursued by physicians, due to their inherent defecits in self-confidence, lack of moral values pursuant to money laundering, smoke screening, and glutton for personal wealth while contributing little to society, AND strong feelings of jealousy and inadequacy.

Source: my own mind

Have a nice day! 🙂

I was trying to be P.C.!

 

[Poety]

main entry: LEECH
Kingdom: Dirty
Phylum: Bloodsuckers
Class: Lawyers and Politicians[/B]
Subclass: None
Function: noun
- people who are vehemenently opposed to the cause of financial independence and freedom from debt and loans pursued by physicians, due to their inherent defecits in self-confidence, lack of moral values pursuant to money laundering, smoke screening, and glutton for personal wealth while contributing little to society, AND strong feelings of jealousy and inadequacy.

Source: my own mind

Have a nice day! 🙂

Ummm hon, you ARE a lawyer

 

[organicmatter]

I'd like to thank the OP for broaching this critical subject.
Very few of our colleagues in medical school and residency seem to understand the importance of getting involved in the legislative process. Many will see the light when they start to practice. But even most practicing physicians don't participate in the process.
What does this mean? Physicians will continue to lose political influence, which will leaves us out of the decision process. Bottom line: physician salaries will continue to decline and patient care will suffer.
I agree with a previous poster. There are already organizations that work hard to make our voices heard. For example, the AMA and all the state medical associations lobby on our behalf. But they need to increase physician and student membership. And the membership needs to do more.
What can you do? Contact your state medical association. Pay your dues. Most importantly, inform yourselves. Information is power.

 

[BKN]

Main Entry: cap·i·tal·ism
Pronunciation: 'ka-p&-t&l-"iz-&m, 'kap-t&l-, British also k&-'pi-t&l-
Function: noun
: an economic system characterized by private or corporate ownership of capital goods, by investments that are determined by private decision, and by prices, production, and the distribution of goods that are determined mainly by competition in a free market.

Source: http://www.m-w.com/dictionary/capitalism

Without endorsing either your or medlaw's viewpoint, I would point out that medicine in America or anywhere else is not and can never be a free market.

A free market is defined as one in which there are a large number of buyers, with complete information and under no compulsion to buy and a large number of sellers with complete information and under no compulsion to sell. Under these conditions, the cost of an item floats to the perfect price point.

Medical care never operates in a free market because the information is never perfect and the sellers always have more of the imperfect information than the buyers. Further the buyers aren't the buyers.

The market in the US is further distorted by the payment methods:

1. If you consider the buyers to be the patients, they do not see the costs since if insured they have no disincentive to spend. If uninsured, they have to go to the ED, where they spend time and no money. Further they are under compulsion to buy by conditions far more important than money.

2. If you consider the Insurers the buyers, they don't get to make many of the purchasing decisions. They are not coerced to buy, in fact they do much better if they don't, since they answer to their shareholders, not their clients. Some purchasing decisions are made by their clients (our patients). Weirdly, many of the decisions are made by the sellers (Doctors).

3. For the insured, there are many sellers, but few buyers. The largest single buyer is the taxpayer through the goverment (Mostly feds, some state and local money). Given that the system most resembles a monopsony (one buyer, many sellers).

4. Given the above, providers (hospitals and doctors through the EDs) are under compulison to sell. Not surprising that the government calls the tune, particularly when they can send you to jail when you don't meet the requirements of the medicare/medicaid agreement that the market conditions can coerce you into signing. Other insurers can only sue you.

You would think that with all that market and legal power the government could do whatever it wants, but in fact it's often loses. That's due to several things:

1. Medicine is a profession held to have special knowledge and the government is hesitant to say "This procedure is not needed or of marginal benefit". In fact when the State government of Oregon tried to prioritize care, the federal goverment (Clintion administration) caled it discrimination agianst the disabled.

2. Lobbying and participation in governmental regulation by consumer groups (AARP for one) and professional groups (AMA and AOA as well as specialty organizations).

The OPs original flame was about the Medicare rate reductions. Here's what is actually happening. This is an argument about how to split the pie between AARP, Pharmaceutical houses and MDs.

1. The Nation spends over 15% of GDP on healthcare and doesn't provide care for about 15%. This is twice as much as other developed countries who mostly cover all of their citizens. 😕 😡 A Martian coming on the scene might look at the situation and say the US public and private sector is paying for 2 healthcare systems and getting 0.75 of a system for the money.

2. Where's the money going?
a. Better pay for system working (much better for Doctors)
b. End of life care for Medicare recipients
c. Administrative costs-primarily for private healthcare plans, but also in the government's programs. Don't underestimate this one, it's huge. their army of high school grads with computers vs. ours.
d. Most of the medical research (both NIH and pharm houses) done in the world. It benefits everyone, but we pay for it.
e. Profits to investors in hospital chains, pharm houses, and other healthcare entities.
f. medications

3. The president and congress passes a law transferring the medication costs for medicare recipients from the patients (who were paying them out of their own pocket) to the taxpayers. This is basically a transfer payment to the wealthiest age group to everyone. Certainly there are plenty of poor elderly, but the combination of medicare and social security has elevated the majority of the elderly up. This was a win for the AARP, which organized medicine supports on moral gorunds.

4. It is moral and makes superficial economic sense to pay for meds (antihypertensives, antidiabetics, lipid lowering agents) to prevent expensive complications. Of course that just means you need end of life care later for something else. Overall the expense will go up.

5. Congress and the executive did not come up with a way to pay for this transfer payment.

6. The Republican congress and the president prohibited the CMS (?) from negiotiating with the pharm suppliers on price. BIG win for the Pharm lobby.

7. The government is reasonably determined not to allow the unreasonable costs of US healthcare to increase.

Organized medicine (200 lb gorilla) did try to lobby to prevent the cuts. I wrote a letter myself. But we were hampered by our own ethics and were up against the Pharm lobby and AARP (1000+ lb gorillas).

Well, that's healthcare economics 750. 😴 😴 😴 My point in going through all this is to suggest that healthcare financing is essentially inefficient and irrational in this country. All of your Econ rules are inapplicable and always will be as long as the insurers, the government and politics are involved. You can't get rid of it either. Attempts to go to a single payor system or the "Managed competition" of the Clintion plan to "rationalize" it threaten all of the players. Do away with everything? Nobody wants to go to a system in which healthcare is only available to those with $200 K in the bank.

I've got to stop doing this, it takes way too much time. 😉

 

[BKN]

So I write this 10 minute read explaining all of medicine, economics and politics and I kill the thread 😡

B U M P !

And if anyone cares, i've got a great explanation of why hospitals charge $50 for an aspirin and why anybody who pays his hospital bill is a fool. (as in and his money . . .)

 

[Miklos]

So I write this 10 minute read explaining all of medicine, economics and politics and I kill the thread 😡

B U M P !

And if anyone cares, i've got a great explanation of why hospitals charge $50 for an aspirin and why anybody who pays his hospital bill is a fool. (as in and his money . . .)

Ok, I'll take the bait (plus I'd love to hear about the fool). Great post, but I have a couple issues.

Medical care never operates in a free market because the information is never perfect and the sellers always have more of the imperfect information than the buyers. Further the buyers aren't the buyers.

Not necessarily. In the past, I would agree that was the case, however, should IT revolutionize medicine as it has done other fields, the internet may become the great leveler. While not all patients will educate themselves about their condition, many will.

1. The Nation spends over 15% of GDP on healthcare and doesn't provide care for about 15%. This is twice as much as other developed countries who mostly cover all of their citizens. 😕 😡 A Martian coming on the scene might look at the situation and say the US public and private sector is paying for 2 healthcare systems and getting 0.75 of a system for the money.

Perhaps. However, I think that the government subsidizing healthcare is at the root of the problem. I've seen socialized medical systems in a number of places, and believe me, they are far from a panacea.

My point in going through all this is to suggest that healthcare financing is essentially inefficient and irrational in this country. All of your Econ rules are inapplicable and always will be as long as the insurers, the government and politics are involved. You can't get rid of it either. Attempts to go to a single payor system or the "Managed competition" of the Clintion plan to "rationalize" it threaten all of the players.

Ditto all over the planet. IMO, it is the government getting in the way.

Do away with everything? Nobody wants to go to a system in which healthcare is only available to those with $200 K in the bank.

Why not get rid of it all? Buyers and sellers could come together like they do for other markets. Competition could spur further innovation as well as efficiency.

IMO, there are also two additional problems in healthcare financing.

1) Malpractice reform. My take -- a specialized court system must be built.
2) Healthcare has not yet truly benefited from the IT revolution.

 

[docB]

Organized medicine (200 lb gorilla) did try to lobby to prevent the cuts. I wrote a letter myself. But we were hampered by our own ethics and were up against the Pharm lobby and AARP (1000+ lb gorillas).

Is organized medicine a 200 lb gorilla? I think we often seem more like a hamster in terms of getting our agenda through. Look at national tort reform.

I've always thought that we are hampered by the fact that we haven't divided our national orginizations in to seperate groups, on that lobbies for health care policy and another that takes on physician labor issues. I don't think anyone takes the AMA seriously because they have 2 agendas. They try to argue that we are the doctors so we know whats better for patients AND they argue for stuff that benefits doctors. We are not the only industry where this is a problem. The teachers create the same perception of hipocracy and self interest. They can't keep everyone's trust when they try to push education policy at the same time they are collectively bargaining.

Look at the state of organized EM (for those of you who don't know BKN and I are both EM docs so any discussion will gravitate that way eventually). I do believe in what AAEM is doing and I really owe my career to Bob McNamerra but we are a house divided and I think that does hurt us on national issues that we need to push like overcrowding.

I've got to stop doing this, it takes way too much time. 😉

But it's so fun to be able to rant to people who haven't heard it a zillion times before. My wife has said I'll be sleeping on the couch if I bring up medical screening exams one more time. 😳

 

[Poety]

So I write this 10 minute read explaining all of medicine, economics and politics and I kill the thread 😡

B U M P !

And if anyone cares, i've got a great explanation of why hospitals charge $50 for an aspirin and why anybody who pays his hospital bill is a fool. (as in and his money . . .)

You're too funny - I didn't read that post, it hurt my head - especially after getting my 33,547 DOLLAR BILL FROM HOSPITAL for "room and board" for my daughter????? 😱 😱

 

[BKN]

Ok, I'll take the bait (plus I'd love to hear about the fool). Great post, but I have a couple issues.

Not necessarily. In the past, I would agree that was the case, however, should IT revolutionize medicine as it has done other fields, the internet may become the great leveler. While not all patients will educate themselves about their condition, many will.

Perhaps. However, I think that the government subsidizing healthcare is at the root of the problem. I've seen socialized medical systems in a number of places, and believe me, they are far from a panacea.

Ditto all over the planet. IMO, it is the government getting in the way.

Why not get rid of it all? Buyers and sellers could come together like they do for other markets. Competition could spur further innovation as well as efficiency.

IMO, there are also two additional problems in healthcare financing.

1) Malpractice reform. My take -- a specialized court system must be built.
2) Healthcare has not yet truly benefited from the IT revolution.

THREE GOOD REPLIES, NOW THAT'S WHAT I'M TALKIN' ABOUT.

This is going to take a while and several posts. I'll get to the hospital finances, charges and fools thing when I answer Poety.

Also Miklos, I still haven't figured out how to do that interlacing quotes and replies things you did. If there's an instruction set somewhere, send me a PM please.

First, I think the net already is changing the way we practice. Not much down in the county ED however. When I do run into such a savvy patient, they're still coming to me for advice and opinion. Most of such patients seem to me smart enough to know that 1)much of what is on the net is self-serving, nutty or quackery, 2) Some very good things can be found, 3) research institutions are offering just that, research, and 4) they need their own doctor to make the diagnosis and to give an educated opinion on the rest of it. Nobody's ever going to understand the issues without a medical education. Engineers build the bridges for public safety, pilots fly the airplanes for public safety, doctors. . .well you know. I'll stick to defending the unequal information thing, while agreeing that medicine is always changing and that IT is going to be felt.

As for the rest of your comments, I think that you are letting your political philosophy get in the way of your common sense. I know, I know, that was inflammatory, but that's the way I feel.

I certainly was not proposing "socialized medicine", whatever that is. I was in the USAF MC for 11 years, that's as close as you're likely to get. I thought the system inefficent and boy there's nothing worse for an EP than no cost for an ER visit. Wait a minute. . .that's how it works everywhere 😱

Look, there are many countries with a pure market healthcare system that you could practice in, but they're all in the third world. They work by allowing people with money to see a doctor and everybody else doesn't. Instead they go to a pharmacy or a "healer" or they die at age 25 (or 12 months) of preventable disease.

But once a society gets a little green in their pocket, the citizens demand a system. They demand access and they demand the government step in if they can't get it. Capitalist ideolologues to the contrary (and I'm not using that in a perjorative sense), it ain't gonna happen. The government is getting in the way because that's what the citizens want. BTW, once in a gathering of fine Air Force and Army officers, I suggested that we limit care to active duty troops, move dependent and retiree care to the private sector, and create many ready reserve hospital units for wartime. Among these guys and gals, most of whom considered themselves Republicans and free marketeers it went over rather poorly. (In fact, I'd argue that the military is the most socialist institution in our country, but that's another post).

So the government is in medical care, whether we like it or not. And frankly, we should. American doctors are famous for not understanding their own interests. They vote Republican when most of their money comes from government and the Democrats will put more into the pot. The AMA vigorously opposed medicare and medicaid up to their passage in 1965. Medicare made American medicine, doctors started to get paid for care that they had been doing for chickens or giving away. MDs got to sleep once in a while and started living past their fifties. Medical school faculty got to buy their suits somewhere better than Sears. And BTW people started living longer and better lives. It's the success of medicare and social security that's threatening the nation's finances.

Well enough rant for the moment, just remember that while all of the developed countries have problems with their many different versions of medicine, we pay the most and unlike other countries many folks can't get their antihypertensives and oral hypoglycemics. But they will get their ventilators when they have their hypertensive bleed. 😕

 

[Poety]

Wheres my response to the 33,547. room and board bill (for 5 days, and this didn't include her tests, or her physician fees, etc etc)? Which btw, I told my insurance co. today - I will NEVER complain about insurance AGAIN - if they have bills liek that to pay how do they even make money? I mean REALLY.

 

[BKN]

Wheres my response to the 33,547. room and board bill (for 5 days, and this didn't include her tests, or her physician fees, etc etc)? Which btw, I told my insurance co. today - I will NEVER complain about insurance AGAIN - if they have bills liek that to pay how do they even make money? I mean REALLY.

Short answer-they don't pay anything like that. They are making money hand over foot. The cost to charge ratio is probably about 1:5 and the insurance company probably pays about 1/4 of what your bill said and the hospital has to accept it.

The full discussion of hospital finances will take me at minimum an hour to write and I will have to do it tomorrow. Stay tuned folks.

 

[Miklos]

THREE GOOD REPLIES, NOW THAT'S WHAT I'M TALKIN' ABOUT.

This is going to take a while and several posts. I'll get to the hospital finances, charges and fools thing when I answer Poety.

Also Miklos, I still haven't figured out how to do that interlacing quotes and replies things you did. If there's an instruction set somewhere, send me a PM please.

I do it manually, by inserting ["quote"] and ["/quote"] tags without the "" (had I left them out, the program would have automatically placed a quote around the word and above.. You can also do this by using the wrap quote tags function on your editor, if you have a full function one selected. When I wish to attribute the quotes, I add =XYZ after the inital quote each time. See also http://forums.studentdoctor.net/misc.php?do=bbcode for a better explanation.

First, I think the net already is changing the way we practice. Not much down in the county ED however. When I do run into such a savvy patient, they're still coming to me for advice and opinion. Most of such patients seem to me smart enough to know that 1)much of what is on the net is self-serving, nutty or quackery, 2) Some very good things can be found, 3) research institutions are offering just that, research, and 4) they need their own doctor to make the diagnosis and to give an educated opinion on the rest of it. Nobody's ever going to understand the issues without a medical education. Engineers build the bridges for public safety, pilots fly the airplanes for public safety, doctors. . .well you know. I'll stick to defending the unequal information thing, while agreeing that medicine is always changing and that IT is going to be felt.

Fair enough. I recently read an article in the Economist's Technology Quarterly on Healthcare and IT entitled "The computer will see you now." (subscription only) but also available in PDF on his company's website for free. I would be interested in your (and others comments) on it. A program like his could easily be made available to the general public. Imagine the revolution this would create.

As for the rest of your comments, I think that you are letting your political philosophy get in the way of your common sense. I know, I know, that was inflammatory, but that's the way I feel.

I certainly was not proposing "socialized medicine", whatever that is. I was in the USAF MC for 11 years, that's as close as you're likely to get. I thought the system inefficent and boy there's nothing worse for an EP than no cost for an ER visit. Wait a minute. . .that's how it works everywhere 😱

Look, there are many countries with a pure market healthcare system that you could practice in, but they're all in the third world. They work by allowing people with money to see a doctor and everybody else doesn't. Instead they go to a pharmacy or a "healer" or they die at age 25 (or 12 months) of preventable disease.

But once a society gets a little green in their pocket, the citizens demand a system. They demand access and they demand the government step in if they can't get it. Capitalist ideolologues to the contrary (and I'm not using that in a perjorative sense), it ain't gonna happen. The government is getting in the way because that's what the citizens want. BTW, once in a gathering of fine Air Force and Army officers, I suggested that we limit care to active duty troops, move dependent and retiree care to the private sector, and create many ready reserve hospital units for wartime. Among these guys and gals, most of whom considered themselves Republicans and free marketeers it went over rather poorly. (In fact, I'd argue that the military is the most socialist institution in our country, but that's another post).

So the government is in medical care, whether we like it or not. And frankly, we should. American doctors are famous for not understanding their own interests. They vote Republican when most of their money comes from government and the Democrats will put more into the pot. The AMA vigorously opposed medicare and medicaid up to their passage in 1965. Medicare made American medicine, doctors started to get paid for care that they had been doing for chickens or giving away. MDs got to sleep once in a while and started living past their fifties. Medical school faculty got to buy their suits somewhere better than Sears. And BTW people started living longer and better lives. It's the success of medicare and social security that's threatening the nation's finances.

Well enough rant for the moment, just remember that while all of the developed countries have problems with their many different versions of medicine, we pay the most and unlike other countries many folks can't get their antihypertensives and oral hypoglycemics. But they will get their ventilators when they have their hypertensive bleed. 😕

Fair enough. But, to my knowledge, there has never been a rich country that gone back to private medicine.

 

[BKN]

I


Fair enough. But, to my knowledge, there has never been a rich country that gone back to private medicine.

Exactly

 

[BKN]

Is organized medicine a 200 lb gorilla? I think we often seem more like a hamster in terms of getting our agenda through. Look at national tort reform.

We are a 200 lb gorilla. It's all about the money. We are in the same weight class as the tort lawyers, even though they are far fewer. They contribute much more individually. We've had very good success against them in Texas, some in other states and at the national level. Overall, that war is a draw. We can beat up the nurses, the RTs, the optometrists, the psychologists and most of the rest who want to weasel into our practices on the basis of cheaper but not better. This is mostly at the state level, BTW. Interestingly, in Texas we can't make the motorcyclists put their helmets on. Those guys don't have the money, but they're willing to stuff envelopes, attend rallies, go door to door, etc. all for the chance to get a good head injury. 😱

But we'll never win alone against AARP, AHA, pharmaceutical houses, and the HMOs. WE have to either make them allies or get "the public" mad at em. We're succeeding a bit against the latter two.

I've always thought that we are hampered by the fact that we haven't divided our national orginizations in to seperate groups, on that lobbies for health care policy and another that takes on physician labor issues. I don't think anyone takes the AMA seriously because they have 2 agendas. They try to argue that we are the doctors so we know whats better for patients AND they argue for stuff that benefits doctors. We are not the only industry where this is a problem. The teachers create the same perception of hipocracy and self interest. They can't keep everyone's trust when they try to push education policy at the same time they are collectively bargaining.

Look at the state of organized EM (for those of you who don't know BKN and I are both EM docs so any discussion will gravitate that way eventually). I do believe in what AAEM is doing and I really owe my career to Bob McNamerra but we are a house divided and I think that does hurt us on national issues that we need to push like overcrowding.

I think that all organizations will try to tie their interests to the public. That's the usual and that's the way it should be. Three reasons: 1. It's harder to raise enough money if there isn't a personal interest. Sierra Club will never be able to compete with mining, lumber etc on monetary grounds, only votes will do. 2. The average politician, whose job is to broker compromises, finds genuine altruists/idealists to be rigid, irritating and confusing. 3. Separate organizations can be played against each other. You said it yourself, AAEM has some good issues but they hurt the agenda by going separately to lobby. We should be doing the politics within the profession and then going united to DC and the state houses.

But it's so fun to be able to rant to people who haven't heard it a zillion times before. My wife has said I'll be sleeping on the couch if I bring up medical screening exams one more time. 😳

Ain't it the truth! But you're missing the joys of being faculty. I've got a captive audience who have to listen to me for three whole years 😀 It is nice to have a bigger group, however. 😍

 

[Miklos]

And frankly, we should. American doctors are famous for not understanding their own interests. They vote Republican when most of their money comes from government and the Democrats will put more into the pot.

While I will agree that US doctors are the great beneficiaries of programs like Medicare, there are IMO very solid reasons for them not to vote Democratic:

• The Democratic party is really in bed with the trial lawyers (numero uno financial supporters). John Edwards is merely the best example.
• Most doctors are socially conservative. Not, extremist, mind you, but very well aware of the social factors that contribute to pathology. Whether this is due to the profession itself, medical boards (who’ll revoke licenses on just about any transgression) or the expectations of patients is debatable. The Democratic party is far from being perceived as socially conservative.
• Lastly and most importantly, even though they may be beneficiaries of government largesse, they know that the other side of the coin is increased taxation. This stings especially, as in order to become a doctor, one needs four years of university, four years of medical school and at least three years of a residency (realistically – yes, I know one can cut corners and simply do an internship). So, in those eleven years (and as we know that’s just a minimum), young doctors are earning diddly-squat doing insane hours and going into debt up to their necks. Their buddies from high school and college meanwhile are doing very comfortably. Worse, after that begins the work of building up a practice, etc.. Why in world would they want to vote for party that will inevitably tax them to death and redistribute their hard won income to people who don't make the same efforts they do?

Pardon my rant. (Please note that I'm not a big fan of the big government GOP, either.)

 

[ericdopt]

While I will agree that US doctors are the great beneficiaries of programs like Medicare, there are IMO very solid reasons for them not to vote Democratic:

• The Democratic party is really in bed with the trial lawyers (numero uno financial supporters). John Edwards is merely the best example.
• Most doctors are socially conservative. Not, extremist, mind you, but very well aware of the social factors that contribute to pathology. Whether this is due to the profession itself, medical boards (who’ll revoke licenses on just about any transgression) or the expectations of patients is debatable. The Democratic party is far from being perceived as socially conservative.
• Lastly and most importantly, even though they may be beneficiaries of government largesse, they know that the other side of the coin is increased taxation. This stings especially, as in order to become a doctor, one needs four years of university, four years of medical school and at least three years of a residency (realistically – yes, I know one can cut corners and simply do an internship). So, in those eleven years (and as we know that’s just a minimum), young doctors are earning diddly-squat doing insane hours and going into debt up to their necks. Their buddies from high school and college meanwhile are doing very comfortably. Worse, after that begins the work of building up a practice, etc.. Why in world would they want to vote for party that will inevitably tax them to death and redistribute their hard won income to people who don't make the same efforts they do?

Pardon my rant. (Please note that I'm not big fan of the big government GOP, either.)

Don't forget that we all make "millions" of dollars, or so goes contemporary wisdom. I HATE big gov, hence why I'm Repub...and yes, one of my concerns over the last few years is the increase in big gov under W. For all you who want a nationalized health care plan...Check out BKN's posts and do some time in a VA. 😱 Or a unionized hospital where many of the staff don't give a damn and know they can't get fired.

Docs started their downhill slide in the '60's when we began accepting money from the gov via Medicare/medicaid. Notice how the most competitive specialties are from patients who pay CASH for their procedures. (not all, of course..see Rads). EG: Derm (botox anyone?-no I'm not denigrating this great field), Ophto (LASIX), Plastics (size 38DDD please). Again, I am NOT against any of the above, in fact quite the opposite. More power to those providers.

 

[BKN]

While I will agree that US doctors are the great beneficiaries of programs like Medicare, there are IMO very solid reasons for them not to vote Democratic:

• The Democratic party is really in bed with the trial lawyers (numero uno financial supporters). John Edwards is merely the best example.
• Most doctors are socially conservative. Not, extremist, mind you, but very well aware of the social factors that contribute to pathology. Whether this is due to the profession itself, medical boards (who’ll revoke licenses on just about any transgression) or the expectations of patients is debatable. The Democratic party is far from being perceived as socially conservative.
• Lastly and most importantly, even though they may be beneficiaries of government largesse, they know that the other side of the coin is increased taxation. This stings especially, as in order to become a doctor, one needs four years of university, four years of medical school and at least three years of a residency (realistically – yes, I know one can cut corners and simply do an internship). So, in those eleven years (and as we know that’s just a minimum), young doctors are earning diddly-squat doing insane hours and going into debt up to their necks. Their buddies from high school and college meanwhile are doing very comfortably. Worse, after that begins the work of building up a practice, etc.. Why in world would they want to vote for party that will inevitably tax them to death and redistribute their hard won income to people who don't make the same efforts they do?

Pardon my rant. (Please note that I'm not a big fan of the big government GOP, either.)

MUST. . .NOT. . .GET. . INTO .POLITICAoh yeah I will.

So the dems would tax us to death eh? News: I voted for Reagen twice because he promised fiscal conservatism. What he gave us was crazy tax cuts and the biggest deficit ever. Bush 1 at least saw that this was nuts and cut it back a little. but it took a democratic administration to cut welfare, balance th budget and put us on the road to fiscal sanity for the first time since the depression. Then Bush 2 and cronies make further tax cuts leading to even bigger debt than before. Meanwhile there's a war going on-perhaps the best reason for not putting in a blanced budget or cutting taxes and to top it off, they increase domesitc spending, not having ever seen a corporation they didn't like. This isn't a free market, it's a plutocracy, the worst we've seen since the robber barons. 😡

The fact is, the dems are now the party of fiscal responsibility, how wierd. And the whole tax cut thing, it's about 2% of the GDP. But it's the difference between a country permanently in debt and selling off to China and our other creditors or being strong.

OK, I'll go to my room.

 

[Poety]

MUST. . .NOT. . .GET. . INTO .POLITICAoh yeah I will.

So the dems would tax us to death eh? News: I voted for Reagen twice because he promised fiscal conservatism. What he gave us was crazy tax cuts and the biggest deficit ever. Bush 1 at least saw that this was nuts and cut it back a little. but it took a democratic administration to cut welfare, balance th budget and put us on the road to fiscal sanity for the first time since the depression. Then Bush 2 and cronies make further tax cuts leading to even bigger debt than before. Meanwhile there's a war going on-perhaps the best reason for not putting in a blanced budget or cutting taxes and to top it off, they increase domesitc spending, not having ever seen a corporation they didn't like. This isn't a free market, it's a plutocracy, the worst we've seen since the robber barons. 😡

The fact is, the dems are now the party of fiscal responsibility, how wierd. And the whole tax cut thing, it's about 2% of the GDP. But it's the difference between a country permanently in debt and selling off to China and our other creditors or being strong.

OK, I'll go to my room.

👍 and thats all I'm saying - cuz I'm not going into the political debate thing on this forum 😉

 

[BKN]

Miklos, just so you don't think I'm mad, I'll make comments about your other question.

I read the article, the title was misleading/inflammatory as with most media stuff, even in the economist. It wasn't about computers diagnosing patients directly, neither was it about consumers informing themselves by looking at this stuff. It was about Larry Weed selling decision support software. Nothing wrong with that, but IT isn't going to change the balance between Docs and Patients. Rather, it's going to allow us to do our jobs for them better.

Computers are not going to diagnose unsorted patients in the near future. There's too much variation. It was tried at Pitt in the 80's. They put 15 physician years into a program called INTERNIST, it couldn't perform as well as a human internist. Some of the problem is surely language, which doctors use differently than patients. Also, Its certainly true that a computer can remember long lists of diseases that present with symptom "x" better than any physician but they're not good at defining conditional probabilities accurately. . . If I see a young man in parts of India with recurrent severe febrile illness but knowing nothing else, malaria is a pretty fair guess. I'd have to be nuts to even consider it in a farm boy in Kansas who hasn't traveled. So far, computers can't make that leap without asking the questions about location of practice, demographics of patient, travel history etc. Automated histories can be more complete and save time, but they have to be confirmed by the physician.

I agree that we in Medicine have been slow to adopt IT. Some of that is our innate conservatism that you referred to in the political post, but I assure you more of it is how often the software offered over the last 25 years has been expensive junk. Mostly it was written by people with no understanding of medicine (programmers) or by enthusiastic doctors who were incompetent at computing. Good stuff is finally coming down the pike, but honestly, I still won't use it to make decisions, only to remind me of things.

I have no experience with nor opinion of the particular program Weed is pushing, but I will say he did change the face of medicine and informatics on paper with the POMR. The first clinical book that I read in med school was by a couple of his disciples describing how they used it in their FP to ensure every problem got looked at and everybody got all the screening done. Before that Docs were all just doing acute care medicine with the problem du jour.

I do think that any doc who isn't using the net and other resources right now is doing a bad job. I carry a PDA and look up every drug I prescribe every time. There are too many now for anybody to follow, even in their own patients. In my case, as an EP, I see everything in the formulary, prescribed by somebody else. Unusual presentations and diseases are common in our ED. I'm on the net either to a database like emedicine.com or to search pubmed a couple of times per shift. It's certainly easier to search electronically then look through a textbook. I don't look up many diagnostic algorithms or treatment guidelines. I guess because I've been doing it so long that I pretty much know what's in them since they concentrate on what's common and the average response. My students and residents seem to like them, however. Just remember as you use them the lessons of INTERNIST and PIOPED. They are:
1. sometimes, experienced clinicians perform better than guidelines because guideline were written by physicians to reflect the average response. Often, in particular cases, physicians can see facts about the patient that change the conditional probablilities to such a degree that the guidline recommendations may be in error.
2. Many guidelines were written with the financial interests of the authors in mind. Sometimes they were written by subspecialists with a scope they wanted to use. In other cases it was an HMO, looking for the cheapest solution.
3. Often the guidelines were not written based on data, rather they were written by pooled expert opinion. Experts are frequently wrong, particularly if your patients are different in some important way from their population.

Therefore, I recommend that you not use a guideline that in some way is different from usual practice unless they provide evidence of a confirmatory test against clinical judgement.

Ask a simple question, you get a pageant. 😴 You think you would learn 😴

 

[NRAI2001]

Good thread 👍

Maybe it would be good to get med students interested in these issues, before they disappear into their practices (i.e. med school)?

 

[Miklos]

Miklos, just so you don't think I'm mad, I'll make comments about your other question.

Thanks. I appreciate your reply.