What's your alternative to socialized med?

[leviathan]

My guess is that you practice at a large, university-related hospital in a large city. I would put the quality of care of the average U.S. hospital up against any community Canadian hospital, and the U.S. hospital would win. I certainly think you get good care at a university hospital in Toronto, Montreal or Vancouver, but these state-of-the-art facilities are the exception rather than the norm in Canada.

I'll be interested to hear his reply. If you are referring to the quality in regards to access to imaging, we both agree that community hospitals might not have the same access to imaging services as does the US. But for salaries, they are even higher in the community than large academic centres, as is the same for the US. I'm surprised to hear he makes the same or more, but I know the salaries aren't all that different. EM compensation is on par as we previously discussed. Gas makes about 400k. My friend in general IM bills about 300,000. Family is between 150-200k, etc.

By the way, bulge, were you able to finally get your EM training accredited over there? Or what is your practice situation?

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[bulgethetwine]

My guess is that you practice at a large, university-related hospital in a large city. I would put the quality of care of the average U.S. hospital up against any community Canadian hospital, and the U.S. hospital would win. I certainly think you get good care at a university hospital in Toronto, Montreal or Vancouver, but these state-of-the-art facilities are the exception rather than the norm in Canada.

The drop off with respect to quality is equally large between university-related hospitals and their community counterparts in the U.S. I've worked at both tertiary care and community hospitals in the U.S. after residency (both university and non-university affiliated) so feel qualified to comment.

I don't think the average community hospital in Alabama (or any other state, not picking on Alabama!) is any better or worse then, say, a community hospital in Scarborough. Top notch hospitals in ToMoVan are no longer the only ones with state of the art facilities. It just isn't as backwards as you apparently remember (shrug).

The broader issue, though, isn't just about whether or not the average hospital in Canada = the average hospital in the U.S. The main issue for a lot of my American physician friends is this unfounded fear they have that practicing in a system similar to Canada (or any 'socialized medical system' the U.S. might adopt) means changing your practice to conform with some government oversight.

I'm telling you, the only difference I see is that the bills all go to one destination and all get paid. Period. I still get compensated based on RVUs, procedural load, etc. I'm not on a salary - it's actually not much different than being an independent contractor with the government as your group. No one tells me what or how to practice - it's just a misconception that isn't true! Americans need to get their head around the fact that socialized medicine, at least insofar as a 'single payer system' does not have anything to do with a "socialist" political system.

The irony is, Obama actually DOES want it to be more than single payer. He wants to dictate quite a lot of what happens in U.S. medical care. Hell, even without Obamacare, the the EMTALA/HIPPA/JCAHO committees caused me more consternation in the U.S. than the threat of "government delivered health care" in Canada ever did! JCAHO was always telling me I couldn't have coffee here or there, HIPPA was omnipresent such that I have to click through 4 screens to access lab results on someone in my ER who is an employee of the university, and EMTALA means I fret everytime I discuss a transfer to another hospital.

The true irony is that U.S. physicians should stop crying about how much they fear a Canadian system - and realize that adopting and lobbying for a Canadian system might be the only way to save themselves from both the train wreck that the current system is sure to become and the truly "government controlled" system that Obama proposes. However, with tort reform not part of the package, I'm not sure that even an exact replica of the Canadian system could save U.S. health care costs from spiraling ever upward.

I swear to God I'm not planted to be here as a Pro-Canadian style healthcare supporter. I'm just sayin', I've worked in both systems now, and feel that I'm well positioned to objectively comment on the current, modern day contrasts between the two systems.

 

[bulgethetwine]

I'll be interested to hear his reply. If you are referring to the quality in regards to access to imaging, we both agree that community hospitals might not have the same access to imaging services as does the US. But for salaries, they are even higher in the community than large academic centres, as is the same for the US. I'm surprised to hear he makes the same or more, but I know the salaries aren't all that different. EM compensation is on par as we previously discussed. Gas makes about 400k. My friend in general IM bills about 300,000. Family is between 150-200k, etc.

By the way, bulge, were you able to finally get your EM training accredited over there? Or what is your practice situation?

We have night hawk radiology in Canada, too. This is no different than my experience in U.S. community hospitals in the middle of the night.

I should qualify the salary comments in my last post. I make about the same as I would in the U.S. because of a) my specialty and b) the exchange.

With respect to specialty dependence, I think you do the same or better in Canada vs. the U.S. if you're in primary care or any general specialty including EM, IM, Peds, surgery, etc. I think you make more in the U.S. if you do a non-primary specialty such as interventional rads, derm, etc.

On the other hand, you make a lot more as a CT surgeon in Canada. So clearly, it depends on your specialty.

Also, my current belief that I make the same is based on the current foreign exchange. For those who aren't up on FX rates, right now a Canadian dollar costs about 0.90 cents U.S. Historically (at least over the last 20 years) it's been more like 0.66 U.S. cents to the dollar. So perhaps my salary is 20% higher right now than I should expect going forward.

This might change how much I am willing to tolerate HIPPA coffee bans

 

[GeneralVeers]

We have night hawk radiology in Canada, too. This is no different than my experience in U.S. community hospitals in the middle of the night.

I should qualify the salary comments in my last post. I make about the same as I would in the U.S. because of a) my specialty and b) the exchange.

With respect to specialty dependence, I think you do the same or better in Canada vs. the U.S. if you're in primary care or any general specialty including EM, IM, Peds, surgery, etc. I think you make more in the U.S. if you do a non-primary specialty such as interventional rads, derm, etc.

On the other hand, you make a lot more as a CT surgeon in Canada. So clearly, it depends on your specialty.

Also, my current belief that I make the same is based on the current foreign exchange. For those who aren't up on FX rates, right now a Canadian dollar costs about 0.90 cents U.S. Historically (at least over the last 20 years) it's been more like 0.66 U.S. cents to the dollar. So perhaps my salary is 20% higher right now than I should expect going forward.

This might change how much I am willing to tolerate HIPPA coffee bans

I don't believe any of what you say. Give me some facts.

Also, comparing a hospital in Scarborough would be more like comparing a hospital to the Bronx, or Torrance, CA. Alabama would me more like something bordering James Bay.

 

[Stitch]

However, with tort reform not part of the package, I'm not sure that even an exact replica of the Canadian system could save U.S. health care costs from spiraling ever upward.

Can you comment on the legal/malpractice laws in Canada? I've read that malpractice is on the rise, but obviously still not as prevelent as in the U.S. Are there laws protecting you or is it just a societal attitude?

I'd also be curious about waiting times. I already get tons of people in the ER who say "well I have an appointment with the subspecialist, but it's next week and I can't wait that long. When I was in NY, there were plenty of Canadians who came down to get imaging, sometimes for serious stuff like possible brain tumors.

 

[GeneralVeers]

The data on Canadian physician salaries is hard to come by, but if you look here:

http://www.payscale.com/research/CA/People_with_Jobs_as_Physicians_/_Doctors/Salary

It states the MEDIAN salary for an ER physician in Canada is $101,428. Using an exhange rate of USD$0.901 that comes to USD $91,286.

The same site:

http://www.payscale.com/research/US/People_with_Jobs_as_Physicians_/_Doctors/Salary

Lists MEDIAN salary for an ER physician in the U.S. at $175,282


I do agree that both of these salaries is low (I make considerably more than what is stated), however if the ratios are correct it gives credence to the argument that the pay in Canada for our specialty is considerably less.

 

[bulgethetwine]

The data on Canadian physician salaries is hard to come by, but if you look here:

http://www.payscale.com/research/CA/People_with_Jobs_as_Physicians_/_Doctors/Salary

It states the MEDIAN salary for an ER physician in Canada is $101,428. Using an exhange rate of USD$0.901 that comes to USD $91,286.

The same site:

http://www.payscale.com/research/US/People_with_Jobs_as_Physicians_/_Doctors/Salary

Lists MEDIAN salary for an ER physician in the U.S. at $175,282


I do agree that both of these salaries is low (I make considerably more than what is stated), however if the ratios are correct it gives credence to the argument that the pay in Canada for our specialty is considerably less.

I had always seen the same salary surveys, and when I started really doing my due diligence (i.e. talking to docs in Canada) I realized how off it was. I'm not sure why. I don't know if it's outdated or if it is a reporting bias (for instance, the ABEM salary survey is, of course, only representative of those who actually respond, and it takes their answers at face value) and in Canada reporting bias might actually be a big deal since it might include family doctors who work a few shifts a month in a rural ER and report their income thusly.

EDIT: I just looked - the sample for EM doctors comprised only 420 respondents and included residents!

The can tell you that an EM-boarded physician working a 100% FTE in a Canadian ED (which is the same as what I worked in the U.S. - 12-14 shifts a month) makes a competitive salary compared to the U.S., and maybe even a little more right now (see exchange rate discussion above). And I'm talking competitive to what I made in the U.S. which, similar to you, is higher than the reported median salary which reflects largely academic reporting patterns.

 

[bulgethetwine]

I don't believe any of what you say. Give me some facts.

Also, comparing a hospital in Scarborough would be more like comparing a hospital to the Bronx, or Torrance, CA. Alabama would me more like something bordering James Bay.

First you said only Toronto, Montreal, Vancouver. Now you're saying Scarborough might be okay. We're getting to progressively smaller communities here. James Bay?? I don't know what they have in James Bay, but even if it's not much, I hardly think this constitutes an indictment of the Canadian healthcare model. I don't even know how many people live in James Bay. But 90% of the population of Canada (probably more) lives within a one hour drive of a hospital that is functionally no different than those in the U.S.

I certainly don't really care if you want facts or not - I'm simply giving you my perspective based on having actually worked within both systems in the past 5 years. Clearly you haven't had any actual experience in the Canadian system for quite some time. The beliefs and assumptions you have are exactly what 80% of my physician friends in Canada have, and it's stifling debate and progress on the real issues.

The only thing that is currently "better" about the U.S. is the weather. Otherwise, it's just different, with no real cost differential in salary or in patient care. In my opinion (shrug).

 

[bulgethetwine]

Can you comment on the legal/malpractice laws in Canada? I've read that malpractice is on the rise, but obviously still not as prevelent as in the U.S. Are there laws protecting you or is it just a societal attitude?

I'd also be curious about waiting times. I already get tons of people in the ER who say "well I have an appointment with the subspecialist, but it's next week and I can't wait that long. When I was in NY, there were plenty of Canadians who came down to get imaging, sometimes for serious stuff like possible brain tumors.

Malpractice: Agree with what you said - much less of a concern up here, but on the rise. I tend to practice very defensively up here still becasue that's the way I was trained. My colleagues less so. I will probably get more in line with them as I get more experience. So it's somewhat societal. But we also have malpractice judges not trials by jury. Big difference.

Waiting times: Better in Canada, though this is getting worse. The U.S. is better at empowering their ERs to fight institutional boarding. Less so in Canada in my experience so far.

The subspecialist question is a complicated one. The short answer is, I don't know yet. I'll need a some more time to objectively decide. I know that my ophthalmology follows ups are being done with 24h, I've had no problem getting ortho follow up within 7 days for uncomplicated fractures, I can get a neurologist to see my new onset seizure within 30 days... But I will tell you that many of my U.S. patients also came in to the ED because they "couldn't get an appointment fast enough for imaging" including some for rule out brain tumor. Radiology is a funny thing since patients don't understand the difference between acute imaging (fell, with LOC, on coumadin) and what can be done on an outpatient basis (for instance, rule out brain tumor SHOULD be done on an outpatient basis if there are no other abnormalities/symptoms.


I've been re-reading my posts over the past day. I sound like a drum beater for Canadian health care! It's not perfect (for instance, there is a real need for mid level providers up here which could provide an important component of the health care delivery) but it sure isn't worse from a salary or patient care/service point of view and it is these two issues that I find my colleagues in the U.S. most misinformed about.

 

[GeneralVeers]

First you said only Toronto, Montreal, Vancouver. Now you're saying Scarborough might be okay. We're getting to progressively smaller communities here. James Bay?? I don't know what they have in James Bay, but even if it's not much, I hardly think this constitutes an indictment of the Canadian healthcare model. I don't even know how many people live in James Bay. But 90% of the population of Canada (probably more) lives within a one hour drive of a hospital that is functionally no different than those in the U.S.

Scarborough is hardly a little hick town, like you'd seen in Alabama. It's essentially contiguous with Toronto, the largest metro area in Canada.

The only thing that is currently "better" about the U.S. is the weather. Otherwise, it's just different, with no real cost differential in salary or in patient care. In my opinion (shrug).

Except for the superior access to diagnostics, state-of-the-art drugs, better cancer survival rates, quicker referrals to specialists, and overall more control of your care. But then those aren't as important as being "nice" to everyone.

 

[leviathan]

Except for the superior access to diagnostics, state-of-the-art drugs, better cancer survival rates, quicker referrals to specialists, and overall more control of your care. But then those aren't as important as being "nice" to everyone.

I've gotta admit, I have difficulty disputing anything you say considering I've yet to work in *either* health care system, besides in the capacity of a paramedic. I've read cancer mortality rates as being higher in Canada for some types, and higher in the US for others. But since you refuse to accept any of the numerous health markers that show Canada and the rest of the western world being far ahead of the US, I don't know how you can then try to quote stats in your favour. What state of the art drugs? Which specialists are quicker, and by how much? I can ask the SO about referral times, as she is a family doc. Any specialists I've ever needed to see took up to 1 month max (dermatologist), or shorter (2 weeks for an ophtho for a long standing problem). Public vs. private funded health care won't change that, only the doctor supply.

PS - As a medic, I've worked both in Vancouver as well as the Okanagan valley (interior of British Columbia). In the city of Penticton (pop. 40,000) they have a CT scanner + MRI. I don't know if a city any smaller than 40,000 would really need their own unit, or if they'd have one in a US town of a similar size. Any thoughts?

 

[GeneralVeers]

I've read cancer mortality rates as being higher in Canada for some types, and higher in the US for others.

Which cancers have better outcome in Canada? As far as I know, none.

But since you refuse to accept any of the numerous health markers that show Canada and the rest of the western world being far ahead of the US, I don't know how you can then try to quote stats in your favour.

The "markers" like "infant mortality" and "access to care" are always put out by groups with a vested interest in promoting universal care. The U.S. has much higher rates of obesity and diabetes, and these are societal issues rather than healthcare issues, so it's difficult to compare a lot of the diabetes-related illnesses, like CAD. As has been mentioned numerous times the infant mortality statistic that is bandied about in every argument about universal care is completely illusory.

What state of the art drugs? Which specialists are quicker, and by how much? I can ask the SO about referral times, as she is a family doc. Any specialists I've ever needed to see took up to 1 month max (dermatologist), or shorter (2 weeks for an ophtho for a long standing problem). Public vs. private funded health care won't change that, only the doctor supply.

For an insured patient (~90% of the poulation, not counting illegals) I can get a referral to any specialist in town typically within 7 days, often within 24 hours for optho and ENT. The stats in Canada from several years ago demonstrated a mean of 4 weeks to see an oncologist and 8 weeks to see a radiation oncologist, whereas here those referrals are often done in 2-3 days if there's an urgent need.

PS - As a medic, I've worked both in Vancouver as well as the Okanagan valley (interior of British Columbia). In the city of Penticton (pop. 40,000) they have a CT scanner + MRI. I don't know if a city any smaller than 40,000 would really need their own unit, or if they'd have one in a US town of a similar size. Any thoughts?

Small cities I've worked in with a dedicated MRI in hospital:

Alice, TX - population 15,000
Kleburg, TX - population 10,000
Havasu, AZ - population 55,000

So far in my experience no community hospital greater than 50+ beds is without one, although I'm sure there are a few examples.

 

[leviathan]

The "markers" like "infant mortality" and "access to care" are always put out by groups with a vested interest in promoting universal care. The U.S. has much higher rates of obesity and diabetes, and these are societal issues rather than healthcare issues, so it's difficult to compare a lot of the diabetes-related illnesses, like CAD. As has been mentioned numerous times the infant mortality statistic that is bandied about in every argument about universal care is completely illusory.

What I'd like to see is a study comparing life expectancy between countries in people who have diabetes, CAD, obesity, low SES, etc. That would control for some of the differences.

For an insured patient (~90% of the poulation, not counting illegals) I can get a referral to any specialist in town typically within 7 days, often within 24 hours for optho and ENT. The stats in Canada from several years ago demonstrated a mean of 4 weeks to see an oncologist and 8 weeks to see a radiation oncologist, whereas here those referrals are often done in 2-3 days if there's an urgent need.

Somehow I doubt 90% of the population has access to that kind of speedy care. You can prove me wrong though.

Small cities I've worked in with a dedicated MRI in hospital:

Alice, TX - population 15,000
Kleburg, TX - population 10,000
Havasu, AZ - population 55,000

So far in my experience no community hospital greater than 50+ beds is without one, although I'm sure there are a few examples.

Wow an MRI for a population of 10,000? Does the thing actually even get used?

 

[DoctorMedic]

lived in town of 20k and had MRI come every other day, was at another sister hospital the other days that had population of about 25k. They are always booked up.

 

[leviathan]

Talked to the s/o she says most of her cancer patients get in to see an onc within 2 weeks, within 1 if they are lucky. Surgeon within a week or two. A family member of hers has rectal CA and was seen by an oncologist 1 week after tissue diagnosis, and 2 weeks after seeing the onc she got radiation therapy. If it's CA that needs urgent therapy they can be seen within a week by a rad onc.

 

[GeneralVeers]

Talked to the s/o she says most of her cancer patients get in to see an onc within 2 weeks, within 1 if they are lucky. Surgeon within a week or two. A family member of hers has rectal CA and was seen by an oncologist 1 week after tissue diagnosis, and 2 weeks after seeing the onc she got radiation therapy. If it's CA that needs urgent therapy they can be seen within a week by a rad onc.

I wasn't basing my numbers on anecdotal evidence. I was basing it on the official stats that were published in Maclean's several years ago.

 

[bulgethetwine]

Scarborough is hardly a little hick town, like you'd seen in Alabama. It's essentially contiguous with Toronto, the largest metro area in Canada.



Except for the superior access to diagnostics, state-of-the-art drugs, better cancer survival rates, quicker referrals to specialists, and overall more control of your care. But then those aren't as important as being "nice" to everyone.

At

 

[GeneralVeers]

But if you cite one area, then look at all of them. Afterall, infant mortality data is better in Canada than the U.S.

Why do you guys keep bringing this up? It's been demonstrated time and time again that America resuscitates babies at much lower birthweights than other countries do, which directly contributes to higher mortality rates. If you really want to compare infant mortality, then look at newborns greater than 27 weeks of age. Unfortunately this data does not (to my knowledge) exist.

 

[Stitch]

Why do you guys keep bringing this up? It's been demonstrated time and time again that America resuscitates babies at much lower birthweights than other countries do, which directly contributes to higher mortality rates. If you really want to compare infant mortality, then look at newborns greater than 27 weeks of age. Unfortunately this data does not (to my knowledge) exist.

Absolutely true. Here's a writeup I did not long ago addressing the infant mortality myth. Up to Date also has an excellent entry. I do believe that some countries do better than we do, but we're not nearly at the bottom of the list. Most of those rankings are not comparing the same things.

 

[leviathan]

I wasn't basing my numbers on anecdotal evidence. I was basing it on the official stats that were published in Maclean's several years ago.

Kind of like the official stats you reported that said emergency physicians make $80,000/year in Canada?

Maclean's is known to be a poor source of information, especially after that fiasco they had about ranking universities.

I'd really love to see how someone could reliably report the average wait times for specialists. All I know is the average wait times where I live are not what you're reporting at all, anecdotal or not.

 

[GeneralVeers]

Kind of like the official stats you reported that said emergency physicians make $80,000/year in Canada?

Maclean's is known to be a poor source of information, especially after that fiasco they had about ranking universities.

I'd really love to see how someone could reliably report the average wait times for specialists. All I know is the average wait times where I live are not what you're reporting at all, anecdotal or not.

Anyone can use anecdotes to prove any point (your relative, and my uncle stories). What I'd like are actual facts comparing salaries in Canada and the United States, as well as comparative stats on outcomes. I will keep looking for both of these.

 

[DoctorMedic]

found this

According to a 2001 Canadian census, Canadian specialists make roughly $125,000 a year. According to the U.S. Department of Labor, specialists make about $228,000 a year. That $100,000 more isn't always worth it.

"Based on a discussion with at least ten different American colleagues, I've established the idea that there is greater income in the U.S. is fallacious," says Dr. Barry Rubin, chief of vascular surgery with Toronto's University Health Network. "There is huge competition for patients, a large amount of medical malpractice insurance, and a huge cost in running a private clinic."

For what it's worth.

 

[leviathan]

found this

According to a 2001 Canadian census, Canadian specialists make roughly $125,000 a year. According to the U.S. Department of Labor, specialists make about $228,000 a year. That $100,000 more isn't always worth it.

Hahaha...if that was a stat for family doctors, I'd agree with it as an average income..even though that is still low for them. Find me ANY specialist, even one single person, in the entire country who makes that kind of money with a 1.0 FTE. Clearly when we are using statistics to back our points, they are meaningless anyway if these are the kinds of numbers we're coming up with.

"Based on a discussion with at least ten different American colleagues, I've established the idea that there is greater income in the U.S. is fallacious," says Dr. Barry Rubin, chief of vascular surgery with Toronto's University Health Network. "There is huge competition for patients, a large amount of medical malpractice insurance, and a huge cost in running a private clinic."

For what it's worth.

Hmm...I'm guessing there's a lot of overhead involved just trying to get money from your patients and their insurance providers in the US? As for malpractice, that is a no-brainer. Out of curiosity, what do you guys pay for malpractice in EM? The CMPA posts the fees for various specialties on their website. EM is as low as $2000/year in BC, or as high as about $6000 in Quebec.
https://www.cmpa-acpm.ca/cmpapd04/docs/membership/fees/2009cal-e.pdf

 

[deleted65604]

Sorry to get off the topic of Canada vs. US.

I read a great article in the Emergency Physicians Monthly (July 2009, volume 16 Number 7) by Mark Plaster.

http://www.epmonthly.com/index.php?option=com_content&task=view&id=515&Itemid=43

"The Josiah Plan", talks about an Amish dude with SVT. Once a year he showed up in the ER and asked them to shock him. No other tests, no sedation, no IV, no lab...

"It only hurts for a second or two. It feels like a horse has kicked ye. But then it's over real quick. I don't need any of yer IVs or medicine."

Mark comments,

"At the time I thought of Josiah Yoder as merely an interesting anachronism, a good story to tell at dinner. But now, as I grow older and internalize the broader scope of health care in America, I see that this man embodied much of what is missing in the health care debate.

Mr. Yoder embodied the essence of preventative health. His religion led him to a vigorous lifestyle absent some of the biggest blights of our society, namely drugs, alcohol, and tobacco. While society isn't going to embrace the Amish religion in large numbers, we can learn that public social pressure is the best and cheapest way to change lifestyle habits.

Second, despite his humble surroundings, Josiah was not ignorant of his true health needs. He didn't come in for a hang nail. But he didn't die in the field either, having neglected to seek appropriate medical care. He had become appropriately educated as to important warning signs and symptoms. Mass media could be used for this purpose, but because media is driven by money, the majority of education is about erectile dysfunction, overactive bladders, and insomnia. I'm so tired of hearing commercials tell the viewer to "Talk to your doctor," I could scream. "I don't want to talk to you about your overactive bladder. And if you can't sleep, TURN OFF THE TV!"

Third, Josiah embodied the sense of responsibility that comes with communal spending. He felt an obligation to his neighbors not to overspend on his health care. His money from the mason jar was for birthday gifts. And his neighbors, though generous, had needs of their own. So he wasn't about to spend his money, or theirs, on over priced or unneeded care. With insurance, patients have the idea that they are spending the money of some faceless company. Or worse, with public insurance, some feel that their health care is a right, paid for not from their own taxes, but by ‘all those rich people.'"

Standing ovation.

Well put Mark.

What is the number one problem with our medical system today? It is incredibly expensive. Why? Because on a daily basis, we order way too many tests. Why? In part, because of malpractice, in part because people are divorced from the payment of bills by third party payors (or never intend to pay them anyway).

Every time I order labs, the patient should say, Why? What will that change? How much will it cost? Is it absolutely necessary? What is the alternative? What do you expect to find? But they don't. They don't care. Now, if you are truly sick, you should sit your butt in the bed and let me take care of you. But if you are part of the vast majority of people that clogs my ER with non-emergent, or urgent (and some even non-urgent complaints), you should care very much about the cost of everything I order.

Every step we take in divorcing the current population from the immediate burden of the bills, we will raise costs more.

That is why I predict that our number one problem in America with healthcare (cost) is going to get dramatically worse with more government involvement and further divorcement from the immediate consequence of medical bills.

 

[DoctorMedic]

those numbers weren't to prove a point, they were the only ones I found. Malpractice for EM varies by state though. States like NY and NJ have higher premiums.

 

[deleted65604]

I guess I really haven't answered the original post.

If I were all-powerful and could trample upon the souls of those under me, I would mandate a system where there was a kind of three strikes and you're out clause. If you have COPD, you have 3 clinic visits to quit smoking and then any medical treatment related to the treatment of your COPD is on your dime. If you are diabetic, and over-weight, you have 3 years to lose 10% of your body mass, or your diabetic treatment is on your own dime.

Since a huge part of medical costs are incurred in the last 6 months of life, we need to be less aggressive with people over 85. For example, if your 85 year old grandma needs dialysis, she will get peritoneal dialysis or nothing. If you want IV dialysis, you or your family can fork over the dough. When families have to choose between paying for cable and having grandma around for another arthritic, crippled up 10 years, reasonable medical decisions are more likely to be made.

If you are a smoker, you shouldn't have the ability to sue doctors over your missed stroke/MI/cancer or bad outcomes from these diagnoses. If you clearly played a role in the development of your disease, you can't go blaming doctors for bad outcomes. Anyone on public assistance programs should get kicked off immediately if they are using illegal drugs, abusing alcohol, or smoking cigarettes. Why should we support your habit?

 

[Dwindlin]

That is why I predict that our number one problem in America with healthcare (cost) is going to get dramatically worse with more government involvement and further divorcement from the immediate consequence of medical bills.

Anyone on public assistance programs should get kicked off immediately if they are using illegal drugs, abusing alcohol, or smoking cigarettes. Why should we support your habit?

Two statements I couldn't agree with more.

 

[Old_Mil]

Since a huge part of medical costs are incurred in the last 6 months of life, we need to be less aggressive with people over 85. For example, if your 85 year old grandma needs dialysis, she will get peritoneal dialysis or nothing. If you want IV dialysis, you or your family can fork over the dough. When families have to choose between paying for cable and having grandma around for another arthritic, crippled up 10 years, reasonable medical decisions are more likely to be made.

Why even pay for peritoneal dialysis? Euthasol is a lot cheaper. Let's just put all the gomers down when they hit 80.

Somehow, a mindset that says "Jack, who barely graduated from high school and now lays around on his mothers couch when he's not driving his Hyundai to his job at McDonalds is more worthy of health care dollars than Major Tom who stormed the beaches of Normandy based on his age" has infected the medical community. I'm not sure where it came from, but this sort of utilitarianism spits on the grave of Hippocrates.

Enough with the ageism already.

 

[deleted65604]

I'm all for treating the elderly with respect. I believe that you can gauge the morality of a culture by the way their elderly are treated. However, death is not the enemy. Life is a terminal disease. Prolonging suffering is not doing anyone a favor. If a doctor feels that they are simply prolonging suffering, they should have the ability to tell the family frankly, that this test, or that treatment is simply prolonging the inevetible.

Where I did residency, we had several illegal aliens who showed up to our ER 3 times a week for dialysis. They stayed in the US, because that is a terminal disease in Mexico. Nowhere in the world do people get state-funded IV dialysis. They get intra-peritoneal dialysis or nothing. It is adequate treatment. It is easier on lifestyle. I'm talking about thinking outside the box and helping the public get educated on what is or isn't reasonable expectations for their health-care for their beloved family members.

My mom recently visited an 85 year old lady, who is in a nursing home and unable to get out of her bed. She is in constant severe pain, and her quality of life sucks. The woman is recieving chemotherapy for cancer. Why should we fund this? Why should we not have the guts as doctors to stand-up and tell people that they are going to die and that it is OK.

The problem is that we all train in academic places where the sky is the limit as far as treatment. I remember the first time that I was working in a rural community and I found a big old liver tumor that was probably primary liver cancer. I tried to admit the patient to her doctor for biopsy and work-up. He came in and saw the patient and told her that she was going to die and that there was nothing to do. At first, I was surprised. Now, I respect him for his candor. In an academic setting, they would admit the patient (mostly because the attending wouldn't want to come in and see the patient and discharge them home). Then they would probably give her chemotherapy, if nothing else to educate the residents and build our database of knowledge. What is a better course of action for a lot of terminal diseases? Focus on comfort and minimizing testing that won't change treament.

 

[GeneralVeers]

We have 60 illegals at UMC in Las Vegas who come in 3 times weekly for their dialysis. Each time they need to be admitted, and the renal doctor has to consult.

The burden these patients are placing on the system is making it tough for actual U.S. citizens to receive proper care through the county system.

I know it sounds harsh and insensitive, but all 60 should be deported to Mexico. If they die, well it's sad, but we should not be responsible for picking up the slack in Mexico's health system.

 

[Hawkeye Kid]

We had the same thing at our county hospital. Reliably, on Tuesday and Friday mornings, the same handful of folks would show up for HD. They had to get admitted so that the HD was considered "emergent" so the hospital would get paid. And, since medicine admitted everything for all medicine subspecialties, they had to be admitted to the gen med service with renal consulting. At least some folks had the foresight to develop an efficient process by which they went straight to the dialysis unit without a huge ED workup, though we still had to see them for "screening" purposes (usually the nurses would take the chart to an atttending or upper level EM resident who knew the drill to avoid an intern or student launching into a big workup).

There was also a young guy from Asia who happened to be in town with a traveling entertainment group when he developed renal failure from an uncommon primary renal process. By the time this had been worked up, treated, etc, it was several weeks later and his group had moved on and was back in Asia. Now the guy is here, where he knows no one, can barely communicate, and can't afford to go home. So he comes in for is pseudo-scheduled HD (except when it's inconvenient and then he comes in with pulmonary edema, elevated troponins, etc). I really wonder when someone will decide that it's cheaper, easier, and maybe even more humane to just buy him a plane ticket and send him home.

 

[Jeff698]

If Obama and the Democrats want to "reform" the malpractice system, and eliminate nuisance lawsuits as well as put caps on damages then I'm willing to listen to their proposals concerning rationing, physician reimbursement cuts, and increased bureaucracy

I think this is the most catastrophic failure in the administration's current attempts to get reform past. It would be such a simple (from my perspective, anyway) matter to include a true no-fault liability system (like your beloved NZ) and they'd have made huge inroads towards getting physician support.

Take care,
Jeff

 

[deleted65604]

Below is a fascinating vignette that is rather depressing, and I think, sheds light on the role that modern physicians have in shaping healthcare.

It is a story told by a physician on SERMO.

In 1992, as a young idealistic physician who was disturbed by what was happening to healthcare, I started Law School at a very prestigious University with the goal of working on legislative aspects of Healthcare Reform. (Tuition was $20,000 a year paid for by weekend and evening ER work) After starting Law School Clinton got elected. One of the Law Professors was on Hillary's 564 member committee. This professor offered a seminar course on Healthcare reform co-taught with the Schools of Public Health and Social Work. Each student had to request permission to be in the class and express a committment to health care reform. None of my calls to the Law Professor were returned so finally I accessed her via her secretary who got her on the phone. The Law professor (who had never met me) said she did not return my calls because she had no intention of letting a Physician in her course for "the same reason" there were no practicing physicians on Hillary's committee, quote " physicians have been a roadblock to health care reform and I will not have a roadblock in my class.....physicians lack the intellectual capacity to make the mental leap required for health care reform." I could not convince her to let me in the course despite informing her that I was actually for healthcare reform and a Clinton supporter. Simply being a Physician was enough to be discriminated against and denied access to a course. The next day I filed a discrimination claim under the Law School's discrimination policy only to be informed by the Law School Dean that the policy only applied to protected groups and being discriminated against based on being a "privileged white male Physician" did not give me standing for a claim or protection under the policy. ( I am the youngest of 8 children, my dad died when I was 11 months old, I was raised by a widow and started working with my brothers when I was 5 and have always paid my own way, yet I automatically carry the adjective of "privileged" by being a "white male physician" I guess). I was an AMA member back then. I assumed the AMA would be interested or provide some guidance, but none of my calls to the AMA were returned and the Legal Department of the AMA took messages but again did not respond. I learned then that my 7 years of paying dues were a waste.

Washington bureaucrats don't want our ideas. The lawyers don't want our ideas. They don't deal what we have to deal with. They don't see what we see. They have no idea what needs to change... We do.

OK, maybe I'm being a little fatalistic.

 

[GeneralVeers]

I think this is the most catastrophic failure in the administration's current attempts to get reform past. It would be such a simple (from my perspective, anyway) matter to include a true no-fault liability system (like your beloved NZ) and they'd have made huge inroads towards getting physician support.

Take care,
Jeff

Obama and the Dems are in the pockets of the trial lawyers, and Republicans have no incentive to push this issue.

It would take a catastrophic loss of doctors and enormous public outcry before anything will get done.

 

[deleted109597]

For you, there will be a tax on bitterness.

Damn. Would they take barter? I don't think I would have enough money to cover it.

 

[GeneralVeers]

Damn. Would they take barter? I don't think I would have enough money to cover it.

I'd be out of business as well. I'd actually end up owing money to the government, as my bitterness exceeds my actual income.

 

[deleted65604]

I like the ideas expressed by this website:

http://www.localhealthcarereform.com/
good quote:

"Most health care reform proposals represent centralized government political and economic solutions to what are local, social, ethical, and organizational problems.

The only health systems that exist, exist locally; those most affected by today's 'solutions' are not involved in decisions made for them"!

I also like the argument for socializing food services nationwide:

http://localhealthcarereform.com/ya...Nutrition-_A_single_payer_system.20673901.pdf

 

[It'sElectric]

I'm not sure if this video has been linked here, so I apologize if it already has. A light-hearted, but honest look into what we potentially have to look forward to. Be careful what you wish for...

http://www.youtube.com/watch?v=q2jijuj1ysw&feature=fvw

 

[DoctorMedic]

great video!

 

[deleted109597]

And another.
Indian Health Services

 

[EJacobs]

n/m