Which Presidential Candidate Do You Think Best Serves Psychiatry

[whopper]

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I wouldn't want a doctor calling the shots on system that I proposed (incentives & disincentives, rewards/punishments), and certainly not in a case where mental illness is concerned. It leads to too many ways for the patient/doctor relationship to get messed up. In psychiatry, that relationship is more complex than with a PCP.

I'd want a system analogous to NJ's point system. A system that's easily understood (pretty much anyone in NJ understands--you get a ticket you're insurance goes up, the vast majority knows what can and what will not get you a ticket--its called getting your driver's liscence), on purely objective variables (BP, weight, gym membership, use of tobacco, incorporate a driving point system into health insurance, LDL levels, etc) that are within the typical patient's knowledge to understand.

And if someone does end up paying a higher rate--it doesn't have to go through the roof. It just has to go up to the point where it can decrease the antisocial behavior.

If you'd think that'd lead to more stigmatization of certain patients-I disagree. None of my proposals has a "judgemental" factor involved. NJ's traffic point system doesn't cause stigma on specific drivers. They are based on purely objective & controllable variables. I do though see why someone could've gotten that idea from my previous posts, because of the sarcasm of one of my posts & because I didn't clarify every detail.

Which I guess reveals one of my own opinions on government. In general I am a libertarian in philosophy, though not a backer of the Libertarian party (neither the Dems or the GOP seem to be libertarian, the libertarian party itself is going nowhere.)

We are in a society where several hard working & responsible people cannot afford healthcare. IMHO, people wasting healthcare dollars causes harm to others by preventing them from affording healthcare.

 

[OldPsychDoc]

Who will make these decisions?

I will.

Prepare thyself for a humungously large caseload, My Liege, High Emperor Anasazi...
😀

 

[BabyPsychDoc]

MItt is definitely not my choice with Ron in the running, but he may be a better choice than others out there. If Ron drops out, I'll have to re-evaluate who is the next best candidate.

Obviously these are my interpretations, so I welcome input from people.

Healthcare
Mit: Deregulating healthcare, change the tax code, and provide healthcare to every citizen.

Ron: Talks a lot about individual's right to information, access to care, and supports avenues to make healthcare more affordable (tax deductible, small biz support to provide affordable care, encourage doctors to negotiate with insurance companies instead of taking what they are offered, healthcare saving account).

Stem cell research
Mitt: Against it.
Ron: Against the federal gov't paying for it. He wants to leave it as a state and private citizen issue.

Pro-life vs Pro-choice
Both are pro-life, though Ron is more hardline about it. I'm not wild about his hardline stance, but I appreciate his consistency in support of the issue. This definitely is a difficult issue for me (as I believe in pro-choice).

Education
Mit: Supports No Child Left Behind (burning federal funding on something that at best needs to be fixed, and in reality doesn't work)

Ron: Supports more realistic spending, and he doesn't want to throw money at a broken system. He wants more parental involvement and 'real' standards. I need to read more about his stance, so I'd welcome anyone who knows more about it.

Privacy
Mit: National ID system and very much in support of The Patriot Act.

Ron: Against The Patriot Act and against a National ID system. He believes this violates citizen's rights, which he wants to protect.

Taxes
Both are in favor of cutting taxes, simplifying the code, etc. Ron wants to eliminate the IRS, while Mit wants to just simplify. I think both have good plans (from what I've read).

Immigration
Mit: Securing borders, enforcing the laws, new biometric verification, stricter employer verification, and increasing legal immigration. The biometric verification is a bit scary, but everything else is closer to Ron's plan. I'm not sure how he would handle amnesty issues.

Ron: Much more hardline (which is needed). Secure the borders, enforce the laws, no offer of amnesty, no chain immigration, and equal allowances for people from various countries.

International Issues
Mit: Wants better international support and is in favor of sending troops abroad to protect our interests (not nec. Iraq? but he thinks we need a strong presence)

Ron: Protect our home front. We are spread too thin and are too involved in fights of other countries.

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There are obviously many other issues, but I tried to pick some of the issues that effect healthcare, while also including some other major issues. I'm sure I missed a bunch....but I need to go start my real research work now. 😀

Some references for those interested in these two candidates:

http://www.ronpaul2008.com/
http://www.mittromney.com/
http://www.bostonherald.com/news/national/politics/2008/bios/view.bg?articleid=1063102
http://nyletterpress.wordpress.com/2007/09/30/3/
http://www.lewrockwell.com/paul/paul252.html
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In case anyone cares to see where they may fall during the race: http://www.electoralcompass.com/

YAY! Romney wins the MI nomination! I have not done as detailed analysis of candidate's policies as you obviously have. However, I think Romney is the best president America could get these elections. Yes, he has changed his official view on issues like abortion or gay rights since the time he was running for governor in Massachusets. I can forgive him this, as politics in general is a slimy business and other candidates have shown themselves to be even more hypocritical. I think if Mitt won the elections he would be quite moderate in his social policies (based on his previous track record).

Other than the abortion (I am strongly pro-choice) and the gay marriage issues, I am more or less happy with most of Mitt's proposed policies. Yes, he supports No Child Left Behind. But, he also favours charter schools (which imho are a great alternative to ordinary state schools for parents unable to afford private education). He is against illegal immigration, but he wants to increase legal immigration (which is great for people like myself), and he does not mind chain immigration that much (hey, if I move to the US, I want my parents to be nearby - and if I can support them, why should not I?). Taxes must be cut - as well as federal spending. I also like the idea of Federal Home Schooling Tax credit. I wholeheartedly agree with his plans for healthcare management.

Stem cell research....Well, I am not thrilled with his stance on the issue. I like to think that his stated opposition to stem cell research (as well as his pro-life stance) are intended to win the hearts of hard-core evangelicals that are wary of the Mormon in the presidential race. Heck, the guy's wife is suffering with MS; you would think he might be somewhat interested in stem cell research from that point of view.

In summary, I think Mitt is a highly intelligent, successful businessman and politician who could make an excellent President if Americans give him the chance. Too bad, me and my husband do not live in the US at present - I probably would be at the forefront of Romney's campaign in the state!😀

Sorry, T4C, your detailed post deserves a much better response, but I am working night float this week and I need a NAP!😴

 

[BabyPsychDoc]

I wouldn't want a doctor calling the shots on system that I proposed (incentives & disincentives, rewards/punishments), and certainly not in a case where mental illness is concerned. It leads to too many ways for the patient/doctor relationship to get messed up. In psychiatry, that relationship is more complex than with a PCP.

I'd want a system analogous to NJ's point system. A system that's easily understood (pretty much anyone in NJ understands--you get a ticket you're insurance goes up, the vast majority knows what can and what will not get you a ticket--its called getting your driver's liscence), on purely objective variables (BP, weight, gym membership, use of tobacco, incorporate a driving point system into health insurance, LDL levels, etc) that are within the typical patient's knowledge to understand.

And if someone does end up paying a higher rate--it doesn't have to go through the roof. It just has to go up to the point where it can decrease the antisocial behavior.

If you'd think that'd lead to more stigmatization of certain patients-I disagree. None of my proposals has a "judgemental" factor involved. NJ's traffic point system doesn't cause stigma on specific drivers. They are based on purely objective & controllable variables. I do though see why someone could've gotten that idea from my previous posts, because of the sarcasm of one of my posts & because I didn't clarify every detail.

Which I guess reveals one of my own opinions on government. In general I am a libertarian in philosophy, though not a backer of the Libertarian party (neither the Dems or the GOP seem to be libertarian, the libertarian party itself is going nowhere.)

We are in a society where several hard working & responsible people cannot afford healthcare. IMHO, people wasting healthcare dollars causes harm to others by preventing them from affording healthcare.

"Well, high BP runs in my family...Yeah, and heart disease, too...and you know, they did find a gene that makes you fat...so, like, why should I be paying extra if it's all my genes?!" I can just hear patients say that in response to your proposals. Gyms can be used as social clubs - after all, once your ticket is stamped, there is no obligation to exercise. Check this out http://news.bbc.co.uk/1/hi/health/6426785.stm - are you going to propose random checks of cotinine on every citizen just to make sure they are not lying about their smoking habits?

I think we will have to agree to disagree on this one, whopper.

 

[Therapist4Chnge]

Sorry, T4C, your detailed post deserves a much better response, but I am working night float this week and I need a NAP!😴

Eh, no worries. If anyone found it helpful, that is good enough for me. I think people need to become more politically aware.

-t

 

[Anasazi23]

"Well, high BP runs in my family...Yeah, and heart disease, too...and you know, they did find a gene that makes you fat...so, like, why should I be paying extra if it's all my genes?!"

Well, because you're a much bigger risk to the insurance company - regardless of where you are gene-wise.

I could say the same about car insurance. I remember when I turned 16, and had my hot rod musclecar. The insurance company charged me more because "I was a male." I can't help that...it's in my chromosomal makeup. But they sure as hell dinged me for it because I was a statistical risk - one that would cost them money more than an honor student recluse girl who borrows their mom's mini-van.

 

[Faebinder]

Well, because you're a much bigger risk to the insurance company - regardless of where you are gene-wise.

I could say the same about car insurance. I remember when I turned 16, and had my hot rod musclecar. The insurance company charged me more because "I was a male." I can't help that...it's in my chromosomal makeup. But they sure as hell dinged me for it because I was a statistical risk - one that would cost them money more than an honor student recluse girl who borrows their mom's mini-van.

Admit it... you always secretly wanted to be a girl..... 😀

 

[Hurricane]

And if someone does end up paying a higher rate--it doesn't have to go through the roof. It just has to go up to the point where it can decrease the antisocial behavior.

Are your seriously equating being fat with being antisocial?

 

[whopper]

"Well, high BP runs in my family

True, don't penalize simply because there's high BP, penalize if there's high BP & the patient chooses not to treat it. BP has a multifactorial inheritance pattern.

Some reports showing incentives can work...
http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/GetPaidToLoseWeight.aspx

In 2003, before StayWell started, 33% of its U.S. employees were considered high insurance risks. By 2006, that percentage was down to 14%. Similarly, its "low risk" group went from 12% to 21% of employees. And its medical and prescription drug costs per employee dropped between 2005 and 2006, the company says.

http://www.foxnews.com/story/0,2933,297907,00.html?sPage=fnc.health/nutrition

The research published in the September issue of the Journal of Occupational and Environmental Medicine found that cash incentives can be a success even when the payout is as little as $7 for dropping just a few pounds in three months.

We'll agree to disagree...since I think I hogged enough time presenting my little point system idea.

Anyways, out of all the top candidates: Guiliani, Romney, McCain, Clinton, Obama, if any of them won, I'd be alright with it. Not because I'm loving any of them, just that I like them better than what we got now.

The only 2 "major" candidates I'm really hating now are Edwards & Huckabee.

Ron Paul--disagree with him too much, but I respect the guy.

 

[Therapist4Chnge]

Guiliani is getting scarier by the day. I read his book a few years ago, and I've followed him closely for the last 7-8 years (I was a NYC regular), and I was a supporter. He seems like a good leader (though not a great person). He is the kind of guy that will get things done, but I think we may not want to know how he gets things done, and for whom he does things for. I am concerned about special interest influence with him, along with Hillary.

-t

 

[whopper]

Hillary's bought. That's the biggest thing I don't like about her.

Guiliani, I was very impressed with his performance as mayor in NYC. Improvements that were deemed impossible for years were not only done by him, they were done quickly, practically and with significant effect. Comparing him with the previous mayor-Dinkins was like comparing Mr Wolf from Pulp Fiction vs Gilligan.

Had this impression even before 9/11.

My own opinion is people's personal lives should be separated from their performance. If you needed brain surgery, do you want the best neurosurgeon who had cheated on his wife or one with a worse record who was faitthful?

In matters where someone can control the fate of millions of lives--their personal life is not an issue IMHO. It'd be better of course if they had simple & respectable personal lives, but their professional performance is more important when it comes to considering them for office.

 

[futuredo32]

I like Guliani's position on many issues. If he wins Florida and that gives his campaign a much needed boost, he could have a chance. He's pretty moderate. He supports a woman's right to choose, said he'd propose initiatives to promote healthy lifestyles, said he'd tie Medicaid payments to a state's success in promoting preventive care and tracking obesity for children, and he supports loosening restrictions on federal funding of embryonic stem cell research.
Personally, I could care less about his personal life, but it might sway some voters away from him.
McCain isn't a bad choice either. He attracts a lot of independent voters and could have a chance against Obama or Hillary, in my opinion.
Romney has a lot of business experience. Based on things I've read on SDN, the changes he made to healthcare in Massachusetts are not good and I'm hoping he isn't the Republican nominee.

 

[OldPsychDoc]

Anyone think that this is a good idea? 😡
Perhaps they could expand on it by reducing all health risks to a "credit score"?

 

[BabyPsychDoc]

Anyone think that this is a good idea? 😡
Perhaps they could expand on it by reducing all health risks to a "credit score"?

"The Healthcare Analytics tool will be used after patients receive care and after a bill is generated to help hospitals make better financial planning decisions, Hurley said." What a load of crap - and they actually expect anyone to believe it?!

YIKES! It is kind of scary that things like this are being seriously contemplated.

 

[Faebinder]

WOW WOW WOW.... I mean on one hand I recognize how in our world of medicine we need money cause a lot of things are going without being paid for... on the other hand that link just made a chill run down my spine.

Hard decisions are up ahead of us it seems. Back in the old times, physicians did indeed do charity work but the truth be told.. those without pay capability did not get treated because it would sink physicians down. We have been lucky to avoid these hard decisions because insurance is doing the dirty job for us: denying the patient treatment they cant afford.

 

[PsyKardinal]

This medical credit score, and universal health care are both scary concepts that we will have to work through and adapt to at some point. I fear what a huge godawful buearcratic mess it will all become. As an LPC I seriously am concerned that all independent practioners will get screwed royally by the coming changes. Good luck to all.

Jeff

 

[HCE]

This medical credit score, and universal health care are both scary concepts that we will have to work through and adapt to at some point. I fear what a huge godawful buearcratic mess it will all become. As an LPC I seriously am concerned that all independent practioners will get screwed royally by the coming changes. Good luck to all.

Jeff

I don't see these concepts as similar at all...quite the opposite...the medical credit score sounds like a clever-talking technique dreamed up by private insurers/banks and other "free-enterprise" vanguards. Universal Health is an attempt to take health care out of the hands of the private insurers..maybe I'm missing something, but I guess we don't know enough yet about this thing. I would add the word "more" between "screwed" and "royally", since said screwing is already happening.

 

[futuredo32]

WOW WOW WOW.... I mean on one hand I recognize how in our world of medicine we need money cause a lot of things are going without being paid for... on the other hand that link just made a chill run down my spine.

Hard decisions are up ahead of us it seems. Back in the old times, physicians did indeed do charity work but the truth be told.. those without pay capability did not get treated because it would sink physicians down. We have been lucky to avoid these hard decisions because insurance is doing the dirty job for us: denying the patient treatment they cant afford.

I've only had a few months of rotations, so I'm sure there's a ton I haven't seen, but I have never seen a patient denied care for any reason. Is it all that common?

 

[Faebinder]

I've only had a few months of rotations, so I'm sure there's a ton I haven't seen, but I have never seen a patient denied care for any reason. Is it all that common?

Huh?! You mean back in the days or now? Back in the days you get denied medical care if you dont have money.. now with insurance, you will get denied surgeries/interventions/medications/hospitalizations. In the hospital your view is skewed because everyone in the hospital is probably not denied anything obvious. In the hospital, you will occasionally see someone not get medicine A because they cant afford it or procedure B because they cant afford it but not as common. As an outpatient, people don't know what they are truly being denied. The reduced reimburisement for psychotherapy is an example.

 

[futuredo32]

Huh?! You mean back in the days or now? Back in the days you get denied medical care if you dont have money.. now with insurance, you will get denied surgeries/interventions/medications/hospitalizations. In the hospital your view is skewed because everyone in the hospital is probably not denied anything obvious. In the hospital, you will occasionally see someone not get medicine A because they cant afford it or procedure B because they cant afford it but not as common. As an outpatient, people don't know what they are truly being denied. The reduced reimburisement for psychotherapy is an example.

Thanks. 🙂
I did mean now and not in the past. I have seen doctors ask about a patient's insurance coverage and offer less expensive drugs based on insurance, but haven't seen anything else that seemed to differ in patient care between patients with and without insurance.

 

[whopper]

I've seen plenty denied certain things.

Psychiatrically: several patients cannot afford the nongeneric meds, psychotherapy, addiction rehab, brain scans (to help r/o organic pathology), private inpatient institutions.

And another thing bugging me is I've seen several doctors prescribe meds with no consideration if the patient could afford them. I've seen dozens of patients with no insurance, no financial assistance & with very limited economic support prescribed lexapro, and no one told them citalopram was available for $4/month, then not be able to afford the lexapro. When I tell them about the $4 alternative they're all upset--"why didn't my doc tell me about this? I would've rather taken that!"

I'm not suggesting that poor patients only be given generics, but for several, the generics work just as good, and the pt is more than willing to take it because of the cheaper price. I've seen several who could afford the nongeneric want the generic just so they could save the money.

 

[OldPsychDoc]

I've seen plenty denied certain things.

Psychiatrically: several patients cannot afford the nongeneric meds, psychotherapy, addiction rehab, brain scans (to help r/o organic pathology), private inpatient institutions.

And another thing bugging me is I've seen several doctors prescribe meds with no consideration if the patient could afford them. I've seen dozens of patients with no insurance, no financial assistance & with very limited economic support prescribed lexapro, and no one told them citalopram was available for $4/month, then not be able to afford the lexapro. When I tell them about the $4 alternative they're all upset--"why didn't my doc tell me about this? I would've rather taken that!"

I'm not suggesting that poor patients only be given generics, but for several, the generics work just as good, and the pt is more than willing to take it because of the cheaper price. I've seen several who could afford the nongeneric want the generic just so they could save the money.

If we're not paying attention to this stuff, we're not helping the patient. How can we blame a patient for non-compliance when we're not giving any thought to their ability to afford the next month's prescription? The damn Forest reps turn us into Lexapro pushers--when after 4 weeks their own data shows no separation between celexa and lexapro in effectiveness!

 

[whopper]

How can we blame a patient for non-compliance when we're not giving any thought to their ability to afford the next month's prescription?

Agree--its a 2 way street. Patients need to be in charge of their health, but so do doctors.

Its a shame because one of the places I've seen, its the social workers demanding the docs give out more generics, because those social workers are the only ones really concerned about the disposition after discharge.

Doctors have an insulated position in this regard. We're like mechanics with customers that know nothing about car repair. IF we give patients some advice--they don't know enough to tell if we're giving them enough info.

That's one of the reasons why I was on my Seroquel rant several months back. Its become the new antihistamine everyone's giving out. Why not just give out benadryl?

Just as much as I've ranted about certain patients wasting the system's money, so to are certain doctors in this regard.

 

[BabyPsychDoc]

Its a shame because one of the places I've seen, its the social workers demanding the docs give out more generics, because those social workers are the only ones really concerned about the disposition after discharge.

Maybe, it is because the doctors are not trained to think about these issues.

Doctors have an insulated position in this regard. We're like mechanics with customers that know nothing about car repair. IF we give patients some advice--they don't know enough to tell if we're giving them enough info.

Erm....S/he does not need to understand all the intrinsic pathways and receptors in the brain, but s/he may well be taught the basic information necessary to manage her/his illness. (Eg, "You need to take this medication three times a day, because if you do not you will find [fill in the blank] and that could lead to [fill in the blank]. And if the medication is working, then you can expect [fill in the blank], and if it does not seem to work within this period of time, we may think about making some adjustments. And, you might develop this or that side effect, and this is what you should look out for".) Obviously, the amount of detail you give to each patient needs to be tailored to their understanding, which will depend on the intellectual ability, SES, level of education as well as severity of their mental illness. I would think, it is a part of our job to determine the level of patient's understanding: it is like a part of the initial assessment, imho.

 

[whopper]

Maybe, it is because the doctors are not trained to think about these issues.

I think its more that the certain docs don't care & they aren't being held liable by their respective institutions. At least where I'm at, this isn't just one place, one hospital, one practice, one discipline. Its everywhere.

I have of course seen several doctors make sure their patients can afford the meds, but the number doing so is not the overwhelming majority.

Just like some docs always give the same antipsychotic, some of the older docs still give out tricyclics because that's what they're used to doing, its IMHO more laziness than lack of training.

S/he does not need to understand all the intrinsic pathways and receptors in the brain, but s/he may well be taught the basic information necessary to manage her/his illness.

True--and cost of the medication is one of the factors involved. Most of my patients, when I give them the option & explain the differences between lexapro & citalopram usually pick citalopram, even the patients that can afford lexapro. Most of the patients I see being prescribed lexapro that aren't mine are just assigned the med-the patient had no say & doesn't have an idea of the price or the choices of the other meds.

I understand that most of us do not have the time to educate the patient on everything, especially in the age of managed care, however when a patient cannot afford a nongeneric, price, choice of med & alternative means of getting that med obvioiusly are issues that need to be discussed.

 

[biogirl215]

As much as I know I'm going to regret sticking my head in here and commenting on politics, I'm pro-universal health care (not necessarily government-run) because non-group policies seem to have a system of "If you get sick, we WILL find a way to drop your coverage," which is something I'm surprised that more physicians, psychologists, and other self-employed hc providers aren't worried about. Also, the amount of paper work the current system generates is appalling--I've seen a urgent care clinic bill something six times in one day because they didn't know what to bill it as. I can't imagine trying to deal with that on top of dealing with cancer or another serious disease.

I've known plenty of people (many of them children) whose serious diseases/disorders (leukemia, chemo-related vision loss, brain tumors, massive brain damage, etc.) couldn't be tied to the old mantra of obesity, two packs a day, and a 12 pack of Bud Light. People should try to take care of themselves, yes, but that doesn't mean you'll never get sick.

On an aside, I know I can never financially afford to be self-employed--I'm one of those damn "uninsurable" people, due to cerebral palsy (why a non-progressive condition would make one uninsurable, I have no idea)--certainly not something I could have prevented with "lifestyle choices" (fyi, my mother was a "model" of good prenatal care--didn't make a difference). I could likely never afford to practice privately due to the high costs (premiums and deductibles) of high-risk pool insurance and couldn't do so at all in states like Florida, where there is no open high risk pool.

Just my two cents.

 

[TheWowEffect]

As much as I know I'm going to regret sticking my head in here and commenting on politics, I'm pro-universal health care (not necessarily government-run) because non-group policies seem to have a system of "If you get sick, we WILL find a way to drop your coverage," which is something I'm surprised that more physicians, psychologists, and other self-employed hc providers aren't worried about. Also, the amount of paper work the current system generates is appalling--I've seen a urgent care clinic bill something six times in one day because they didn't know what to bill it as. I can't imagine trying to deal with that on top of dealing with cancer or another serious disease.

I've known plenty of people (many of them children) whose serious diseases/disorders (leukemia, chemo-related vision loss, brain tumors, massive brain damage, etc.) couldn't be tied to the old mantra of obesity, two packs a day, and a 12 pack of Bud Light. People should try to take care of themselves, yes, but that doesn't mean you'll never get sick.

On an aside, I know I can never financially afford to be self-employed--I'm one of those damn "uninsurable" people, due to cerebral palsy (why a non-progressive condition would make one uninsurable, I have no idea)--certainly not something I could have prevented with "lifestyle choices" (fyi, my mother was a "model" of good prenatal care--didn't make a difference). I could likely never afford to practice privately due to the high costs (premiums and deductibles) of high-risk pool insurance and couldn't do so at all in states like Florida, where there is no open high risk pool.

Just my two cents.

I think you make some very good points. While I am not for government run free-for-all health care system, something needs to done for the hordes of uninsured and uninsurable.

Think of a hard working factory worker who loses his job. He gets a new job after a few months but they don't offer health insurance. He decides to try a solo plan. He/she has DM, HTN and this is not from unhealthy eating habits. Remember DM can be genetic and HTN can be a consequence. He calls up an insurance compnay and is told that either he can't be insured because of pre-existing conditions or he'll have to pay a very high premium which almost equals 2 weeks of his wages😱. This is just one example of how horrible the system is.

Now, I am not sure what that "something" is but judging from the political climate, I am sure that "something" is going to happen within next 3-5 years. We should all be prepared. For psychiatry point of view, it might turn out to be good rather than bad.

P.S.- When a service industry is making record profits and consumers are hardly satisfied, something is not quite right. First thing we need is- More oversight and accountibility for the insurance industry. More permanant solutions can then follow this.

 

[futuredo32]

I think you make some very good points. While I am not for government run free-for-all health care system, something needs to done for the hordes of uninsured and uninsurable.

Think of a hard working factory worker who loses his job. He gets a new job after a few months but they don't offer health insurance. He decides to try a solo plan. He/she has DM, HTN and this is not from unhealthy eating habits. Remember DM can be genetic and HTN can be a consequence. He calls up an insurance compnay and is told that either he can't be insured because of pre-existing conditions or he'll have to pay a very high premium which almost equals 2 weeks of his wages😱. This is just one example of how horrible the system is.

Now, I am not sure what that "something" is but judging from the political climate, I am sure that "something" is going to happen within next 3-5 years. We should all be prepared. For psychiatry point of view, it might turn out to be good rather than bad.

P.S.- When a service industry is making record profits and consumers are hardly satisfied, something is not quite right. First thing we need is- More oversight and accountibility for the insurance industry. More permanant solutions can then follow this.

I think that if health insurance wasn't tied to one's job, it would help with situations like the one that you described. If employers paid employees the money that they were spending on health insurance instead of just giving the employee health insurance, the employee could spend that money on any health insurance they chose and could take it with him/her from one job to the next. Of course, not all employees would actually spend the extra money on health insurance.🙁

 

[TheWowEffect]

I think that if health insurance wasn't tied to one's job, it would help with situations like the one that you described. If employers paid employees the money that they were spending on health insurance instead of just giving the employee health insurance, the employee could spend that money on any health insurance they chose and could take it with him/her from one job to the next. Of course, not all employees would actually spend the extra money on health insurance.🙁

One problem with this is that emloyers can negotiate cheaper rates with insurance companies but an individual can not. That is why there is a need for oversight and regulation for the insurance companies.

 

[MBK2003]

Just like some docs always give the same antipsychotic, some of the older docs still give out tricyclics because that's what they're used to doing, its IMHO more laziness than lack of training.

Frankly, this is one of the reasons that I am in favor of preferred medication lists, needing prior authorizations for non-preferred medications, and for closer scrutiny of physician prescribing practices (particularly for the multiple antipsychotic Rx patients). Yes PAs are a pain in my butt, but I'm tired of seeing adolescents for psychopharm second opinions who have gotten trials of Effexor XR and Cymbalta, one of which has been shown to be not effective in adolescent depression, and surprisingly the teens are still depressed and not functioning. If any of these kids had been medicaid, the PCP would have quickly realized the Prozac and Zoloft are 1st line for adolescent depression. It's the same with the ADHD-ODD kid (diagnosed by PCP and parents as pediatric bipolar) who comes to me from the PCP on Abilify qam and Seroquel qhs (for sleep of course). Again, had they been on medicaid, this would be unacceptable practice without a child psychiatrist weighing in.

Sorry for the rant!

 

[whopper]

Hey, rants are cool, besides, we're your colleagues--we'll understand and we probably have the same frustration.

I got a problem with employer mandated healtch care.
1-it sticks a big burden on employers. Several small businesses cannot afford them nor afford their employees the big savings that big business paid healthcare provides.
If anything this hurts the small business owner the most, while it doesn't hurt as badly the big business owner (but it still hurts them too).

2-employer paid healthcare can diminish patient privacy.
(for that reason, I am strongly against Edwards--he wants business to bear the burden of healthcare.)

I also got a problem with "free market" health coverage. As with my example with the meds mentioned above, healthcare is often not a simply supply vs demand situation where the consumer (the patient) knows if they want the product or not. Often times they only know what their doctors tell them-and the doctor as mentioned above often times will not give them enough information for that patient to make the best informed decision.

Several factors in healthcare go against the capitalist model
1-healthcare funds are organized as communal
2-patients do not have enough data to make informed consumer decisions
3-several patients do not take responsibility for their own health until they reach "emotional insight", and that is often times when it is most expensive to treat the disease (they don't lower their cholesterol until after the MI, then after that they'll do anything you tell them to do).

In short--this is a convoluted problem and I fear that because of its complicated nature, any system proposed will be far from ideal, add to that the number of special interests that are willing to throw a hammer on any suggestion that will take away their stake in the pie.

My suggestion-separation needs to be done on what aspects work by market driven forces, and the factors that don't. Those factors that do work by market factors need to be kept free market. Others, such as factors that are communal need to have systems where people are given incentives to act communally.

What we got now is a system that does not encourage communal activism nor is it allowing the free market to do what it normally does best--provide the best price with the highest quality. Both need to be tapped.

 

[OldPsychDoc]

One problem with this is that emloyers can negotiate cheaper rates with insurance companies but an individual can not. That is why there is a need for oversight and regulation for the insurance companies.

👎

That's why we ought to just cut out the middleman and get rid of the insurance companies...

 

[TheWowEffect]

👎

That's why we ought to just cut out the middleman and get rid of the insurance companies...

I guess we'll have to start with regulating them and then, may be, eventually get rid of them😉


P.S.- But then, I used to think that I was a citizen of United States of Utopia until I realized I actually lived in United States of America.

 

[OldPsychDoc]

I think that if health insurance wasn't tied to one's job, it would help with situations like the one that you described. If employers paid employees the money that they were spending on health insurance instead of just giving the employee health insurance, the employee could spend that money on any health insurance they chose and could take it with him/her from one job to the next. Of course, not all employees would actually spend the extra money on health insurance.🙁

Again, cut out the middle-man. Make insurance mandatory. Premiums paid through taxes (like Medicare). Yes, taxes go up, but so do wages. Costs go down. Providers, hospitals still can have incentive to compete in marketplace based on evidence-based health care, measured outcomes, etc. Individuals can have incentives to reduce their own health care burden through tax credits/discounts for "good behaviors" or reduced utilization--but for those who need care, it will be there and paid for.

Yes I know I'm a shameless liberal on the socialist fringe...but sometimes we can be right about things. (Conservatives are right sometimes too--Reagan did win the Cold War, despite my screams of protest back in the day...)

 

[MBK2003]

Providers, hospitals still can have incentive to compete in marketplace based on evidence-based health care, measured outcomes, etc. Individuals can have incentives to reduce their own health care burden through tax credits/discounts for "good behaviors" or reduced utilization--but for those who need care, it will be there and paid for.

While we're at it, can we get some more outcomes research in all areas of medicine, so that we can help patients make decisions about whether to pursue x, y, or z treatment? In the same way that I'm not excited about paying for a questionable surgery for low back pain, I'm also not excited about paying for 2 years of play therapy/sand therapy for ADHD/ODD (why 2 years you ask, because "he wasn't doing better").

And if I'm asking for the world, however about seamless electronic access to medical records and diagnostic testing results.

 

[biogirl215]

I think you make some very good points.

Thanks!🙂

I think that if health insurance wasn't tied to one's job, it would help with situations like the one that you described. If employers paid employees the money that they were spending on health insurance instead of just giving the employee health insurance, the employee could spend that money on any health insurance they chose and could take it with him/her from one job to the next. Of course, not all employees would actually spend the extra money on health insurance.🙁

The problem I see with this, in addition to what Wow pointed out, is the issue of lifetime benefits caps, which are usually about $1-1.5 million, though I've seen them as low as $100k (how much that would protect you in the event of a serious illness, I don't know) and as high as about $2.5 million. High risk pools generally run at about $1 million, with a few higher and many significantly lower. The uninsurable, who can only be served by a high risk pool, would be SOL if they exceeded the lifetime benefit cap, especially as most states require 18 months of residency to buy into the state's high risk pool, and the move and waiting peroid would probably not be feasible for someone whose medical condition(s) lead them to "use up" the cap. The nice thing about group health insurance is that getting a new job also "resets" the cap, so the speak.

(FYI, the first three months of my life used about $1 million in payout, so I know it is definitely possible to reach those levels... Ideally, no one should ever have to, but it happens).

 

[PeeWee137]

Yes I know I'm a shameless liberal on the socialist fringe...but sometimes we can be right about things. (Conservatives are right sometimes too--Reagan did win the Cold War, despite my screams of protest back in the day...)

its ok to be a liberal and a doctor!!! i got ripped apart the other day for saying i may vote for one of the democratic candidates. why does being a doctor mean you have to vote republican?!? and it makes me feel super selfish to vote for someone that will solely benefit me and my chosen career. there are much bigger problems out there.


sorry i have nothing useful to add to this riveting discussion. i really am learning alot from everyone's comments. 🙂 carry on.

 

[futuredo32]

The problem I see with this, in addition to what Wow pointed out, is the issue of lifetime benefits caps, which are usually about $1-1.5 million, though I've seen them as low as $100k (how much that would protect you in the event of a serious illness, I don't know) and as high as about $2.5 million. High risk pools generally run at about $1 million, with a few higher and many significantly lower. The uninsurable, who can only be served by a high risk pool, would be SOL if they exceeded the lifetime benefit cap, especially as most states require 18 months of residency to buy into the state's high risk pool, and the move and waiting peroid would probably not be feasible for someone whose medical condition(s) lead them to "use up" the cap. The nice thing about group health insurance is that getting a new job also "resets" the cap, so the speak.

(FYI, the first three months of my life used about $1 million in payout, so I know it is definitely possible to reach those levels... Ideally, no one should ever have to, but it happens).

I understand what you and OldPsychDoc are saying and I agree our current system is far from perfect. We would save a lot of money if we cut out the middle man, but I would rather fix our existing system instead of just scrapping it and ending up with lower quality healthcare like they have in countries with socialized medicine where people die while on waiting lists.

I think that oversight and regulation for the insurance companies make healthcare much more attainable for so many and some of the candidates have suggested insurance portability and allowing people to buy insurance across state lines.

 

[OldPsychDoc]

I understand what you and OldPsychDoc are saying and I agree our current system is far from perfect. We would save a lot of money if we cut out the middle man, but I would rather fix our existing system instead of just scrapping it and ending up with lower quality healthcare like they have in countries with socialized medicine where people die while on waiting lists. .

I'd REALLY like to see some figures about this "dying on waiting lists" that I hear so much about---particularly to compare it to the risks of "dying uninsured" here in the Land of Plenty. 🙁 Because, really, there's Plenty of dying going on out there, and poverty is a clear risk factor for premature mortality.

I think that oversight and regulation for the insurance companies make healthcare much more attainable for so many and some of the candidates have suggested insurance portability and allowing people to buy insurance across state lines.

Interesting...as an alternative to the evils "socialized medicine", you suggest that the solution might be found in another layer of bureaucratic regulation? 😕

And on a related subject...

 

[nancysinatra]

why does being a doctor mean you have to vote republican?!?

(Warning: the following is truly a rant. You can see that I did not study at all during MLK weekend and now am several days behind, and picturing myself flunking out, which of course makes me think of med school as being totally unfair--the absolute epitome of cruel, unregulated forces gone awry. Not trying to offend anyone here though!)

I wonder if there is any correlation between the ruthlessly cutthroat nature of med school and the fact that so many doctors are republicans. I would think that for your average bleeding heart liberal--who wants to see everyone thrive and do well--a typical day of med school would be kind of tough. Especially in the first two years. At least at my school, there's a really overt sense of competition during those two years. If you're not interrupting someone in PBL, you're staring at an exam score posted on a wall, calculating how everyone did in terms of mean and standard deviation. It's a perpetual process of some people rising to the top while others are falling to the bottom. For socialist types (like me), this is just painful to have to watch. Whereas I think my classmates who take a rather laissez faire view of the world and don't mind that stuff--I think they have a better experience in med school! Maybe they find inspiration just being there. Whereas maybe liberal-minded people tend go into fields that are more affirming of ALL the people in them. I know my mom (who's a democrat) is in social work, and there, it seems like if you want to say the slightest, even halfway critical thing about someone, you have to do it in the nicest possible way, complementing them first and only after a long time really ever getting to the point. None of this "you're two standard deviations below the mean and we're going to post it in public!" that we see in med school. (However, my mom is a lutheran who lives in Minnesota so that could explain the over-the-top niceness too.) Anyway, I'm just saying. Med school (to say nothing of pre-med!) is one big filtering process, and not everyone likes to see people sorted out that way. It can be hard if you're the type who wants everyone to succeed.

 

[nancysinatra]

Reagan did win the Cold War, despite my screams of protest back in the day...)

Are you sure? I mean, wouldn't the USSR have collapsed in 1991 either way? Their internal problems were pretty bad, so bad that I doubt either Carter (in 1980, right?) or Mondale (in 84), if they'd been president instead of Reagan, would have been able to prop them up even if they'd wanted to. I'm not saying they DIDN'T want to--just that it would have been awfully hard. Anyone who was there at that time might have "won" the Cold War...

 

[futuredo32]

I'd REALLY like to see some figures about this "dying on waiting lists" that I hear so much about---particularly to compare it to the risks of "dying uninsured" here in the Land of Plenty. 🙁 Because, really, there's Plenty of dying going on out there, and poverty is a clear risk factor for premature mortality.

Interesting...as an alternative to the evils "socialized medicine", you suggest that the solution might be found in another layer of bureaucratic regulation? 😕

I searched high and low and couldn't find any reliable overall statistics about deaths in countries with socialized medicine due to being on a waitlist nor could I find any about people dying in the US because they didn't have insurance. I did ask here before about people being denied treatment due to their inability to pay and the consensus seemed to be that no one had seen a patient denied anything obvious, which I interpreted to mean that no one had seen a single patient die because they were uninsured. (not scientific by any means, but I couldn't find any reliable source that said anything to the contrary.) We do provide care for the poor, our tax dollars pay for their Medicaid. Poverty is a risk factor for mortality, but the poor are more likely to smoke, eat unhealthy, abstain from exercise, etc.
I did find the following-

138 people died on a waiting list for heart surgery in the Netherlands in 1994. http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=10336916

" The Health Service may not be able to afford the next generation of cancer drugs, senior doctors have warned. Specialists fear that the NHS will be "crippled" by the increasing range of breakthrough treatments. Some believe that private health insurance is the only way to fund the most expensive drugs. Their concerns raise the prospect of cancer patients spending thousands to have a chance of survival. Furthermore, if patients pay for their own drugs, many NHS trusts refuse to cover the cost of care. Ministers have ruled out "co-payment", saying it would undermine the founding principle of the NHS if the well-off, who could afford to buy drugs privately, also received free care.
Nick James, professor of clinical oncology at the University of Birmingham, said the gap between the drugs available and what the NHS can afford to fund, will grow. The NHS cannot afford to pay for all care for all patients now and certainly won't be able to in the future. The individual may have to play a greater role."

(I didn't post the entire article, just bits and pieces)
So either no one in the UK will have access to the latest and greatest cancer treatment or just the wealthy will be able to purchase the best medicine available to save their lives despite the fact that the entire country pays for healthcare with their taxes.
http://www.dailymail.co.uk/pages/li...ain.html?in_article_id=454891&in_page_id=1774

The economic cost of waiting for health care in Canada was nearly $15 billion in 2007, according to new data released Tuesday by the Canadian Medical Association.
http://www.nationalpost.com/news/story.html?id=239713
A typical Canadian seeking surgical or other therapeutic treatment had to wait 18.3 weeks in 2007, an all-time high, according to new research published Monday by independent research organization the Fraser Institute.

The 2007 survey found the total median waiting time for patients between referral from a general practitioner and treatment, averaged across all 12 specialties and 10 provinces surveyed, increased to 18.3 weeks from 17.8 weeks observed in 2006. This was primarily due to an increase in the first waiting period, between seeing the general practitioner and attending a consultation with a specialist.
Ontario recorded the shortest waiting time overall (the wait between visiting a general practitioner and receiving treatment) at 15.0 weeks, followed by British Columbia (19.0 weeks) and Quebec (19.4 weeks). Saskatchewan (27.2 weeks), New Brunswick (25.2 weeks) and Nova Scotia (24.8 weeks) recorded the longest waits in Canada.

http://www.healthservices.gov.bc.ca/cpa/mediasite/waitlist/median.html

NHS dentists are refusing to treat patients with poor teeth because they do not get paid enough to carry out the work.......

http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/05/28/nhs28.xml
There were many more articles like those above and I would hate to be a patient in any of these countries. I would definitely prefer some government intervention in the US to ensure that we do not spend time waiting lists. Not all of the people on waiting lists die, it seems like some would die witing almost a half a year to see a specialist. And for those who are, for example, waiting for a joint replacement, spending weeks on end in pain due to a needed joint replacement can have many reprocussions - narcotic addiction, loss of income due to an inability to work, muscle weakness, etc. Our healthcare system is far from perfect, but IMO, it's far superior to anywhere else. I'd rather that we worked to improve our healthcare system by regulating the insurance agency and encouraging people to take responsiblity for themselves (if they are physically and mentally capable of doing so) instead of switching to the alternative.

 

[Therapist4Chnge]

I think as people age they get more conservative, and I'd think that as income increases they'd become more conservative. I'd think both factors contribute to your idea nancy.

I know I am in the minority being a grad student and republican, but eventually more people will come around to the dark side. 😀

-t

 

[Hurricane]

I think as people age they get more conservative, and I'd think that as income increases they'd become more conservative. I'd think both factors contribute to your idea nancy.

Maybe I'm still young (ok, no) and naive, but I find it really sad that people would change their beliefs on a range of social justice issues because they have more money. Or, alternatively, vote for people with the opposite position on such issues because their fiscal conservatism wins out.

 

[OldPsychDoc]

Maybe I'm still young (ok, no) and naive, but I find it really sad that people would change their beliefs on a range of social justice issues because they have more money. Or, alternatively, vote for people with the opposite position on such issues because their fiscal conservatism wins out.

Winston Churchill is quoted as saying that one who is not liberal at age twenty has no heart, and one who is not conservative at fifty has no mind.

I think it has less to do with one's fiscal position in life than a mark of how life experience and pragmatism tends to wear down one's youthful idealism. (Speaking as one FAR closer to 50 than to 20 🙁) Still, as you all can see, I haven't wholly sold out to The Man. 😀 I've also found it interesting that my parents, Cold-War-raised Eisenhower/Nixon Republicans, were both working in Reaganomics-ravaged social programs by the late 1980s, and have totally swung to the left now as Medicare-dependent seniors!

 

[Therapist4Chnge]

Winston Churchill is quoted as saying that one who is not liberal at age twenty has no heart, and one who is not conservative at fifty has no mind.

I think it has less to do with one's fiscal position in life than a mark of how life experience and pragmatism tends to wear down one's youthful idealism. (Speaking as one FAR closer to 50 than to 20 🙁) Still, as you all can see, I haven't wholly sold out to The Man. 😀 I've also found it interesting that my parents, Cold-War-raised Eisenhower/Nixon Republicans, were both working in Reaganomics-ravaged social programs by the late 1980s, and have totally swung to the left now as Medicare-dependent seniors!

I really think that is a big part of it.

-t

 

[whopper]

Having liked in the UK for 3 months while being a foreign student in their NHS system....

I searched high and low and couldn't find any reliable overall statistics about deaths in countries with socialized medicine due to being on a waitlist nor could I find any about people dying in the US because they didn't have insurance.

As with pretty much all socialized health systems, the waiting list is only for non-emergency cases. If someone had an acute/emergency situation that required immediate action it was given.

However don't be so quick to now welcome that system. Several patients had to wait over a year to get even simple medical procedures/surgery if it were not an emergency. Several of them were not able to work as a result of the waiting list--and as a result were then put on welfare for the duration. In the UK, welfare differed vs the US. People were more open to taking & using it, while in the US, its culturally seen as a mark of shame to be on welfare.

Imagine the gov waste--a guy being put on welfare for a year because he had to wait for his hernia surgery?

While we're at it, can we get some more outcomes research in all areas of medicine, so that we can help patients make decisions about whether to pursue x, y, or z treatment?

Not exactly what you mentioned but similar, If everyone in the US had an advance directive, this could save the system a lot of money because ICU intervention is very expensive. Several people, if they took the time to think about it would've rather been DNR. Take a look at the Terry Schiavo case. Had she had a written advance directive, imagine the amount that would've been saved that had gone into the legal battle & medical care. IMHO-adding to the "credit" system I mentioned, someone with an advance directive ought to get a credit for that.

why does being a doctor mean you have to vote republican?!?

I'm in a blue state-NJ. Most of the docs I know who voted GOP in the national election did so not because they liked the GOP but because they disliked the Dems even more. The last presidential election, one of the hospitalists mentioned, "Bush is a buffoon, but I cannot vote for Kerry & Edwards. Edwards was a freakin ambulance chaser!!"

The special interests unfortunately have messed up the issue. The GOP has more backing from insurance companies, and the Dems have more funding from trial lawyers--so guess what? The GOP uses every bad lawyer stereotype it can when it comes to the healthcare debate and selectively argues for tort reform. The Dems do the same with private healthcare, selectively pushing against insurance companies. Each side is entrenched with the special interest money. Whenever someone wants to fix the system and it means gaining ground on the other side--the special interest starts pouring in money in negative ads. After a few months of it, everyone gets sick of the issue and it gets put under the rug for a few years.

 

[OldPsychDoc]

I'm in a blue state-NJ. Most of the docs I know who voted GOP in the national election did so not because they liked the GOP but because they disliked the Dems even more. The last presidential election, one of the hospitalists mentioned, "Bush is a buffoon, but I cannot vote for Kerry & Edwards. Edwards was a freakin ambulance chaser!!"

.

I think we should all vote Republican, given how their policies have provided us with such a wealth of new PTSD and TBI to treat.🙁

 

[Hurricane]

Not exactly what you mentioned but similar, If everyone in the US had an advance directive, this could save the system a lot of money because ICU intervention is very expensive. Several people, if they took the time to think about it would've rather been DNR. Take a look at the Terry Schiavo case. Had she had a written advance directive, imagine the amount that would've been saved that had gone into the legal battle & medical care. IMHO-adding to the "credit" system I mentioned, someone with an advance directive ought to get a credit for that.

While I agree that end-of-life care eats up a disproportionate amount of heath care spending, there's something about providing a financial incentive for being DNR that makes me uncomfortable. I have to say I'm not a big fan of your point system proposal. I think it favors the wealthy. Lower-socioeconomic classes are more likely to fit many of the demographics you want to penalize: for example, they're more likely to be obese, in part because healthy food costs more, etc. And I also think tax-credit incentives and health savings accounts favor the higher classes, because who else is going to be able to figure them out, or hire somebody to figure them out for them?

Anyway, this year our insurance got changed from Cigna to Aetna. Last night as I was navigating the crappy-ass Aetna website trying to figure out what the hell my benefits are, it dawned on me that all of the candidates' solutions (except Kucinich who hasn't got a snowball's chance in hell) involves covering everyone under the same f'd up system of private insurance companies we've got now, a system that is despised by both consumers and providers. Because everyone is howling about "choice." Yeah, like I had so much choice when my employer decided to switch insurance companies. (why should your employer be involved at all in your health coverage anyway?) I mean, yeah, theoretically I could have opted out, but really, come on. Under our current system, "choice" is in effect a myth. And even if people really do have a choice, what's the point if the choice is between bad or worse.

Sorry for the rant. Color me cranky.

 

[whopper]

there's something about providing a financial incentive for being DNR that makes me uncomfortable. I have to say I'm not a big fan of your point system proposal.

I'm not saying give financial incentive for being DNR. Give financial incentive for just having an advance directive-period.

Lower-socioeconomic classes are more likely to fit many of the demographics you want to penalize: for example, they're more likely to be obese, in part because healthy food costs more, etc. And I also think tax-credit incentives and health savings accounts favor the higher classes, because who else is going to be able to figure them out, or hire somebody to figure them out for them?

I also suggested a fat tax, and other ideas such as taking unhealthy food out of schools & putting in healthy food instead. (Kinda like in Super-Size Me). If anything the proposal's I'd like would give incentives for the very people you are mentioning to get fit & in shape. It doesn't just have to be seen as punishment. Several businesses for example are offering rewards for people who keep in shape, and studies are showing those reward systems have siginificant effect.

But maybe we'll have to agree to disagree....then again, like anyone's going to implement my suggestion!