Which specialty will get hurt the most by Socialized Healthcare?

[Tulaner]

I am personally offended that a Canadian is coming on here, asserting a position on the AMERICAN health care system, which provides an existential threat to the uniquely AMERICAN way of life, and then makes fun of us using nothing more than petty name calling.

Guess what, McGill, if Benedict Arnold had won the Battle of Quebec, your country wouldn't even exist. If the militia of New York had followed orders and invaded undefended British forts in 1813, your country wouldn't exist.

If the US had not been there to defend you against the Nazis and the communist USSR, your country wouldn't exist.

You have lived your entire existent holding on to daddy Britain coat saying "Daddy, protect me!" You were too cowardly to revolt when we did.

Your socialist system has been propped up for years by its proximity to the US system. While socialized medicine is great for a cold, it is catastrophic if you need experimental brain surgery or any test requiring expensive equipment.

Even though your government doesn't provide choice. Your people effectively have a private option by traveling 100 miles South to the land of the Free. Socialized Medicine in the US will also be bad for Canadians and INCREASE YOUR COSTS.

Please stop commenting on American public policy. You literally have no vote on the subject as a foreigner. And I'm glad, because you're either hopelessly brainwashed or ignorant or both. In any case, your methods of debate are juvenile and insulting for someone with a set-presumed level of education.

By the way, my aunt lives in Toronto. She needed a hip replacement. So did her poodle. She could go to her vet and pay for her dog to get one on demand. She had to wait 11 months to get one in Canada. 11 months of chronic pain and disability. True story.

Maybe I should have become a freakin' vet. There not socializing animal medicine any time soon. Why? Because animals tough it out and don't flood the available airways with sob stories.

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[Tulaner]

You know, I've actually figured it out. McGill isn't even a physician. He's not even a medical student, I guarantee he is no older than the age of 20. He is the classic internet troll who gets enjoyment out of goading people. I bet he is a Canadian HS student who backs up ridiculous assumptions with cursory google searches.

There is no reasoning with this man, because he is not a man, he is a child. Clearly, he is, as only a child could act like this. I remember being young, naive, and hurtful. He is only wasting the valuable time that we, as professionals, can translate into actual productivity. He, on the other hand, is using this as a procrastination tool to put off doing his geometry homework.

Even for people on here who for some reason want socialized medicine, they try and support their statements with facts and respectful discourse.

While we are on here to engage in genuine debate, he is on here just to push people's buttons. In this case, the buttons of people far more accomplished than himself. His immaturity is the only thing on display.

I suggest people on both side of this debate simply IGNORE everything he says. He could post 50% of the posts in this thread. Disregard them. They are invisible and irrelevant. He is not on here to debate anything real.

We should not give him the respect we give each other as a natural function of being older and intelligent. Because he is most evidently neither.

 

[Geri_Gal]

Woah. What is with the personal attack?

McGill is the only Canadian on this forum and provides a valuable perspective.

There is a world that exists outside the United States. Are we really the land of the Free, when our young physicians are burdened with $250,000 of debt?

Globalization & the internet age have shaken the world's balance of power. We would benefit from listening to outside perspectives with an open mind. Jingoism and isolationist nationalism in the setting of global financial crisis have never historically ended well for nations.

 

[Bill_Brasky]

Woah. What is with the personal attack?

Go back and read McGill's posts, they are nothing BUT personal attacks and emoticons. Of course it would be interesting to have another perspective, but only if that person is interested in engaging in some sort of honest debate. I grew tired of his antics and am only back now because he seems to have left temporarily.

Edit: Now that I have found the ignore list option my life is better. He is the only one on it and in almost three years of SDN is the only person I have ever even considered ignoring.

 

[CambieMD]

I wish I knew. I interviewed for anesthesioloy and did several anesthesiology rotations in med school but the whole CRNA issued scared me away. I do not know about radiology, radiation oncology, or ortho as far as future reimbursement.

There has been talk about the death of certain specialties for years. CRNAs cannot do all of the cases out there. It is not that simple. At my facility the CRNAs have vaious comfort levels. Some place lines others don't. Some do not perform OB care. Are all of the CRNAs out there willing to take call? Are there enough CRNAs to staff all of the surgical cases performed. This issue is not as simple as some think. I can see a need for less anesthesiologists in the future but anesthesiologist will not be put out of business as a group.

Universal health care will not work in this country. There are several important issues that must be addressed. For starters. The US consumes more illicit drugs per capita than any other nation. What will be done to reduce the drug use and the resultant health issues. End of life issues need to be addressed. In England you do not receive HD if you are past a certain age. How will that issue be delt with in the US.

Cambie

 

[HarveyCushing]

Any body want to take a stab at how positions in academic medicine will be impacted vs. those in PP under socialized medicine? Since academic positions are already paid less than those in PP, will they see less of an impact if/when we move to a socialized system?

 

[gryffindor]

umm yes because it is your responsiblity to make sure you can take care of yourself instead of "gambling" with other peoples money. That's what you are doing when you say you would rather gamble and spend the money on cable, cause when you do have that catastrophe you would then go on the gubment dole and ask for taxpayer assistance.

It's the same as car insurance, a responsible person carries car insurance, even though they may never need it. I wish I had all my premiums back, but if you ever need it that makes it worth every penny.

There are catastrophic plans that suit young people well and you could get a very good deal on premiums while being covered if a major trauma/cancer etc occured. You would continue to pay cash for your regular visits, and save money on premiums by having a high deductable with coverage for catastrophic events only.

The goal is to eventually become self insured, but until you can do so it is smart to keep some kind of coverage, even if it means doing without cable.

Give up cable and take on some personal responsibility? Now there's an idea. If we actually did that, our country wouldn't be in this predicament today. I'm sure we all have at least one Medicaid patient with iPhone story to share.

 

[novastorm]

Give up cable and take on some personal responsibility? Now there's an idea. If we actually did that, our country wouldn't be in this predicament today. I'm sure we all have at least one Medicaid patient with iPhone story to share.

I take your Medicaid with iPhone and raise you on medicaid talking on a blackberry in another country for hours.

 

[badasshairday]

I think Rads will be hit, but they will still do pretty well $ wise, just not so well as they do now.

Cards will also be hit.

 

[dilated]

There is a world that exists outside the United States. Are we really the land of the Free, when our young physicians are burdened with $250,000 of debt?

Only someone with breathtaking mathematical illiteracy could describe starting 250k in debt and making 200k a year as being "burdened" compared to having no debt and making 100k. I'll take that "burden" any day over the crappy socialized paycheck.

 

[Geri_Gal]

Only someone with breathtaking mathematical illiteracy could describe starting 250k in debt and making 200k a year as being "burdened" compared to having no debt and making 100k. I'll take that "burden" any day over the crappy socialized paycheck.

There are a lot of people in this country that would take your "crappy socialized paycheck".

Debt has an insidious psychological toll and not every doc makes 200k/year. Why do you think our country has such a shortage of primary care providers? Most physicians in 'socialized' systems make a comfortable living. Our system primarily benefits the rich. Do you honestly think you will ever make as much money as an insurance or pharmaceutical company executive?

Don't worry about the U.S. health care system becoming 'socialized' -- there is a lot of fear mongering in the media about this. The entrenched interests are just worried about a change in the status quo. Any change in the structuring or regulation of the insurance industry or big pharma would likely = a lot of profit loss. Everything I've read/heard from the Obama administration involves using the current structure of private/public insurance.

 

[Chonson]

The numbers listed in this article appear to be gross (ie before expenses). 160,000 before paying rent is not good. 220,000 before paying rent etc is not good. Overhead can be 50% easily (assuming overhead in Canada is similar to overhead in USA).

Also, aren't these numbers in Canadian dollars?

 

[THX]

I am Canadian and while I'm only starting medical school next year, I thought I'd add a few things to the topic.

Personally, I've never quite understood the antagonism towards what this forum calls 'socialized medicine'. Sure, it's not perfect - but it has noble intentions and from my experience it works well when you need it the most (based upon family members and what I've seen in the hospital). Though, admittedly, it does need a fair bit of tweaking and hopefully over the next decade it will become slightly more private. I think neither the Canadian or the American system has yet to find to right balance of public/private - and change is slow because we're both anchored by ideology.

But the main issue that seems to prop up is about reimbursement rather than quality of care. I don't know why everyone believes doctors here are not paid well. Sure, they are capped and will never see a million per year, but just about every doctor I know has a fancy car, a superb home in a wealthy neighborhood and their kids go to nice schools. What else do you want? Not to mention that their medical school debt is minimal and almost non-existent in some provinces (ie. my total tuition cost over 4 years will be slightly less than 16k USD). Although, it is true that family doctors are not being treated fairly salary wise, everyone else seems to be making between 140k and 300k.

I don't know enough about how the health care system works to offer any more in-depth thoughts than what I just have - but I do think we should all be open to change.. sometimes change is good.

 

[asmallchild]

But the main issue that seems to prop up is about reimbursement rather than quality of care. I don't know why everyone believes doctors here are not paid well. Sure, they are capped and will never see a million per year, but just about every doctor I know has a fancy car, a superb home in a wealthy neighborhood and their kids go to nice schools. What else do you want? Not to mention that their medical school debt is minimal and almost non-existent in some provinces (ie. my total tuition cost over 4 years will be slightly less than 16k USD). Although, it is true that family doctors are not being treated fairly salary wise, everyone else seems to be making between 140k and 300k.

I don't know enough about how the health care system works to offer any more in-depth thoughts than what I just have - but I do think we should all be open to change.. sometimes change is good.

As a pre-med student or just being a general member of the public, I can understand how doctors or even medical students' complaints fall on deaf ears.

As a med student though, you begin to see why the complaints are so common.

16K USD doesn't even cover half my tuition. For one year.

For those who had to take out loans to cover all their tuition and living expenses (putting aside debt from college which can often be staggering for a lot of students), then try and scrounge by on a resident's salary while watching the interest accumulate, and then come out and make <150K can be a disheartening experience.

The doctors with the fancy cars and wealthy homes you speak of made their dough during times that were much more favorable towards physicians. (After all, anyone tried paying back massive loans and sporting a fancy car in a wealthy neighborhood on 150K or less? Forget about sending the kids to a nice private school, I doubt you'll even get the car payments in)

Finally, I don't think anyone has mentioned a change where physicians stand to make more (I've seen plans where primary care docs stand to lose less than specialists. Still not a gleaming future to embrace). So how can anyone welcome change with open arms?

 

[Coastie]

Go back and read McGill's posts, they are nothing BUT personal attacks and emoticons. Of course it would be interesting to have another perspective, but only if that person is interested in engaging in some sort of honest debate. I grew tired of his antics and am only back now because he seems to have left temporarily.

Edit: Now that I have found the ignore list option my life is better. He is the only one on it and in almost three years of SDN is the only person I have ever even considered ignoring.

Agreed. I don't think that the ravings of a canadian carribbean medical student have much weight when railing against the US medical system...

Socialism abounds. Obama is taking us further down the rabbit hole each day, and all patients will suffer, as will all specialties. It doesn't help that a medical student I worked with today told me that she felt that DNP's should do exactly what doctors should....

American medicine and American principles are quickly fading away in the current environment, and we have to fight for our patients to the last tooth and nail as long as we can..

 

[Excelsius]

This thread makes me sad.

So we provide all these people; lazy, illegal, otherwise with insurance on the backs of every hard working citizen of this country and in the process destroy our health care system as we know it? Will these grateful people even use their insurance wrought off the backs of the masses? It's not like anyone in this country is denied care, anyone can go into a ER and be admitted just fine, anybody who has spent any appreciable time in the ER knows this. All we are currently seeing is the end of America as we know it and this is colorfully illustrated by a wonderful Canadian in this thread. Wont be the land of the free much longer.

Are you really a medical student? I just don't get how some in the field can be so clueless about their own profession: 1. Have you seen that special on TV showing video evidence how some ERs/hospitals put their patients in a cab and drop them near the entrance of a free hospital? 2. Do you know the quality of a lot of these free hospitals? Many of them are run by students who don't know much and are just experimenting. Do you have any idea how much more it costs to go to ER than to get a preventive or at least a non-ER treatment? I don't think you know the answers to any of these questions, but you do like to talk about right or wrong.

I don't particularly disagree with your main point that everyone should pay for a treatment, but the dilemma is that there are some members of the society who just can't afford it. What can we do? When your parents get old one day, can't afford medical care, and don't have a child like you who makes good money and is able to help them (or have a bastard, wealthy child who cares not), what are we going to do? Take them out of the ER and let them die on the curb? Yes, maybe we should. At least then this will be AMERICA, by your high standards. Euthanasia would definitely be more humane. Oh but wait, conservatives/republicans/evangelicals also do not believe in euthanasia! They are "pro"-life. And so is their god. So yes, letting patients die on the curb is better, lest we make god angry. Is this some of the most twisted ideology or what?

 

[msiu79]

This thread makes me sad.

So we provide all these people; lazy, illegal, otherwise with insurance on the backs of every hard working citizen of this country and in the process destroy our health care system as we know it? Will these grateful people even use their insurance wrought off the backs of the masses? It's not like anyone in this country is denied care, anyone can go into a ER and be admitted just fine, anybody who has spent any appreciable time in the ER knows this. All we are currently seeing is the end of America as we know it and this is colorfully illustrated by a wonderful Canadian in this thread. Wont be the land of the free much longer.

so you define uninsured people as "lazy, illegal"?

what about those hard working legal Americans who just get layoff recently due to the economy crisis? they are also uninsured now

i am really upset to see people like you in health care field (or going to health care field) , because uneducated people who define "uninsured people" as lazy and illegal dont deserve to be in health care field and dont deserve patients' trust

i think you should go work for the private insurance company instead

 

[TPBC]

Well put. Call me a liberal but, the government needs to take on the so called "castastrophic" health care problems where a middle class family with health insurance gets wiped out financially when a major crisis hits. No one who works their whole life to make a few pennies should be decimated financially by a health care crisis in their family. Yes, it could happen to you or a loved one.

What makes me sad is that 54 y/o Caucasian woman who used to see me in outpatient clinic for depression, worked her butt off in her small cleaning business with her husband, had severe degenerative knee disease and needed knee replacement, did not qualify for Medicaid, and did not make enough money to pay for exorbitant premiums demanded by private insurance companies.

What makes me sad is that 61 y/o black man who worked all his life making cars for a company like GM, is now seeing his healthcare and retirement benefits cut by the failing company. He has HTN, DM, and colon cancer, does not qualify for Medicare/Medicaid, has to choose between his medications and food every month.

What makes me sad is that 33 y/o young man whose MS was suddenly declared a pre-existing condition by the insurance company who bought a solo plan from.

There are countless stories like this. Do you even realize the amount of burden the ER visits you speak so highly of have on taxpayer dollars? This is the weakest argument I have heard against comprehensive healthcare reform.

 

[novastorm]

Are you really a medical student? I just don't get how some in the field can be so clueless about their own profession: 1. Have you seen that special on TV showing video evidence how some ERs/hospitals put their patients in a cab and drop them near the entrance of a free hospital? 2. Do you know the quality of a lot of these free hospitals? ...

You're kidding right? Oh my I don't even know how to comment. Keep believing that TV.

 

[Excelsius]

You're kidding right? Oh my I don't even know how to comment. Keep believing that TV.

Well, it seems you're serious. Just think about it for a second: do you think that a reputable TV station is going to film a special on healthcare, fake the ACTUAL footage of the drop off of numerous patients (often disoriented, sitting on the f***ing curb not knowing what the hell is going on) near a hospital door, and then air those numerous fake footages on national TV? Are you kidding me? You need to look around and try to see what is going on in the nation, not just your particular locale.

P.S.: I knew a postdoc with whom I used to do research. He once visited Chicago with his gf, who had no insurance at the time. Something happened to his gf and he had to get her to a hospital. Anyway, they were delivered to some free clinic in Chicago. The environment was so lacking that one of the white doctors saw these two entering the hospital and immediately had to rush them to a room because he was afraid that that these white patients might get shot or otherwise assaulted! The postdoc was very shaken. Afterwards, the doctor had to personally drive them to their hotel. The doctor (or perhaps a resident?) was very nice, but this shows you the terrible conditions in many of these free clinics. I also got to volunteer in the LA general hospital. After just a short while I was pretty depressed. It was common for me to hear residents trying to figure out what was wrong with the patient as if it is some kind of a damn experiment. And no, there was no attending on many occasions and these residents did the prescriptions themselves, even though I heard them talk about how they were not sure what the problem was with the patient. You obviously have no idea about what's going in the field.

 

[DHT]

Well, it seems you're serious. Just think about it for a second: do you think that a reputable TV station is going to film a special on healthcare, fake the ACTUAL footage of the drop off of numerous patients (often disoriented, sitting on the f***ing curb not knowing what the hell is going on) near a hospital door, and then air those numerous fake footages on national TV? Are you kidding me? You need to look around and try to see what is going on in the nation, not just your particular locale.

P.S.: I knew a postdoc with whom I used to do research. He once visited Chicago with his gf, who had no insurance at the time. Something happened to his gf and he had to get her to a hospital. Anyway, they were delivered to some free clinic in Chicago. The environment was so lacking that one of the white doctors saw these two entering the hospital and immediately had to rush them to a room because he was afraid that that these white patients might get shot or otherwise assaulted! The postdoc was very shaken. Afterwards, the doctor had to personally drive them to their hotel. The doctor (or perhaps a resident?) was very nice, but this shows you the terrible conditions in many of these free clinics. I also got to volunteer in the LA general hospital. After just a short while I was pretty depressed. It was common for me to hear residents trying to figure out what was wrong with the patient as if it is some kind of a damn experiment. And no, there was no attending on many occasions and these residents did the prescriptions themselves, even though I heard them talk about how they were not sure what the problem was with the patient. You obviously have no idea about what's going in the field.

Holy crap. I don't even know where to start with your posts.

EVERYONE knows that preventative medicine is far more cost effective than paying for the problem once it happens. Thats the whole point of primary and secondary prevention. I'm not sure why you even brought this up, but my guess is that it sounded nice in your head so you wrote it down. There is no doubt that ER's are expensive and its partly due to the legal climate of our nation. They are required to do an overly extensive workup for simple common problems which drives up the cost of health care which we all get to pay for. Write your congressman for tort reform.

You seem to like bashing the quality of the facilities at "free" hospitals. Where do you expect the money to come from to upgrade? All the patients not paying for medical care? You get what you pay for son. If someone gave you a free car, would you expect it to be a porche? These people are getting FREE HEALTHCARE and should be grateful for it. Sadly most are not. In fact, the uninsured patients are the most ungrateful, litigious, patient population that I can think of.

TV stations will play whatever gets ratings. They don't care about the accuracy of their report. There is plenty of irresponsible reporting going around, anyone older than 20 should know this and you definitely shouldn't take a single example seen on TV as the norm seen around the nation. For example, I've seen CNN report on the link of vaccines and autism (if you don't know, the link has been completely disproven many times over in well designed studies - anyone with an IQ > 70 knows this). But now I have to deal with the ******s (read: parents) who won't vaccinate their kids because they don't want them to get autism.

I would like to point out that a resident is a doctor...

I don't know of too many situations where a resident will sign off on a patient without attending approval. In fact, I would venture to say that it rarely if EVER happens. Sure residents may talk about patients and may have no idea what a patient has, but thats how they learn and they have an attending looking over their shoulder.

If you're so smart, what is your diagnosis for "vague abdominal pain" with a negative work-up? Want to get an MRI? When that's negative do you want to get an exploratory laparotomy? There are plenty of mysteries in the art of medicine, some resolve in time, others will progress to the point where they can be diagnosed...You don't always have to know the problem to treat the symptoms (ex: Phenergan for nausea, opioids for pain, ect..)

Do you know what the lowest form of evidence it is? Its testimonial - which is what your story and what your TV program are. Its an n of 1 and can therefore not be generalized to the nation as a whole. I promise you that there is plenty of quality of free care going around. I see it all day every day. All those TV drama's of patients getting turned away without insurance and dying is complete BS. Hospitals are required by law to provide emergency care and deliveries. If an uninsured patient with a gunshot wound presents and hemodynamically unstable, I promise a private hospital will not buy them a cab ride and wish them luck. I didn't see that TV story you are talking about (because I've been too busy working in a hospital to watch the fantasy the media likes to portray), but I'm guessing that the patient had nothing life threatening and could easily handle the cab ride to the free hospital. Remember, that most of the "free" hospitals receive government aid to be able to take these patients.

We already have socialized healthcare. EVERYONE receives some basic level of care regardless of their ability to pay. Everyone else that can pay, pays extra to cover those who can't. The problem in our system is in the lawyers and insurance companies, not in the doctors who sacrifice their lives to be s**t on constantly by those they work so hard to help.

I suggest you learn more about the practice of medicine before you comment on it in such a condescending manner.

 

[thedrjojo]

I think those that stand to lose the most in this are....

INSURANCE COMPANIES!

These companies have 30% overhead most of the time, compared to 3% at Medicare (even with all its problems, it gets better health results than these private insurance companies too).

The only way reform can really happen in this country AND keep private insurance is to do, as the AMA proposes, the Swiss system and set a standard of what a base system has to cover and set that plan to have an overhead of at most 4%. Companies can make money on expanded plans with higher premiums and overhead. This is probably not ideal (a socialized INSURANCE plan would be ideal), but would be a step up from what we have. This does not deal with the issue of assuring everyone has one of these plans, but it will make them cheaper and easier to get ahold of. Except for the denials, etc.

The differences in pay will be decreased, but still there, under a single payer system. Medicare/Medicaid still pays Orthopods much more then Family Practice (I think its funny Medicaid will pay a doc $14 for a physical exam, but then pay the transportation people $120 for getting that person to and from the docs office). Coming from someone planning on going into tertiary care, We need to level the pay field. Yeah, even after 7 years different training as the pediatric CT surgeon suggested, do you really need to be making 6, 7, 8 fold more money? No. The difference can be $200,000 vs $400,000 and I don't see any problem with that. We all are expecting our patients to choice health insurance over the iPhone, but can't they expect us to drive a Ford instead of a BMW(We are all proud of the USA right? Best country on gods given earth, or whatever Hannity says, right? Does he drive american?)? Or only have 1 home instead of 3? We deserve to live comfortably, but really, does ANYONE in this world really need more than like $250,000 anyway (and yes, I know with $200,000 in debt from med school, after interest has accured during my 5 years of residency + 2years research + 2 years fellow it will be closer to $400,000 to pay back, or ~$3500 a month if it's paid over 10 years, so ~$42,000 a year for that 10 years, but I also came from simple upbringing and don't feel entitled to anything more than to do what i love and live comfortably).

 

[later2pharm]

is this a serious thread? you all think medicine is going to be socialized in the us? do you even know the meaning of socialized medicine?

 

[DHT]

is this a serious thread? you all think medicine is going to be socialized in the us? do you even know the meaning of socialized medicine?

I ALMOST made a post very similar to this explaining why this is a moot conversation because socialized healthcare will never happen in this country. Insurance companies and lawyers (two of the largest lobbying groups) stand to lose too much and will never let that happen. Not to mention the American public would not tolerate socialized care for more than a couple years. In fact, I almost welcome socialized healthcare for a few years so Americans can see how good we have it here, and perhaps they will learn to appreciate or respect us again.

But for now, the talk of socialized healthcare (or a national healthcare plan) is really just rhetoric for political leverage, nothing more.

 

[dilated]

We deserve to live comfortably, but really, does ANYONE in this world really need more than like $250,000 anyway (and yes, I know with $200,000 in debt from med school, after interest has accured during my 5 years of residency + 2years research + 2 years fellow it will be closer to $400,000 to pay back, or ~$3500 a month if it's paid over 10 years, so ~$42,000 a year for that 10 years, but I also came from simple upbringing and don't feel entitled to anything more than to do what i love and live comfortably).

So why aren't you out there fighting to get baseball players and hedge fund managers capped at 250k? Nobody "needs" more than whatever the bare minimum of living is. How this leads into the idea that we ought to be happy to take massive pay cuts is beyond me. The other interests in health care love nothing more than stupid little altruistic doctors because they can squeeze them for more money for themselves. I should probably say "future doctors" because somehow the desire to give away 100k a year in salary seems to magically vanish when people start actually working as doctors.

 

[womp]

There are a lot of people in this country that would take your "crappy socialized paycheck".

The lot of people in this country also don't go through 7 to 9+ years of schooling and training AFTER college. Nor do they work (I mean really work, not sit at the comfort of home and read/write) 80 hours a week for 3 to 5 years like slaves at whims of their PD's. Yes, most people in the country would take the doctor's crappy socialized paycheck, only because most people in the country know deep down that under a fair compensation system, they are vastly overpaid if the physician makes just over $100k after all he goes through.

 

[Llenroc]

It's hard to argue that doctors salaries should be capped at whatever, when you have numbskull, anal rapist basketball players whose only real achievement was inheriting 6'8" of height that get paid $30 million for putting a ball into a hole.

 

[thedrjojo]

I'm not advocating capping doctors salaries, I was more trying to point out that the biggest concern on the board here seems that 1) patients are lazy and not willing to give up anything for health care and 2) Doctors aren't willing to give up anything in the way of pay to advocate for health care for all...

Do I think sports stars get paid too much? Yes and No. As long as people sink billions of dollars into sports to watch, buy jersey's, etc, I would MUCH prefer the players who are actually doing the work to get the money than executives and bosses pocketing billions of dollars exploiting the players. Just like I HATE seeing insurance companies pocketing billions of dollars exploiting not only the customers, but the doctors they pay by squeezing every last dollar from what they have to pay us. Once the INSURANCE industry goes away from a FOR PROFIT model in medicine, then the wealth can actually be distributed to THE DOCTORS, the ones actually providing the service. Think about it: insurance premiums are going up 16% each year... are Doctor's salaries going up 16% each year? No, they are stagnant or even going down. But what is going up millions of dollars each years? Stock options and bonuses for CEO's of these companies for raking in the profits. How can any system that allows people to profit from denying and controlling healthcare be supported by anyone with any shred of morals.

While I support single payer, I see the downsides and could support a multipayer system in the right circumstance:
1) Non-profit or capped overhead - make sure the money being spent actually goes to delivery of health care, not to those running the companies
2) No ability to deny service - Who needs health coverage more than those with conditions that need health care? I am still flabergasted by the fact that insurance companies won't cover people because they have medical conditions when they are in the business of providing payment for medical conditions!!!
3) Not tied to employment - this is a no brainer
4) Universal claim form - this is for all those docs out there who hate to have to fill out 25 different types of claim forms, will save them time filling out paperwork, especially if it can be tied to EMR

I am sure I am missing things that would be required or needed, like how they set the payment schedules and values, what is determined as required to be included in plans and what is considered extra stuff that may be allowed to be given at a profit (a la the swiss system the AMA touts), or how to ensure or enforce universal coverage.

The Socialized Insurance (its not socialized healthcare unless we all become government employees - not once has that been even thought of being done) will hurt the insurance companies the most, and that is perfectly ok (and appropriate) in my mind.

And don't get me started on making Hospitals non-profit. Again, more administrators and suits squeezing healthcare dollars away from actual providing and paying for care. Between the insurance companies and for profit hospitals, how much of the $6000 GDP per capita actually goes to the delivery of medicine... no wonder other countries with $3000 GDP per capita can provide every individual with health care.

 

[circulus vitios]

I think those that stand to lose the most in this are....

INSURANCE COMPANIES!

These companies have 30% overhead most of the time, compared to 3% at Medicare (even with all its problems, it gets better health results than these private insurance companies too).

The only way reform can really happen in this country AND keep private insurance is to do, as the AMA proposes, the Swiss system and set a standard of what a base system has to cover and set that plan to have an overhead of at most 4%. Companies can make money on expanded plans with higher premiums and overhead. This is probably not ideal (a socialized INSURANCE plan would be ideal), but would be a step up from what we have. This does not deal with the issue of assuring everyone has one of these plans, but it will make them cheaper and easier to get ahold of. Except for the denials, etc.

The differences in pay will be decreased, but still there, under a single payer system. Medicare/Medicaid still pays Orthopods much more then Family Practice (I think its funny Medicaid will pay a doc $14 for a physical exam, but then pay the transportation people $120 for getting that person to and from the docs office). Coming from someone planning on going into tertiary care, We need to level the pay field. Yeah, even after 7 years different training as the pediatric CT surgeon suggested, do you really need to be making 6, 7, 8 fold more money? No. The difference can be $200,000 vs $400,000 and I don't see any problem with that. We all are expecting our patients to choice health insurance over the iPhone, but can't they expect us to drive a Ford instead of a BMW(We are all proud of the USA right? Best country on gods given earth, or whatever Hannity says, right? Does he drive american?)? Or only have 1 home instead of 3? We deserve to live comfortably, but really, does ANYONE in this world really need more than like $250,000 anyway (and yes, I know with $200,000 in debt from med school, after interest has accured during my 5 years of residency + 2years research + 2 years fellow it will be closer to $400,000 to pay back, or ~$3500 a month if it's paid over 10 years, so ~$42,000 a year for that 10 years, but I also came from simple upbringing and don't feel entitled to anything more than to do what i love and live comfortably).

Probably not. Should they be free to earn more than $250,000? Absolutely. If you want caps on what you can earn then go practice medicine in socialist hellholes like Germany, where doctors routinely protest over how poorly they are paid.

 

[womp]

duplicate

 

[womp]

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[womp]

I'm not advocating capping doctors salaries, I was more trying to point out that the biggest concern on the board here seems that 1) patients are lazy and not willing to give up anything for health care and 2) Doctors aren't willing to give up anything in the way of pay to advocate for health care for all...

Do I think sports stars get paid too much? Yes and No. As long as people sink billions of dollars into sports to watch, buy jersey's, etc, I would MUCH prefer the players who are actually doing the work to get the money than executives and bosses pocketing billions of dollars exploiting the players. Just like I HATE seeing insurance companies pocketing billions of dollars exploiting not only the customers, but the doctors they pay by squeezing every last dollar from what they have to pay us. Once the INSURANCE industry goes away from a FOR PROFIT model in medicine, then the wealth can actually be distributed to THE DOCTORS, the ones actually providing the service. Think about it: insurance premiums are going up 16% each year... are Doctor's salaries going up 16% each year? No, they are stagnant or even going down. But what is going up millions of dollars each years? Stock options and bonuses for CEO's of these companies for raking in the profits. How can any system that allows people to profit from denying and controlling healthcare be supported by anyone with any shred of morals.

While I support single payer, I see the downsides and could support a multipayer system in the right circumstance:
1) Non-profit or capped overhead - make sure the money being spent actually goes to delivery of health care, not to those running the companies
2) No ability to deny service - Who needs health coverage more than those with conditions that need health care? I am still flabergasted by the fact that insurance companies won't cover people because they have medical conditions when they are in the business of providing payment for medical conditions!!!
3) Not tied to employment - this is a no brainer
4) Universal claim form - this is for all those docs out there who hate to have to fill out 25 different types of claim forms, will save them time filling out paperwork, especially if it can be tied to EMR

I am sure I am missing things that would be required or needed, like how they set the payment schedules and values, what is determined as required to be included in plans and what is considered extra stuff that may be allowed to be given at a profit (a la the swiss system the AMA touts), or how to ensure or enforce universal coverage.

The Socialized Insurance (its not socialized healthcare unless we all become government employees - not once has that been even thought of being done) will hurt the insurance companies the most, and that is perfectly ok (and appropriate) in my mind.

And don't get me started on making Hospitals non-profit. Again, more administrators and suits squeezing healthcare dollars away from actual providing and paying for care. Between the insurance companies and for profit hospitals, how much of the $6000 GDP per capita actually goes to the delivery of medicine... no wonder other countries with $3000 GDP per capita can provide every individual with health care.

Amen. I used to work in the finance sector, I know exactly the level of fleecing from the labors of others involved in the business world. The disgust is what caused me to pursue medicine in the first place. I actually wanted to earn my paycheck. I have a lot of respect for the main players of other fields too, like engineers.

I mean, how much expertise is really needed to run Excel spreadsheets, Outlook and PowerPoint presentations all day? That just described the daily activities of 90% of investment bankers. I'm one who is glad the financial world is melting down. They had it coming.

Another fleecer is the retail (CVS, Walgreens) pharmacist, whose only existence is because of a statute requiring a pharmacist in every pharmacy. Litigation lawyers are probably king though.

 

[Jamers]

is this a serious thread? you all think medicine is going to be socialized in the us? do you even know the meaning of socialized medicine?

The sad truth is, no. I have been on several rotations where very intelligent physicians will make similar claims about socialized health care. I sit quietly while they announce all the "facts" of what socialism means and how our country will somehow "transform" into this. Sometimes I want to go and buy a history book and make them read the sections pertaining to socialism so they can just be quiet. Or ask them to describe for me one presidential term that changed the United States from a democracy to something else. People hear this stuff on FOX and take to mean 100% truth without doing their own research on it. It just makes me sick.

 

[Poitiers2]

I like the Netherlands example cited by a poster above.

That system is currently and predictably bankrupting the state of Massachusetts.

What inevitably happens in all these government boondoggles is that the poor consumer far more in healthcare expenses than the rest of the nation (history of poor decision making and a lack of education meets a multitude of other factors), and thus prices continue to soar.

We continue to talk of the 47-million uninsured, and yet no one mentions that at least 30% of these are illegal immigrants.

There are ways of approaching this healthcare mess that don't begin with more mandated government spending, intervention, and uprooting of the system.

While the system used in the Netherlands and Massachusetts is less egregious than some systems, I see both as inherent failures. I'll also point out that Mass is probably the most highly educated and wealthy state in the nation. If costs were going to be low in any one state, I'd have guessed it would be that one.

I hear the likes of Obama & Co. talking about rationing healthcare, and quite frankly, it makes me cringe. This is an assualt on physicians, the healthcare field, and yes, the patients.

 

[novastorm]

Considering all this talk about things not being possible, and this new actual threatening of the use of budget reconciliation, I think we have much to lose from HR 767. Scary stuff people. I really encourage you to read up on some of what congress thinks is best for America. Just the other day I heard some man on TV that said doctors should work for free.

New York Times
"To cope with the growing shortage, federal officials are considering several proposals. One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. A third would expand the National Health Service Corps, which deploys doctors and nurses in rural areas and poor neighborhoods."
Link

Although I find this article is a little misleading the worst of the shortage is as it states rural areas and then I would put doctors who take medicare (or new medicare) patients in urban areas. I mean some don't find the fight for 25 dollars for an office visit worth it and some days I don't blame them. I do like how they realize the whole debt vs. primary care delima, that may be a good thing. But the more NP, PA thing is a little disturbing.

 

[235750]

I hear the likes of Obama & Co. talking about rationing healthcare, and quite frankly, it makes me cringe. This is an assualt on physicians, the healthcare field, and yes, the patients.

Immigrants are far less likely to be seen by physician and do not represent a disproportionate financial burden on the US health care system. Do some research and make more informed opinions.

While the system used in the Netherlands and Massachusetts is less egregious than some systems, I see both as inherent failures.

While no system is perfect, their system is beter. The 'system' in the US is a complete failure. American's will be paying close to 20% of their GDP on healthcare if trends continue. And yet, in Europe they get better results even though they spend less. And that's from the likes of JAMA & Co.

I hear the likes of Obama & Co. talking about rationing healthcare, and quite frankly, it makes me cringe. This is an assualt on physicians, the healthcare field, and yes, the patients.

Obama's main sucess has been expanding SCHIP. The goal is to allow access to more people. The patients in the US will be better off for it. Again do some research: you'll find the majority of reveiws on SCHIP to be positive (read here, here and here about the crowd out effect)

 

[DHT]

Immigrants are far less likely to be seen by physician and do not represent a disproportionate financial burden on the US health care system. Do some research and make more informed opinions.

Gotta read more than the abstract buddy. That study is referring to US citizens who immigrated to America therefore paying taxes and statistically most likely health insurance (permanent residents, those on visas and a few illegals were also included. Judging by how the data were collected, I would expect illegals to be almost negligible). Therefore this study has very little to do with the illegal non-US citizen immigrants mentioned previously who utilize our healthcare without paying taxes or health insurance. That population represents about 12M of the 47M uninsured "americans" and no doubt does burden the system.

On a side note, even if this study were referring the illegal immigrants, it would still mean nothing. Even though they statistically utitilize healthcare less than US born citizens, that does not mean they do not burden the system. They just do so at a lower rate than US born citizens (ie: 20M immigrants would have the same burden as 10M US born citizens). But it doesn't matter because that is not what the paper was about.

While no system is perfect, their system is beter. The 'system' in the US is a complete failure. American's will be paying close to 20% of their GDP on healthcare if trends continue. And yet, in Europe they get better results even though they spend less. And that's from the likes of JAMA & Co.

Again, nice try. Don't you think there are some VERY significant confounders in that study? It is true that America spends more of their GDP on healthcare than most (if not all) industrialized countries, however they have some unique problems to contend with:
1. The litigious nature of America - There is no doubt that the US has the most vicious lawyers in the world. Although some lawsuits are well justified, there is still a huge proportion that are not. This money doesn't just come from nowhere, it is indirectly included in the total cost of healthcare. Every dollar taken from a physician, hospital, pharm company, or device company is indirectly pulling from the total cost of health care because this money must be recouped somehow and therefore charges are passed onto the consumer. Not such a problem in the UK. This leads to #2.
2. Defensive Medicine - Doctors in America are no longer allowed to use their best clinical judgement when it comes to medicine. Because of #1 physicians will do overly extensive work-ups for common things or run tests which have very low yield. This is mostly to cover their asses for the 1/1,000,000 chance that 30 yo with classic Sx of GERD is really having an MI. We all get to pay for those extensive work ups. Not such a problem in the UK.
3. Newest Technology - New technology is expensive. The US places a strong emphasis on new technology and drugs despite questionable cost effectiveness. Is it worth 4x the cost for a 5% survival benefit? Well it would be if it were your survival. Another issue I am placing in this category is our over-utilization of imaging. There is no question that other countries spend only a FRACTION of what we do on MRI/CT/PET/ect... See #2 for reason.
4. Medical Futility - This phenomenon started when medicine stopped being so paternalistic in America (note that paternalistic healthcare is the norm around the world still). This is what happens when you let the uneducated public make decisions about healthcare. "Grandma (98yo) wouldn't want us to let her die. She would much rather be PEGed, Trached, and put on the ventilator farm for 3 years first." End of life care is probably the most expensive part of healthcare. There are numerous examples that seem to be the norm over here. Believe me, other countries don't burden themselves as much with this.

Other confounders:
1. Don't forget that the US is one of the least healthy modern countries in the world. Its our terrible lifestyle/habits that cause this. Although europeans smoke slightly more than in the US, we are WAY fatter. Diabetes is a very expensive disease to manage. No I'm not talking about the insulin/drugs. Im talking about all the long-term complications that go along with uncontrolled sugars. So I am not surprised that the average life expectancy is lower in the US, especially because I would expect smoking+obesity to be synergistic, not additive when it comes to negative health consequences. Modern medicine can only do so much.

2. Satisfaction - Trust me, when the UK population rated their hospitals, they did not know what they were missing in the US. They are accustomed to what they have and expect it to be the norm. A US citizen getting healthcare in the UK would be horrified (I know from when my father was hospitalized following a car accident in the UK). Remember, Americans love to b***h. Something like this could not be judged unless those polled were admitted to representative hospitals in each of the countries.

3. Note the affiliations of the authors...no doubt their opinion may be slightly biased...

I'm not saying our system is perfect, but to say that it is inferior to nationalized systems like the UK or Canada can only be due to a grossly uninformed opinion.

 

[235750]

Gotta read more than the abstract buddy. That study is referring to US citizens who immigrated to America

You are right in that point. I apologize, I meant to put two articles up and I forgot this article here. The previous article demonstrated that legal immigrants were less likely to be seen by a physician. The article I forgot to post which is linked in this paragraph shows that illegal immigrants are less likely that US born Latinos to get medical attention, thus making them the least likely to be seen be a burden on the system.

That population represents about 12M of the 47M uninsured "americans" and no doubt does burden the system.

Of course they do use the medical facilities in the US to some degree. They will use public facilties to be sure, but the question is, are they a disproportionate burden to the system? The answer to that is a resounding 'no'. The American farm and housing industries would collapse, for example, without their cheap labor.

I will grant you that with the discussions being thrown arounf here, the issue of undocumented people is the area with the most grey. Undocumented people are, by definition, harder to trace and study. That said, it seems to be pretty simple why people are allowed to work in the USA: because Americans want them to. As I said, there are industries in the US that would collapse without their help. That tied with the evidence that shows they are not a burden on the medical system, and that they add billions to social security, and you can see that they are a benefit to the United States.

On a side note, even if this study were referring the illegal immigrants, it would still mean nothing. Even though they statistically utitilize healthcare less than US born citizens, that does not mean they do not burden the system. They just do so at a lower rate than US born citizens

But again, if they put more in and take less out, then that seems to be very relevant. They pay payroll taxes that they will never benefit from through cliaming social security, and they help keep the American economy competitive with their cheap hourly work. You would certainly not be able to get any produce from CA at the price you currently do if it wasn't for undocumented workers.

Again, nice try. Don't you think there are some VERY significant confounders in that study?
1. The litigious nature of America
2. Defensive Medicine

I think you misunderstand again. The point is that the American medical system is more expensive AND has worse outcomes for their patients. OK, so the American legal system needs reform and that's one reason why it's so expensive. But is that also why the health outcomes in US patients are worse? Are the lawyers killing patients??

3. Newest Technology - New technology is expensive. The US places a strong emphasis on new technology and drugs despite questionable cost effectiveness. Is it worth 4x the cost for a 5% survival benefit? Well it would be if it were your survival.

Again, the article looked at outcomes. If the newest technology is better, than we would've expected better outcomes in the US, especially in people who more wealthy. Make sense? But Americans did not have improved outcomes as compared to their British counterparts, so it seems that the investment in newer technology did not pay off. I myself was surprised that the richest British citizens were still better off than the Americans in the same wealth category, and that's an important finding.

4. Medical Futility - This phenomenon started when medicine stopped being so paternalistic in America (note that paternalistic healthcare is the norm around the world still). This is what happens when you let the uneducated public make decisions about healthcare. "Grandma (98yo) wouldn't want us to let her die. She would much rather be PEGed, Trached, and put on the ventilator farm for 3 years first." End of life care is probably the most expensive part of healthcare. There are numerous examples that seem to be the norm over here. Believe me, other countries don't burden themselves as much with this.

Believe you? Wow, nice argument British people do take care of their sick and dying, they have nursing homes, and they spend a lot on end of life care. You don't have to believe me on that, you can look that up. English people don't take their old people out back and kill them like old yeller'.

In England they actually pay the elderly and infirm when they visit their doctor, to compensate them for their travel expenses. Paying for the travel arrangements of every elderly British person visiting the hospital seems rather expensive, don't you think?

Other confounders:
1. Don't forget that the US is one of the least healthy modern countries in the world. Its our terrible lifestyle/habits that cause this. Although europeans smoke slightly more than in the US, we are WAY fatter.

It sounds as if you didn't read the article this time! They accounted for as many measures of health that they could, including BMI. So...read the paper again my friend!

2. Satisfaction - Trust me, when the UK population rated their hospitals, they did not know what they were missing in the US.

Wow, another, "trust me" line? The result of this paper was: American's pay more for worse outcomes. It sounds like people in the US are the ones who don't know what bad deal they are getting

I'm not going to interject personal statements like you do, except to say I have worked and been a patient in both American and English hospitals before (BUPA and NHS), and I can say that all are very good quality. If you have some empirical measurements that show hospitals are better in the US, get back to us. I think you'll find things like MRSA infection rates are lower in England.

3. Note the affiliations of the authors...no doubt their opinion may be slightly biased...

A conspiracy theory! I love it. This is always the fall-back argument that the sophist takes. If you don't like the conclusion, then attack the character of the researchers!

They're called peer reviewed journals for a reason. Even if the people who published this are evil limies, it still went through the peer review process. What this means is that a a lot of experts got together and evaluated this work and agreed that this was a good article. It's JAMA my friend. I hate to burst your bubble, but their standards are pretty high.

I like how you completely ignored SCHIP. Honestly, I would agree that it is difficult to take a stance against it. After all, it does reprsent the feared socialized medicine that a lot of people in this forum seem to misunderstand.

I'm not going to argue with you on this anymore because America is already moving towards (or at) to universal coverage (ie SCHIP), and discussing it on a student forum isn't going to change anything. Did you know it's not just Massachusetts that you should be scared about? In PA, every child under the age of 18 is eligible for state-funded health insurance, thanks to CHIP. Every child! Sounds like that awful universal healthcare coverage I've been hearing so much about Of course it's been like that for several years...I wonder why people are only just starting to yell 'socialist'? I think Jamers had it about right.

I'm not saying our system is perfect, but to say that it is inferior to nationalized systems like the UK or Canada can only be due to a grossly uninformed opinion.

What a lot of people (myself included) are saying is that the current mess the US is in can be improved by incorporating aspects from other models. No-one is suggesting we switch to the English NHS, myself included. The point is, their health outcomes are better, so it would be very un-American to not investigate and see what they're doing right. Based on the evidence, universal coverage is the way to go, and we'll be there soon

 

[DHT]

Your post is quite long and I don't really have time to respond to everything, but I did have 1 question:

Honestly, I did not read your JAMA article last night because it was late I thought it was one that I had read several times in the past. Now I have read your JAMA article three times now and fail to see how it supports your conclusion. Maybe I am stupid or I am missing something, so please enlighten me (really, I'm not being condescending, I want to learn even if it means I am wrong right now). My understanding is that when they are controlling for the behavioral risk factors (smoking, obesity, ect..) they are doing so to analyze the health differences between the SES classes within a country, not the health differences BETWEEN the countries. My conclusions: 1. The US is less healthy than the UK (based solely on self reported responses and controlled only for age and SES class and not behavioral risk factors). 2. Low SES has worse health outcome markers than High SES when controlling for the behavioral risk factors.

I would also like to point out that in the comments section, they say "Because screening rates for cancer are generally higher in the United States than in England, this may play a role in the higher rates of cancer in the United States. Greater incident mortality from cancer in England may also be important." They cite two papers to support this. The higher incident mortality is what I was referring to in an earlier post about cancer mortality between UK and US. Higher incident morality for cancer is a bad thing. Higher screening is a good thing, and ironically something that most proponents of nationalized systems consider an advantage for their cause. I'm sure there are other measures of quality of care other than the incident morality rate of breast, prostate, and lung cancer, but I don't know those off the top of my head.

So my statement still stands as the poor health/habits of Americans at least partially accounts for the shorter lives seen in Americans.

I "ignored" SCHIP because I didn't have a problem with what you said...

EDIT: I am no longer interested in debate over nationalized healthcare, because quite frankly I don't care. But if you can clarify that article for me I would love to hear it.

 

[doc4life95]

Based on the evidence, universal coverage is the way to go, and we'll be there soon

Please cite this evidence

 

[randomedstudent]

How about $400/month as a healthy 25 yo in NYC? COBRA wasn't a much better choice, it was close to $300/month. I chose to become an uninsured statistic and prayed that I didn't get run over by a delivery bike rather than pay $4800 to a faceless insurance company for crappy coverage. I used that $4800 instead to pay cash for the two times I needed some minor medical care and still came out ahead by at least $4500.

I don't have a data plan on my cell phone. I'm probably the last person under the age of 30 still watching TV with rabbit ears.

When I graduate residency in 3 months to move back to Manhattan, I'm on my way to becoming an uninsured statistic again. Back to the prayer and paying cash until I get married and get on my future husband's plan.

Where are the $100/month insurance plans? I'd pay that even for just catastrophic coverage and pay cash for the rest of my physician visits.

I would be happy to pay at a retainer practice for primary care for me and my family in the future. I'd rather pay a physcian the monthly premium rather than send it to BC/BS for the CEO's bonus.

Doubt you'll see this but just in case and for the benefit of the discussion in general....I had an individual insurance plan for 2 years when it would've cost $300/month to be added to my husband's....I figured I could find one cheaper which I did...I paid $75/month for pretty decent coverage (albeit no maternity which was fine for me), included 3 paid primary care visits per year and deductible was $1000 (so hardly "catastrophic").....I am a healthy female in my mid-20's.

 

[3dtp]

You should ask him about working with the gov't to let old people die...lol... because apparently that is what is happening in universal healthcare

Well, actually you may indeed have a point there. My colleague's mother is from Toronto. She was denied rehab/PM&R services by Ontario as part of Ontario's health benefit system following a fall and a hip fracture. So, we brought her to the states, as we have so many other Canadians living in the near border areas where cash was paid for the rehab. Lest you doubt this, my practice in a Canadian border state was about 40% Canadian since there were lengthy delays in obtaining specialty care on your side of the border, delays that would adversely affect outcomes.

The reason her mother was denied: She was over age 90. This despite the fact that she had an ECOG performance status of 0, she lived alone and managed all of her ADLs/AADLs prior to her fall, recovered quickly from her fall,( as older folks go), and needed rehab for deconditioning during her convalescence.

Ain't no panacea north of the border, and fewer choices. And don't forget Ottawa built this system and then dumped it on the provinces to find a way to fund it. Just how to fund the system was the topic of a rather heated series of first ministers conferences several years ago, as I vaguely recall and the system is not out of the financial woods yet.

As for an interesting twist, I was given an insurance restriction on an out of network referral for a carrier I don't do business with. The insurer agreed to cover treatment costs, but denied the patient prescription drug covered to manage the side effects of therapy. So, the insanity of this is I write a prescription, phone her PMD, who then signs my prescription, charges her insurance for an office visit, my patient who doesn't drive has to travel from my facility to her PMD's office 55 miles away, to get a drug to manage side effects. Fortunately, the PMD gets paid for the visit, the patient gets vitals checked and the patient's volunteer drivers deduct mileage and lunch at all of our expense. If we could bring at least a little sanity to this system, we might all do better.

Government has a different concept of sanity than the rest of us. If you doubt that, go buy an airline ticket and just think about taking a tube of toothpaste with you past the TSA....or try to leave the US[SR] without official government permission... And then ponder what a fully government controlled system will really be like?

"Billions and billions" Carl Sagen
"A billion here, a billion there. Pretty soon we'll be talking real money here." The Late Senator William Proximire D-Wisc.
Updated version: "A trillion here, a trillion there, ...." 3d

 

[3dtp]

4. Medical Futility - This phenomenon started when medicine stopped being so paternalistic in America (note that paternalistic healthcare is the norm around the world still). This is what happens when you let the uneducated public make decisions about healthcare. "Grandma (98yo) wouldn't want us to let her die. She would much rather be PEGed, Trached, and put on the ventilator farm for 3 years first." End of life care is probably the most expensive part of healthcare. There are numerous examples that seem to be the norm over here. Believe me, other countries don't burden themselves as much with this.

Just an observation. Accepting what you say at face value, and without supporting evidence other than personal observation working in those countries, it appears, superficially to be true.

But what must be considered: End of life care is the most expensive part of health care. This is indeed true, whether the life lasts 98 years, 98 months or 98 hours. We do not spend a lot on care when we are healthy. This is an absurd arguement, and one that played a key role in insurance company support, both financial and editorially in Oregon's assisted suicide laws.

It is far cheaper to not treat illness, particularly life threatening illness than it is to treat, care for and palliate at the end of life. This is equally true for an infant as it is for a geriatric patient.

 

[CambieMD]

Just an observation. Accepting what you say at face value, and without supporting evidence other than personal observation working in those countries, it appears, superficially to be true.

But what must be considered: End of life care is the most expensive part of health care. This is indeed true, whether the life lasts 98 years, 98 months or 98 hours. We do not spend a lot on care when we are healthy. This is an absurd arguement, and one that played a key role in insurance company support, both financial and editorially in Oregon's assisted suicide laws.

It is far cheaper to not treat illness, particularly life threatening illness than it is to treat, care for and palliate at the end of life. This is equally true for an infant as it is for a geriatric patient.

End of life can be very expensive and is often futile. I do not want to get into the assisted argument. The point that I make is that end of life issues and care must be adequately addressed. Too much money is wasted because no one wants to decide what the next move should be. Am I saying that big brother should decide , no. I have seen dozens of patients left on vents and drips for days, needlessly. Can this continue?

Health care dolllars are spent on the back end when they should be spent @ other points in the process.

Cambie

 

[thedrjojo]

Well, actually you may indeed have a point there. My colleague's mother is from Toronto. She was denied rehab/PM&R services by Ontario as part of Ontario's health benefit system following a fall and a hip fracture. So, we brought her to the states, as we have so many other Canadians living in the near border areas where cash was paid for the rehab. Lest you doubt this, my practice in a Canadian border state was about 40% Canadian since there were lengthy delays in obtaining specialty care on your side of the border, delays that would adversely affect outcomes.

The reason her mother was denied: She was over age 90. This despite the fact that she had an ECOG performance status of 0, she lived alone and managed all of her ADLs/AADLs prior to her fall, recovered quickly from her fall,( as older folks go), and needed rehab for deconditioning during her convalescence.

Ain't no panacea north of the border, and fewer choices. And don't forget Ottawa built this system and then dumped it on the provinces to find a way to fund it. Just how to fund the system was the topic of a rather heated series of first ministers conferences several years ago, as I vaguely recall and the system is not out of the financial woods yet.

As for an interesting twist, I was given an insurance restriction on an out of network referral for a carrier I don't do business with. The insurer agreed to cover treatment costs, but denied the patient prescription drug covered to manage the side effects of therapy. So, the insanity of this is I write a prescription, phone her PMD, who then signs my prescription, charges her insurance for an office visit, my patient who doesn't drive has to travel from my facility to her PMD's office 55 miles away, to get a drug to manage side effects. Fortunately, the PMD gets paid for the visit, the patient gets vitals checked and the patient's volunteer drivers deduct mileage and lunch at all of our expense. If we could bring at least a little sanity to this system, we might all do better.

Government has a different concept of sanity than the rest of us. If you doubt that, go buy an airline ticket and just think about taking a tube of toothpaste with you past the TSA....or try to leave the US[SR] without official government permission... And then ponder what a fully government controlled system will really be like?

It is a shame that care has to be rationed for a 90 year old who has quality of life. There is a triangle in healthcare of functions: Low Cost, Increased Access, and High Quality. It is believed to be impossible to manage all 3. If you have low cost and universal access, the quality will undoubtedly suffer. If you have high quality and high access, costs will not be able to be maintained. You can have high quality health care at a low cost, but only if not many people can get into it.

I keep hearing all these screams of rationing this and rationing that. The US rations more than any of these places. While in Canada or the UK the rationing might be based on age, or prognosis, or functional status, here in the good ole US of A, the rationing is based solely on the all mighty dollar. Your example points that out perfectly: a 90 year old can get rehab because he can pay. In the hospital right now that I am at I have a 63 year old who had an MI and coded several times while getting angioplastied and suffered anoxic encephalopathy. He has since regained most mental status but shows the signs of being in a hospital bed for 3 months and could use rehabilitation before returning home. Because he has no insurance, he has been sitting in the hospital for over a month now awaiting placement because he has no way of paying for the placement (hospital being "funded" by charity care, meaning they won't really see a dime of it).

These Right winged "socialist" fear mongers fail to mention or care about this rationing because it only effects poor and middle class individuals who have LONG been lost by them. They only care about if they will be unable to assure they will always have care because they are more deserving than anyone else for it.

@ DHT: In the US of A, each prescription medication costs approximately 40% more than what individuals in other nations have to pay for these same BRAND NAME prescriptions. Why is that? Because there is purchasing power in the national programs. Plus, the companies expect the US population to foot the bill for all those tv advertisements, print ads, and free lunches they give to doctors which clearly are shown to influence prescription habits (except all you wonderful doctors here on the forums... I am talking about other, less well informed and insightful docs out there who lack integrity and are easily influenced...). And since most medication research is actually already publically funded via NIH grants, and much research on drugs is performed at publically funded University Hospitals, and considering R&D is only about 1/3rd of pharm companies budgets compared to advertising nearly twice as much, a socialized insurance system wouldn't stifle new drug development and usefulness.

The idea that the government is going to put in place treatment guidelines and tell doctors how to practice should actually be looked at as a positive. Treatment guidelines help make sure all patients are treated appropriately with the most current and accurate treatment protocols. Some doctors still practice on what they learned in med school and residency 40 years ago. It should be mandated that all CHF patients are started on an ACE, on a statin, and on Aldactone when they ef is less than 40%. All ICU's should practice proper SIRS protocols, all inpatient diabetics should be on appropriate insulin sliding scales, all inpatients should be on proper DVT protocol. Time out sheets and checklists of all surgical instruments used should be standard of care in all OR's. Doctors shouldn't be allowed to let their preconceived notions and prejudices prevent patients from getting optimum care. These regulations need to result from large, multicenter, randomized control experiments, and based on science and nothing else (which seeing how the republican right operates, I find that is going to be increasingly difficult). Cookbook medicine, as it is affectionately called, is at times, actually in the best interest of the patient.

 

[danzman]

It is a shame that care has to be rationed for a 90 year old who has quality of life. There is a triangle in healthcare of functions: Low Cost, Increased Access, and High Quality. It is believed to be impossible to manage all 3. If you have low cost and universal access, the quality will undoubtedly suffer. If you have high quality and high access, costs will not be able to be maintained. You can have high quality health care at a low cost, but only if not many people can get into it.

I keep hearing all these screams of rationing this and rationing that. The US rations more than any of these places. While in Canada or the UK the rationing might be based on age, or prognosis, or functional status, here in the good ole US of A, the rationing is based solely on the all mighty dollar. Your example points that out perfectly: a 90 year old can get rehab because he can pay. In the hospital right now that I am at I have a 63 year old who had an MI and coded several times while getting angioplastied and suffered anoxic encephalopathy. He has since regained most mental status but shows the signs of being in a hospital bed for 3 months and could use rehabilitation before returning home. Because he has no insurance, he has been sitting in the hospital for over a month now awaiting placement because he has no way of paying for the placement (hospital being "funded" by charity care, meaning they won't really see a dime of it).

These Right winged "socialist" fear mongers fail to mention or care about this rationing because it only effects poor and middle class individuals who have LONG been lost by them. They only care about if they will be unable to assure they will always have care because they are more deserving than anyone else for it.

@ DHT: In the US of A, each prescription medication costs approximately 40% more than what individuals in other nations have to pay for these same BRAND NAME prescriptions. Why is that? Because there is purchasing power in the national programs. Plus, the companies expect the US population to foot the bill for all those tv advertisements, print ads, and free lunches they give to doctors which clearly are shown to influence prescription habits (except all you wonderful doctors here on the forums... I am talking about other, less well informed and insightful docs out there who lack integrity and are easily influenced...). And since most medication research is actually already publically funded via NIH grants, and much research on drugs is performed at publically funded University Hospitals, and considering R&D is only about 1/3rd of pharm companies budgets compared to advertising nearly twice as much, a socialized insurance system wouldn't stifle new drug development and usefulness.

The idea that the government is going to put in place treatment guidelines and tell doctors how to practice should actually be looked at as a positive. Treatment guidelines help make sure all patients are treated appropriately with the most current and accurate treatment protocols. Some doctors still practice on what they learned in med school and residency 40 years ago. It should be mandated that all CHF patients are started on an ACE, on a statin, and on Aldactone when they ef is less than 40%. All ICU's should practice proper SIRS protocols, all inpatient diabetics should be on appropriate insulin sliding scales, all inpatients should be on proper DVT protocol. Time out sheets and checklists of all surgical instruments used should be standard of care in all OR's. Doctors shouldn't be allowed to let their preconceived notions and prejudices prevent patients from getting optimum care. These regulations need to result from large, multicenter, randomized control experiments, and based on science and nothing else (which seeing how the republican right operates, I find that is going to be increasingly difficult). Cookbook medicine, as it is affectionately called, is at times, actually in the best interest of the patient.

While I understand what you are saying, I think you are wrong. The logical conclusion to cookbook medicine is that you no longer need physicians to make any decisions. Rather, you look at book, you do what book says, if it doesn't work, you look at book, etc. Have you ever actually seen a government program tha has been run in an efficient manner? It will never work. The system we have in place is not a bad one, and I can think of a million ways to improve it. But trying to build a socialist run healthcare system will never work in this country, as it doesn't work in any country as efficiently as one would think.

 

[dacrocytic]

Would you believe..
Canadians come to the US to use our health care system
they have to wait months for an MRI

and ofcourse public US hospitals will not refuse a single patient.

in a way universal healthcare already negatively affects us

 

[thedrjojo]

While I understand what you are saying, I think you are wrong. The logical conclusion to cookbook medicine is that you no longer need physicians to make any decisions. Rather, you look at book, you do what book says, if it doesn't work, you look at book, etc. Have you ever actually seen a government program tha has been run in an efficient manner? It will never work. The system we have in place is not a bad one, and I can think of a million ways to improve it. But trying to build a socialist run healthcare system will never work in this country, as it doesn't work in any country as efficiently as one would think.

My argument is not that ALL of medicine will be a cookbook, but that there are certain things, certain times, that there is one best way to approach things, or that it has been shown in a systematic fashion to work better with a specific protocol. Parts of the steps in the cook book depend on a skilled clinician to make a determination in the flow sheet: does the patient have these symptoms or these symptoms. Clinical judgement falls in that, but then once the judgement has been made, its not a question of "I'm not familiar with ACEi's, but I've been using hydralizine since i was a resident and its what works for me" but that science has shown that ACEi's are most effective and all patients should be on them. That aspect can't be replaced by non physicians. Neither could a surgeon be replaced (atleast on like 97% of cases), or a gastroenterologist performing a colonoscopy, or a plethera of other specialties. Primary care docs are already being marginalized with NP's and PA's, but there is still stuff they have to come to a doctor for.

The system we have in place is most certainly a bad one right now. It is a system that can not sustain itself for much longer. While I admit that many of those stats that show we are substandard compared to every other industrialized nation as far as health outcomes are concerned are skewed and not entirely accurate, we are no where near the top, and if you believe Sean Hannity, that is just not the way things work in America. We are the best, hands down. Anything less is unacceptable. Dacrocytic's point of public US hospitals not refusing patients, when places like University Hosptial in Newark is millions of dollars in the red and continue to get decreasing state funds, eventually it won't be able to sustain itself, and then what happens?