Yale medical students issue demands for diversity

[tymont12]

Because Medicare/-aid pays poorly. I'm not volunteering to work more than necessary for what they pay.

Medicare/caid work is woefully underpaid but it's still fee-for-service, not capitated correct? Which would inherently mean more work = more money.

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[username456789]

Why would single-payer necessarily eliminate the ability of a physician to make more money by working more cases?

Probably because, under such a system, the smart ones would get out of medicine.

 

[username456789]

But it's still fee-for-service, not capitated correct?

For now. That may go by the wayside in the not so distant future.

 

[el_duderino]

Because Medicare/-aid pays poorly. I'm not volunteering to work more than necessary for what they pay.

So you would be able to work more for more money, you just wouldn't want to.

 

[IlDestriero]

High government payer volume bankrupts hospitals, look at all the bankrupt rural and inner city hospitals. I'd have to work more than twice as hard to get the same money.
If every citizen got a Medicare card tomorrow the government would own all the hospitals in no time at fire sale prices. And that's probably a long term goal for many who advocate for "free" health care for all.

 

[VA Hopeful Dr]

So you would be able to work more for more money, you just wouldn't want to.

I guarantee you that if we go single-payer, FFS goes out the window with 5 years.

I've been salaried with no productivity bonus, you better believe I didn't work any harder than I absolutely had to. I'm not unique in this.

 

[charmiedermie]

If the insurance company determines it's elective, then yes. If the government-run single-payer insurance determines it's elective, then yes. It's not like that situation applies only to single-payer.

Elective was the wrong word. Non-urgent is probably more accurate. I'm referring to procedures like knee replacement surgery, since it's for conditions that won't kill you. In your world, I would be told to wait in line to eventually get it done, meanwhile continue to live in pain everyday and watch my quality of life go down. And if I want it done earlier so I'm not in agonizing pain everyday, you'd tell me to pay completely out of pocket, since I have no private insurance available to turn to. It's inhumane.

So you would be able to work more for more money, you just wouldn't want to.

@IlDestriero just told you it wouldn't be worth seeing them financially since they reimburse hospitals way low for the services they render. Why would he overextend himself for that?

 

[el_duderino]

Elective was the wrong word. I'm referring to procedures like knee replacement surgery, since it's for conditions that won't kill you. In your world, I would be told to wait in line to eventually get it done, meanwhile continue to live in pain everyday and watch my quality of life go down. And if I want it done earlier so I'm not in agonizing pain everyday, you'd tell me to pay completely out of pocket, since I have no private insurance available to turn to. It's inhumane.

@IlDestriero just told you it wouldn't be worth seeing them financially since they reimburse hospitals way low for the services they render. Why would he overextend himself for that?

He would work more to make more money.

I'm not saying that single-payer is a perfect solution. Far from it. The problem is it's the only one that's remotely acceptable.

 

[charmiedermie]

He would work more to make more money.

I'm not saying that single-payer is a perfect solution. Far from it. The problem is it's the only one that's remotely acceptable.

He doesn't make more because if you added up all the charges billed, he's reimbursed so very little with Medicaid to make up for those charges. Out of all the numerous possibilities you can think of, single payer healthcare is the only remotely acceptable option, just because you feel better about yourself, when there are people who have to live with pain, suffering, and decreased QOL on a waitlist? Or is it just tough noogies for them?

 

[el_duderino]

He doesn't make more because if you added up all the charges billed, he's reimbursed so very little with Medicaid to make up for those charges. Out of all the numerous possibilities you can think of, single payer healthcare is the only remotely acceptable option, just because you feel better about yourself, when there are people who have to live with pain, suffering, and decreased QOL on a waitlist? Or is it just tough noogies for them?

As opposed to the people who have no coverage at all? What do they get?

Yes, some people will get worse care than they would in the current system.

 

[IlDestriero]

No I wouldn't work more. Look at the VA and the military hospitals. Think any elective cases are starting after 3pm? Ha! No chance. Get in line or get an urgent problem.
I'd work at the parallel private system or go home at 3 and retire to a condo instead of ocean front/view cottage.
You would have to wait 6 months or more for your knee surgery, and that's not my problem. That's the future. Look at socialized systems that exist now. They're still expensive and ration care.

 

[charmiedermie]

As opposed to the people who have no coverage at all? What do they get?

Yes, some people will get worse care than they would in the current system.

Is this really your argument? That those patients who are put on a govt. waiting list for procedures for necessary, but non-life threatening conditions, since you took away all their other insurance choices, should be allowed to suffer because at least you get to say everyone gets a govt. insurance card? So as long as everyone has healthcare, even if it is equally bad healthcare, you consider that a win.

 

[el_duderino]

So as long as everyone has healthcare, even if it is equally bad healthcare, you consider that a win.

It would be a win if people like you worked toward getting everyone coverage that isn't bad.

In my opinion it's a moral imperative for us, as a society, to make sure everyone has health care. Of course I want it to be as good as it can be.

 

[Psai]

It would be a win if people like you worked toward getting everyone coverage that isn't bad.

In my opinion it's a moral imperative for us, as a society, to make sure everyone has health care. Of course I want it to be as good as it can be.

No one is working towards healthcare for all. The goal is healthcare insurance for all. This ensures profits for insurance companies who do their best to deny healthcare with high prices, incredibly high deductibles and terrible coverage. The affordable care act has as orwellian a name as the Patriot act or the department of defense

 

[VA Hopeful Dr]

It would be a win if people like you worked toward getting everyone coverage that isn't bad.

In my opinion it's a moral imperative for us, as a society, to make sure everyone has health care. Of course I want it to be as good as it can be.

A worthy goal, but the problem is (and always has been) how do we do this without bankrupting the country, making sure the care doesn't suck, and preventing abuse while keeping those who provide healthcare reasonably content.

I truthfully think one of the best ways to do this would be to have a government option (in addition to private insurance) to buy into essentially catastrophic insurance (say, 5k deductible) with premiums adjusted for income. Now unlike regular insurance, this deductible is applicable even if you pay cash for something. That's one of the biggest problems now with high deductible plans. They doesn't actually encourage price-shopping because it doesn't work like that. Everywhere will charge the same insurance allowable so its the same price everywhere. For example, I can get my patients a cash MRI for $500 at a free-standing imaging center in town compared to $2500 cash at the hospital systems. If you file insurance, its $2000 no matter where you go for it. So, patients are actually punished for trying to get a better price since the cash price won't apply to your deductible. Change that first off.

Then, set up an HSA-like plan. Tier the amount that the government puts in based on income so that everyone below the poverty line gets enough to cover almost but not all of the deductible (say 95% or something) while those at 2X the poverty line only get enough to cover say 75% and 3X 40%. Then, let everyone get their own health care.

Its the best way I can see to let the free market still have a role while not leaving out the poor.

 

[NickNaylor]

It would be a win if people like you worked toward getting everyone coverage that isn't bad.

In my opinion it's a moral imperative for us, as a society, to make sure everyone has health care. Of course I want it to be as good as it can be.

This is just about as actionable as "I want every kid to get a college education, it's a moral imperative," "I want no one to be homeless, it's a moral imperative," or "I want everyone to do what they love and not have to worry about supporting themselves, it's a moral imperative." No one disagrees that these things are worthy and noble goals worth pursuing. The question is how we achieve those goals given the constraints within which we're operating - that would, for example, make a single-payer system untenable given the political impossibility of such a system today, or the equal impossibility of allowing everyone to be a homebrewed intellectual that doesn't have to work due to economic realities - and the devil is in the details. Platitudes and complaining about things as they are without realistic steps to move towards improvement do us nothing.

 

[el_duderino]

A worthy goal, but the problem is (and always has been) how do we do this without bankrupting the country, making sure the care doesn't suck, and preventing abuse while keeping those who provide healthcare reasonably content.

I truthfully think one of the best ways to do this would be to have a government option (in addition to private insurance) to buy into essentially catastrophic insurance (say, 5k deductible) with premiums adjusted for income. Now unlike regular insurance, this deductible is applicable even if you pay cash for something. That's one of the biggest problems now with high deductible plans. They doesn't actually encourage price-shopping because it doesn't work like that. Everywhere will charge the same insurance allowable so its the same price everywhere. For example, I can get my patients a cash MRI for $500 at a free-standing imaging center in town compared to $2500 cash at the hospital systems. If you file insurance, its $2000 no matter where you go for it. So, patients are actually punished for trying to get a better price since the cash price won't apply to your deductible. Change that first off.

Then, set up an HSA-like plan. Tier the amount that the government puts in based on income so that everyone below the poverty line gets enough to cover almost but not all of the deductible (say 95% or something) while those at 2X the poverty line only get enough to cover say 75% and 3X 40%. Then, let everyone get their own health care.

Its the best way I can see to let the free market still have a role while not leaving out the poor.

The idea that consumers can and will price shop for procedures is nonsense. Virtually no one will do that, or be able to do that. None of this really does anything about the people who decide not to get insurance, either.

 

[el_duderino]

This is just about as actionable as "I want every kid to get a college education, it's a moral imperative," "I want no one to be homeless, it's a moral imperative," or "I want everyone to do what they love and not have to worry about supporting themselves, it's a moral imperative." No one disagrees that these things are worthy and noble goals worth pursuing. The question is how we achieve those goals given the constraints within which we're operating - that would, for example, make a single-payer system untenable given the political impossibility of such a system today, or the equal impossibility of allowing everyone to be a homebrewed intellectual that doesn't have to work due to economic realities - and the devil is in the details. Platitudes and complaining about things as they are without realistic steps to move towards improvement do us nothing.

It's not actionable? How come virtually every other wealthy western nation has already done it, then?

You can't say it's not "actionable" when other people have been doing it for a long time. The fact that there's significant political opposition doesn't somehow make it not worth pursing or possible.

 

[Oo Cipher oO]

The idea that consumers can and will price shop for procedures is nonsense. Virtually no one will do that, or be able to do that. None of this really does anything about the people who decide not to get insurance, either.

People do not currently price shop because there are many roadblocks and few financial incentives to do so in the present environment. People are price conscious in every other single commercial industry so it seems illogical to assume the same can not occur in healthcare.

 

[VA Hopeful Dr]

The idea that consumers can and will price shop for procedures is nonsense. Virtually no one will do that, or be able to do that. None of this really does anything about the people who decide not to get insurance, either.

If you willfully (not because of means, but just being stubborn) decide not to get insurance, that's on you. We can't save those who refuse help.

And yes, if price shopping were easier people absolutely would do it. My cash-paying patients ask me to do it for them all the time. Because of this, I have a list of prices for common things from ultrasounds to outpatient GYN procedures to stress echos.

Your comment shows your ignorance - the reason patients don't price shop is a combination of a) difficulty in getting cash-pricing and b) 30+ years of habit in not having to because of insurance always paying for everything.

 

[VA Hopeful Dr]

People do not currently price shop because there are many roadblocks and few financial incentives to do so in the present environment. People are price conscious in every other single commercial industry so it seems illogical to assume the same can not occur in healthcare.

Bingo

 

[el_duderino]

If you willfully (not because of means, but just being stubborn) decide not to get insurance, that's on you.

I don't accept that.

And yes, if price shopping were easier people absolutely would do it. My cash-paying patients ask me to do it for them all the time. Because of this, I have a list of prices for common things from ultrasounds to outpatient GYN procedures to stress echos.

Your comment shows your ignorance - the reason patients don't price shop is a combination of a) difficulty in getting cash-pricing and b) 30+ years of habit in not having to because of insurance always paying for everything.

I don't agree with that. If I go to the ER and they want to do some blood tests and a CT, I'm not going to walk out with some notes and start calling around to see who will do them cheapest. They're just going to do them right there. Few patients will call around requesting quotes for a specific MRI. It's great that you're a nice guy and are happy to help your patients do that, but I don't see any way that could become common practice. The knowledge gap is just too high and the inconvenience can be very high.

 

[VA Hopeful Dr]

I don't accept that.



I don't agree with that. If I go to the ER and they want to do some blood tests and a CT, I'm not going to walk out with some notes and start calling around to see who will do them cheapest. They're just going to do them right there. Few patients will call around requesting quotes for a specific MRI. It's great that you're a nice guy and are happy to help your patients do that, but I don't see any way that could become common practice. The knowledge gap is just too high and the inconvenience can be very high.

As to the first, too bad. Its like the Medicaid eligible patients I saw in med school. Literally all they had to do was fill out a form and they would get insurance, instead I heard several variations of "I ain't got time for that".

For the second, the ED is always going to be different. Same with inpatient care. You will always need insurance for that and I don't dispute that. But, we can save significant money by encouraging competition outside of that. I had a patient that needed his uvula taken out. His ENT quotes a cash-pay surgical fee of $500, but the hospital OR fee was going to be $15,000. I called a private surgery center in town, OR/anesthesia was $900. Now I will freely admit that patients as of now can't usually actually get anyone to quote prices. If you change the landscape to where everyone is cash pay up to a point, that will change very quickly.

As for the knowledge gap, it is absolutely not too high. If as a patient you have a script that says "MRI Brain w/o contrast", you call around and say "What is your up-front cash price for an MRI Brain w/o contrast". You could do the exact same thing with a lab order form or prescription drugs. Its really not hard at all.

 

[el_duderino]

As to the first, too bad.

It won't be "too bad" if/when we move to an actual universal coverage model. That's where the fundamental disconnect is, anyway.

 

[VA Hopeful Dr]

It won't be "too bad" if/when we move to an actual universal coverage model. That's where the fundamental disconnect is, anyway.

As I've said before, it will take a fundamental shift in the American mindset for that to work. This gets less likely every year as we see more and more problems in other universal-type systems.

Serious question though: if someone doesn't want insurance, and in fact actively fights getting it, why are you so hell-bent on making them have it?

 

[el_duderino]

You have many pipe dreams. It makes me lol.

It's probably just a matter of time.

 

[el_duderino]

Serious question though: if someone doesn't want insurance, and in fact actively fights getting it, why are you so hell-bent on making them have it?

Because it's in everyone's interest for any particular person to have health insurance.

 

[VA Hopeful Dr]

Because it's in everyone's interest for any particular person to have health insurance.

I see... that's not a dangerous mindset at all.

 

[el_duderino]

I see... that's not a dangerous mindset at all.

It's the same mindset that leads us to have government-funded police and fire protection, Social Security, food stamps, unemployment, national defense, Medicare/Medicaid, etc.

 

[el_duderino]

Like President Bernie Sanders?

The extremes of political thought always think their ideas are inevitable, that "it's just a matter of time." Everyone will come around, you're just ahead of your time.

Trump's not going to be president. We're not going to nuke Iran. Guns will never be outlawed. And the NHS will never be replicated in America.

Universal coverage is not an extreme. The US is unusual in that it doesn't already have universal coverage.

 

[VA Hopeful Dr]

It's the same mindset that leads us to have government-funded police and fire protection, Social Security, food stamps, unemployment, national defense, Medicare/Medicaid, etc.

Most of those you can decline if you wish. I have a 70 year old patient who refuses to accept Social Security and Medicare despite being eligible for both. You're saying he should be forced to accept them?

 

[VA Hopeful Dr]

Universal coverage is not an extreme. The US is unusual in that it doesn't already have universal coverage.

True, but historically speak we are much more individualist than anyone else. Still are.

 

[el_duderino]

Most of those you can decline if you wish. I have a 70 year old patient who refuses to accept Social Security and Medicare despite being eligible for both. You're saying he should be forced to accept them?

It should be automatic. I don't have to opt into the local police department or any of dozens of other government services.

True, but historically speak we are much more individualist than anyone else. Still are.

We are, but we still managed to implement social security, welfare, supplemental nutrition programs, Medicaid, EMTALA, etc. And we managed to pass the ACA with its individual mandate and expanded Medicaid. The idea is not extreme or unprecedented.

 

[VA Hopeful Dr]

It should be automatic. I don't have to opt into the local police department or any of dozens of other government services.



We are, but we still managed to implement social security, welfare, supplemental nutrition programs, Medicaid, EMTALA, etc. And we managed to pass the ACA with its individual mandate and expanded Medicaid. The idea is not extreme or unprecedented.

So automatic but with an opt-out? My idea would work just fine with that, though I still don't think you'd have to make it mandatory. What I think you would see if an uninsured person showed up in the hospital is exactly what we see now - the hospital tries their best to get them some form of insurance.

All of those are things that are offered but not required of the general public. Proves my first point. I also wouldn't use the ACA is a pro for your side. That bill saw the largest shift in Congress in over 50 years.

 

[el_duderino]

I don't see any reason for an opt-out. I suppose it might be possible for an opt-out provided you go out and purchase your own coverage that is at least as good. You'd still have to pay into the system, though, or else it would never work. There's a danger of that creating a tiered system. Not sure how we'd approach that... maybe require all providers to take the national system, or something. I dunno. I don't really like the idea of an opt-out.

 

[VA Hopeful Dr]

I don't see any reason for an opt-out. I suppose it might be possible for an opt-out provided you go out and purchase your own coverage that is at least as good. You'd still have to pay into the system, though, or else it would never work. There's a danger of that creating a tiered system. Not sure how we'd approach that... maybe require all providers to take the national system, or something. I dunno. I don't really like the idea of an opt-out.

And see I don't like forcing people to do something unless there is a VERY compelling reason for doing so, and preventing them from incurring significant health care costs isn't compelling enough.

 

[charmiedermie]

It would be a win if people like you worked toward getting everyone coverage that isn't bad.

In my opinion it's a moral imperative for us, as a society, to make sure everyone has health care. Of course I want it to be as good as it can be.

So your response to a real, inhumane example under the system which you said is the only remotely acceptable system, is to put it on me not trying hard enough? You just said care would be worse for some people. Or as long as it is worse for the people you don't really care about, its all good.

The idea that consumers can and will price shop for procedures is nonsense. Virtually no one will do that, or be able to do that. None of this really does anything about the people who decide not to get insurance, either.

Consumers price shop for things that cost much more than some medical procedures. Right now those costs aren't readily available beforehand which is why it doesn't happen, but don't say people don't want to do it. There is a surgical center in Oklahoma that does just that.

You can't say it's not "actionable" when other people have been doing it for a long time. The fact that there's significant political opposition doesn't somehow make it not worth pursing or possible.

People don't want to be put on a 6 month waitlist for a procedure they need badly. That is what is stopping it from being pursued. You know the one which you just told me to pay out of pocket for while in agonizing pain and giving me no choice to buy private health insurance.

I don't accept that.

Great response to @VA Hopeful Dr. You don't accept that there are some people who don't want to buy health insurance? Why can't you accept that I love my private health insurance and want to keep it.

You have many pipe dreams. It makes me lol.

The pipe dream isn't what scares me. His response to my example in his "only remotely acceptable system" where he would let me be in utter pain for 6 months while I wait for a knee replacement, was to tell me to pay out of pocket then, for health insurance I'm already paying for with taxes, because at least he feels better psychologically that everyone has an insurance card. That is what scares me.

 

[el_duderino]

Your straw man argument is intellectually bankrupt.

 

[charmiedermie]

Your straw man argument is intellectually bankrupt.

You've said the only remotely acceptable option is single payer, and your primary goal above all else is universal coverage, even if one of the many downsides is being put on a waiting list. People have pointed out serious flaws in your plan and you either dismiss their concern completely, tell them that you don't accept their point, and imply that your choice is the only moral choice. Which parts do I have wrong?

 

[atomi]

We are, but we still managed to implement social security, welfare, supplemental nutrition programs, Medicaid, EMTALA, etc. And we managed to pass the ACA with its individual mandate and expanded Medicaid. The idea is not extreme or unprecedented.

Correct. It's not extreme or unprecedented. Just socialist and unconstitutional.

 

[atomi]

It should be automatic. I don't have to opt into the local police department or any of dozens of other government services.

Your straw man argument is intellectually bankrupt.

LOL

 

[tymont12]

The government could be impactful by standardizing the forms/processes in how insurances communicate with billers, patients, etc. That's currently a blackhole which wastes so much money through administrative fiddling. I worked out of a billing office for awhile and it was a nightmare.

 

[IlDestriero]

If you willfully (not because of means, but just being stubborn) decide not to get insurance, that's on you. We can't save those who refuse help.

And yes, if price shopping were easier people absolutely would do it. My cash-paying patients ask me to do it for them all the time. Because of this, I have a list of prices for common things from ultrasounds to outpatient GYN procedures to stress echos.

Your comment shows your ignorance - the reason patients don't price shop is a combination of a) difficulty in getting cash-pricing and b) 30+ years of habit in not having to because of insurance always paying for everything.

When my wife had her ortho procedure, we used an in network, non preferred provider. The insurance company told her exactly what the cost would be upfront to the penny. Cash payers may have a harder time getting a total cost for a procedure though.
My hospital regularly negotiates a single upfront fee for the wealthy from abroad for complex cases. It can be done.

 

[NickNaylor]

It's not actionable? How come virtually every other wealthy western nation has already done it, then?

You can't say it's not "actionable" when other people have been doing it for a long time. The fact that there's significant political opposition doesn't somehow make it not worth pursing or possible.

Well, sure, it might be worth pursuing but the fact of the matter is that there is next to zero chance that it will become a reality in the near future due to the politics surrounding the issue. Despite what you might think, this makes any kind of single-payer solution just as difficult to implement as a lack of resources.

This is a common problem I see with progressive folks: there is often a deliberate choice to ignore reality. Thus far, your arguments have relied on your feels and what other countries have done. Neither is particularly convincing to those who don't agree with you and certainly aren't going to convince the populace at large to suddenly be in favor of a government-run healthcare program.

Single-payer healthcare is one solution to the problem. However, it is not the only solution, and depending on your perspective, it certainly isn't the optimal solution.

 

[el_duderino]

Well, sure, it might be worth pursuing but the fact of the matter is that there is next to zero chance that it will become a reality in the near future due to the politics surrounding the issue. Despite what you might think, this makes any kind of single-payer solution just as difficult to implement as a lack of resources.

This is a common problem I see with progressive folks: there is often a deliberate choice to ignore reality. Thus far, your arguments have relied on your feels and what other countries have done. Neither is particularly convincing to those who don't agree with you and certainly aren't going to convince the populace at large to suddenly be in favor of a government-run healthcare program.

Single-payer healthcare is one solution to the problem. However, it is not the only solution, and depending on your perspective, it certainly isn't the optimal solution.

No one in this thread is having their minds changed.

 

[Slack3r]

No one in this thread is having their minds changed.

Except for all the bleeding hearts when they grow up and realize the world doesn't run on butterfly kisses and rainbows.

 

[el_duderino]

Except for all the bleeding hearts when they grow up and realize the world doesn't run on butterfly kisses and rainbows.

I went the opposite way. I grew up and realized that the other citizens of this country are human beings.

 

[charmiedermie]

No one in this thread is having their minds changed.

@NickNaylor also said populace at large. People who have regular jobs, not in healthcare, tend to like their private health insurance and they like their private doctors, whether you like that or not. Private health insurance is a major benefit that attracts good employees. Even unions are trying to go after the law on the cadillac tax because it destroys their plans they worked hard to collectively bargained for. If you can't even convince them of how they benefit, you won't be able to convince anyone else.

I went the opposite way. I grew up and realized that the other citizens of this country are human beings.

You also said you worked for the government for 10 years, that probably had more to do with your support for single payer.

 

[el_duderino]

@NickNaylor also said populace at large. People who have regular jobs, not in healthcare, tend to like their private health insurance and they like their private doctors, whether you like that or not. Private health insurance is a major benefit that attracts good employees. Even unions are trying to go after the law on the cadillac tax because it destroys their plans they worked hard to collectively bargained for. If you can't even convince them of how they benefit, you won't be able to convince anyone else.

People are also terrified to lose their jobs and lose their health insurance... or leave a terrible, toxic job because they can't lose their health insurance.

The tying of health insurance to employment is an anachronistic, idiotic quirk of the history of American health insurance.

 

[charmiedermie]

People are also terrified to lose their jobs and lose their health insurance... or leave a terrible, toxic job because they can't lose their health insurance.

The tying health insurance to employment is an anachronistic, idiotic quirk of the history of American health insurance.

It's not an anachronistic, idiotic quirk. It happened during World War II when wages were frozen in this country and employers still needed a way to attract workers. So health insurance was a huge perk to attract people. It's still a huge perk for people which is why it has stayed. Ask any teacher, police officer, engineer, or businessman how much they value their private health insurance. Even if you didn't have a job, you could still buy COBRA plans or buy health insurance as an individual.