Your Thoughts on the Future of US Health Care?

[justin1390]

I'm just curious as to what you guys have heard or believe.

Private insurance is pulling out of the health care marketplace setup by the ACA. The influx of people most likely represent a fairly high utilizer index. In addition, CMS is squeezing the pennies and life out of non-profit healthcare systems. A local hospital recently lost over 35 million this last year, putting a hiring freeze in what has historically been a top notch industry performer. And MACRA is coming...

Guys, unless the penalty for skipping out on insurance is equal to the cost of insurance (helps buffer the sick utilizers), I'm honestly not sure how in the heck this machine is sustainable. Unless we employ all midlevels for all but the sickest patients...

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[raiderette]

The penalty will be the same next year for ACA. Public option could be on its way. Medicare at 50+ and catastrophic guaranteed for everyone paid for on a line on a tax return.

 

[SurfingDoctor]

Too many parties with competing interests. No one knows what the end result will be, but it's going to be bumpy as hell getting there.

 

[managedcarefin]

Increasing the risk arrangements is coming in a major way, along with the consolidation of services. Within a system you might only have 1 hospital that has a cardiac unit....etc.

 

[DetectiveAlonzo]

****.

Pure ****.

 

[PL198]

I'm just curious as to what you guys have heard or believe.

Private insurance is pulling out of the health care marketplace setup by the ACA. The influx of people most likely represent a fairly high utilizer index. In addition, CMS is squeezing the pennies and life out of non-profit healthcare systems. A local hospital recently lost over 35 million this last year, putting a hiring freeze in what has historically been a top notch industry performer. And MACRA is coming...

Guys, unless the penalty for skipping out on insurance is equal to the cost of insurance (helps buffer the sick utilizers), I'm honestly not sure how in the heck this machine is sustainable. Unless we employ all midlevels for all but the sickest patients...

which is what I've said all along. will be a 2 tier system. midlevels for primary care and low level illness. doctors for actually sick people

 

[scootad.]

How many more years before single payer Medicare for all? It would require both houses of congress to be democratic. With inevitable demographic shifts (white people getting outnumbered), maybe in 10-15 years? Any guesses? 2025?

 

[SurfingDoctor]

How many more years before single payer Medicare for all? It would require both houses of congress to be democratic. With inevitable demographic shifts (white people getting outnumbered), maybe in 10-15 years? Any guesses? 2025?

Whatever happens, it won't be proactively. Policy changes only occur in reactive manners. Add into the fact that even within physicians as a whole, one speciality organization supports the ACA, while another doesn't, it's going to be a mess. When more hospitals start closing their doors, that will be the beginning. How long before that trend causes an actual crisis (and I'm not talking lack of care or coverage, but death), I don't think anyone knows. Most of my colleagues think it is coming sooner rather than later, but I think that is more their hope than their actual guess.

Here is an NEJM editorial on the subject if you are interested.
http://www.nejm.org/doi/full/10.1056/NEJMp1602009#article

The current system already favors the well to do, demonstrated by the worse healthcare outcomes in the lower SES group. Let that continue unabated to the point where care will only be provided to the well to do, you are going to have a lot of angry people who see two options 1) roll over and die or 2) fight hard and force a change. I suspect they have the numbers in their favor to pick whichever they prefer and I don't think in will be option 1.

 

[justin1390]

Whatever happens, it won't be proactively. Policy changes only occur in reactive manners. Add into the fact that even within physicians as a whole, one speciality organization supports the ACA, while another doesn't, it's going to be a mess. When more hospitals start closing their doors, that will be the beginning. How long before that trend causes an actual crisis (and I'm not talking lack of care or coverage, but death), I don't think anyone knows. Most of my colleagues think it is coming sooner rather than later, but I think that is more their hope than their actual guess.

Here is an NEJM editorial on the subject if you are interested.
http://www.nejm.org/doi/full/10.1056/NEJMp1602009#article

The current system already favors the well to do, demonstrated by the worse healthcare outcomes in the lower SES group. Let that continue unabated to the point where care will only be provided to the well to do, you are going to have a lot of angry people who see two options 1) roll over and die or 2) fight hard and force a change. I suspect they have the numbers in their favor to pick whichever they prefer and I don't think in will be option 1.

Excellent post. I completely agree with this. And the problem with reactive change is it's never well thought out. There's too much pressure for people to spend the extra year or two iron out the details or piloting sites.

As we've already seen, the private practice is disappearing, and hospitals are conglomerating to try and distribute the cost. The thought among my med school and now my training institution is that things are going back to capitation. It's brilliant in terms of risk, but my concern is that there will not appropriate effort put in to studying and distributing per capita monies as there should be. Health care populations vary significantly, and I could see scenarios where influx/eflux of patients makes things sticky within months, not years. You figure most hospitals, if profitable, are running in the 1-4% margin. If capitation allow for an optimistic 2%, that could disappear quickly with a few bad years or major local catastrophes (Hurricane Katrina being a great example). There would need to be significant provisions to protect hospitals, because once those go down and the population sickens, it's going to be even more costly...

 

[FiveOClock]

We need to do what India does. Have government run hospitals that people can go to for 100% free. Each physician sees approximately 200 pts a day, and there is little oversight for regulations and record keeping. People who really just need a doctor get to see one.

Then there is the private hospital/offices which accept private insurance and cash and are high quality. This way everyone has minimum health-care, but you get what you pay for. No Medicare/Medicaid or any other government programs, just the state hospitals. This is ultimately a more fair two-tiered system than the future public option, which would ruin private health insurance and force everyone into low-quality, high-cost, **** healthcare.

 

[QualityProcess]

Each physician sees approximately 200 pts a day, and there is little oversight for regulations and record keeping.

huh

 

[SurfingDoctor]

This is ultimately a more fair two-tiered system than the future public option, which would ruin private health insurance and force everyone into low-quality, high-cost, **** healthcare.

Let me get this right? So under this system, poor people get terrible care with no oversight or standard of care, and rich people get whatever they need? And that's "fair"?

 

[Psai]

When the people on medicaid and food stamps have a nicer phone than I do, something is seriously wrong with the system. Maybe you should get what you put in instead of relying on the government to provide by stealing from others.

 

[FiveOClock]

Let me get this right? So under this system, poor people get terrible care with no oversight or standard of care, and rich people get whatever they need? And that's "fair"?

Poor people get care. We have a lot of people complaining about access for the poor. They will now have access to care. We cannot provide access to high-quality care for everyone, it is not possible. For examples of how this does not work, see Canada and England where care is rationed for EVERYONE because of their universal health care system. In this proposed system, at least the vast majority of the country gets access to high-quality care. And who says that government hospitals seeing high volumes of low income pts have to offer lower quality of care? It's more about decreasing the red tape and regulations and allowing people to get the minimum essential care.

When the people on medicaid and food stamps have a nicer phone than I do, something is seriously wrong with the system. Maybe you should get what you put in instead of relying on the government to provide by stealing from others.

Finally somebody who actually gets it. If you contribute nothing to the country, why are you entitled to health care in the first place? It is a consumer good like a phone, car, house, or night out your favorite restaurant.

 

[giantswing]

Poor people get care. We have a lot of people complaining about access for the poor. They will now have access to care. We cannot provide access to high-quality care for everyone, it is not possible. For examples of how this does not work, see Canada and England where care is rationed for EVERYONE because of their universal health care system. In this proposed system, at least the vast majority of the country gets access to high-quality care. And who says that government hospitals seeing high volumes of low income pts have to offer lower quality of care? It's more about decreasing the red tape and regulations and allowing people to get the minimum essential care.



Finally somebody who actually gets it. If you contribute nothing to the country, why are you entitled to health care in the first place? It is a consumer good like a phone, car, house, or night out your favorite restaurant.

Your statements are contradictory.

 

[FiveOClock]

Your statements are contradictory.

Right universal access is illogical, so all plans to implement it will have seemingly contradictory elements. See ACA

 

[SurfingDoctor]

We cannot provide access to high-quality care for everyone, it is not possible.

In this proposed system, at least the vast majority of the country gets access to high-quality care.

You do realize a "vast majority" of people aren't wealthy right? So how are you going to supply them with "high-quality care"?

If you contribute nothing to the country, why are you entitled to health care in the first place?

Coming from someone who hopes to someday practice medicine, this is an incredibly sad statement. It is also illegal in the country (see EMTALA). No one can be turned away it an emergency, no matter what their circumstance.

 

[giantswing]

Right universal access is illogical, so all plans to implement it will have seemingly contradictory elements. See ACA

Just because I don't agree with you doesn't mean I'm illogical.

"We cannot provide access to high-quality care for everyone, it is not possible." doesn't jive with this: "And who says that government hospitals seeing high volumes of low income pts have to offer lower quality of care?"

DUH.

Not arguing the validity of your statement but pointing out that you don't make sense.

Also please don't go into emergency medicine.

 

[Psai]

Coming from someone who hopes to someday practice medicine, this is an incredibly sad statement. It is also illegal in the country (see EMTALA). No one can be turned away it an emergency, no matter what their circumstance.

EMTALA only says that you have to evaluate in the ED. You then stabilize or transfer to a facility that is capable of doing so. Beyond an immediate emergency, there is no obligation to provide care.

 

[SurfingDoctor]

EMTALA only says that you have to evaluate in the ED. You then stabilize or transfer to a facility that is capable of doing so. Beyond an immediate emergency, there is no obligation to provide care.

Right. Last time I checked though, stabilizing a sick patient requires resources and money, which the facility is entitled to use and the patient is entitled to receive. Thus the statement that "no one is entitled" is a fallacy. Also the facility is required to transfer care only if they are incapable of treating the patient. If the hospital has the resources and ability to treat the patient, they have to treat them.

 

[Psai]

An unfunded mandate to provide emergency care is not the same thing as providing equal care for every single person who comes through the healthcare system.

 

[FiveOClock]

Just because I don't agree with you doesn't mean I'm illogical.

"We cannot provide access to high-quality care for everyone, it is not possible." doesn't jive with this: "And who says that government hospitals seeing high volumes of low income pts have to offer lower quality of care?"

DUH.

Not arguing the validity of your statement but pointing out that you don't make sense.

Also please don't go into emergency medicine.

I was saying that high volume govt hospitals does not automatically mean lower quality of care necessarily. The quality of care will be low because of the previous statement which is that it is not possible to provide high quality free care because it is an expensive, scarce commodity. Makes perfect sense to me

 

[SurfingDoctor]

I was saying that high volume govt hospitals does not automatically mean lower quality of care necessarily. The quality of care will be low because of the previous statement which is that it is not possible to provide high quality free care because it is an expensive, scarce commodity. Makes perfect sense to me

Most academic centers provide uncompensated care or "free" care (though nothing is ever free). I suppose the care is low quality to those patients? People don't go wheeling ventilators out of room because patients can't pay. If you think they should, I wouldn't recommended saying it aloud on your ICU rotation. BTW, if I ever heard a trainee suggest that ability to pay would determine the care we provide during their rotation to the PICU, you can bet I would fail them and make it aware to the clerkship director.

http://elischolar.library.yale.edu/cgi/viewcontent.cgi?article=1176&context=ymtdl

 

[SurfingDoctor]

An unfunded mandate to provide emergency care is not the same thing as providing equal care for every single person who comes through the healthcare system.

No one said EMTALA = equal care for anyone in healthcare. So, yeah.

 

[giantswing]

I was saying that high volume govt hospitals does not automatically mean lower quality of care necessarily. The quality of care will be low because of the previous statement which is that it is not possible to provide high quality free care because it is an expensive, scarce commodity. Makes perfect sense to me

Your attitude is gross. Doling out care - or quality of care - based on ability to pay is ethically abhorrent.

 

[FiveOClock]

Most academic centers provide uncompensated care or "free" care (though nothing is ever free). I suppose the care is low quality to those patients? People don't go wheeling ventilators out of room because patients can't pay. If you think they should, I wouldn't recommended saying it aloud on your ICU rotation. BTW, if I ever heard a trainee suggest that ability to pay would determine the care we provide during their rotation to the PICU, you can bet I would fail them and talk to the clerkship director.

http://elischolar.library.yale.edu/cgi/viewcontent.cgi?article=1176&context=ymtdl

Whoever said govt run hospitals will have no ventilators?? Have you ever heard of the VA? There are ventilators. You are missing the entire point which is that instead of providing "insurance" for people that gives poor access to care + massive bills and deductibles, there will be a free option, albeit likely much higher volume with less regulations. It will likely be lower quality care, much like that VA. That is not by design, it is simply coming to terms with reality; govt provides poor quality, rationed services.

And wow, failing students for stating a point of view is incredibly anti-academic and much more shameful than anyone's views on the politics of healthcare. You suck.

Your attitude is gross. Doling out care - or quality of care - based on ability to pay is ethically abhorrent.

I see, so you would rather give people crappy care and claim that it is good rather than coming to terms with reality. What is your opinion on the VA?

 

[SurfingDoctor]

And wow, failing students for stating a point of view is incredibly anti-academic and much more shameful than anyone's views on the politics of healthcare. You suck

Well grades on a rotation aren't based solely on fund of knowledge but implementation of ethically principles and professionalism in medicine. Saying people who can't pay should be provided with inadequate care doesn't sound like a passing student to me because clearly there needs to be more education.

 

[PL198]

Well grades on a rotation aren't based solely on fund of knowledge but implementation of ethically principles and professionalism in medicine. Saying people who can't pay should be provided with inadequate care doesn't sound like a passing student to me.

Ya agree with me or face my wrath!

 

[PL198]

Lol professionalism. What a joke. God forbid someone have a different viewpoint than you

 

[FiveOClock]

Well grades on a rotation aren't based solely on fund of knowledge but implementation of ethically principles and professionalism in medicine. Saying people who can't pay should be provided with inadequate care doesn't sound like a passing student to me because clearly there needs to be more education.

Who said inadequate? You are being ridiculous, Professor. Cheaper and at a higher volume facility does not necessarily imply inadequate. It means using older technology, drugs, more mid-levels. Cheaper, not inadequate. You will not be receiving Harvoni but certainly older drugs for your Hep C

 

[SurfingDoctor]

Who said inadequate? You are being ridiculous, Professor. Cheaper and at a higher volume facility does not necessarily imply inadequate. It means using older technology, drugs, more mid-levels. Cheaper, not inadequate. You will not be receiving Harvoni but certainly older drugs for your Hep C

Okay. Not inadequate. Low quality is what you said. I stand corrected.

 

[qwerty89]

Its funny how political views vary between specialties & practice enviornments. Never ever say you are a republican or conservative in front of an academic pediatrician. On the other hand I've seen private practice ortho docs straight up tell patients "Obama doesn't want us to" when responding to a patient why they won't refill their pain meds.

 

[PL198]

Okay. Not inadequate. Low quality is what you said. I stand corrected.

And that is wrong? Do you think the VA gives care as good as a major academic center? It's inevitable. Everyone can't get the absolute best care

 

[PL198]

Its funny how political views vary between specialties & practice enviornments. Never ever say you are a republican or conservative in front of an academic pediatrician. On the other hand I've seen private practice ortho docs straight up tell patients "Obama doesn't want us to" when responding to a patient why they won't refill their pain meds.

Ya except the ortho won't fail you when you go "herp derp feel the bern" but the academic will try to make your life hell if you disagree with them.

 

[Psai]

Who said inadequate? You are being ridiculous, Professor. Cheaper and at a higher volume facility does not necessarily imply inadequate. It means using older technology, drugs, more mid-levels. Cheaper, not inadequate. You will not be receiving Harvoni but certainly older drugs for your Hep C

This is exactly what I'm talking about. No ones saying take a sick kid off a vent in the PICU. I just think that keeping brain dead people alive in the ICU for weeks is a waste of money. Spending 40k a year on bosentan for an 80 year old with pah who still smokes is a waste of money. Spending 100k on harvoni for a 60 year old ivda with hep c is a waste of money. It's hard to say where the line is exactly but I see some stuff out there that is just not right. If you're a millionaire and you have the money to spend on yourself, sure. But I don't see why people who are putting nothing into the system are getting so much out of it. I see a ton of taxes taken out of my paycheck and none of it is going to me

 

[FiveOClock]

This is an excellent showcase of how the intellectual discourse in medicine has decayed to the point of liberal groupthink. This professor is a typical example of how incredibly intolerant academics has become of alternative points of view. Notice how he suggested that offering cheaper healthcare to people who cannot pay anything was tantamount to "taking someone off the ventilator." He even outlined his plan for how to retaliate against medical students voicing opinions not consecrated by the academic left. Sad times.

Okay. Not inadequate. Low quality is what you said. I stand corrected.

LowER quality. And not by design, by default. How do you not understand this concept?

 

[Anicetus]

Ya except the ortho won't fail you when you go "herp derp feel the bern" but the academic will try to make your life hell if you disagree with them.

I can't wait to tell patients the reason they had to wait 6 months for their GI appointment was because Bernie let 200 homeless people fill up the appointments for the first 5 months.

 

[SurfingDoctor]

LowER quality. And not by design, by default. How do you not understand this concept?

Well, best of luck in your quest to make US healthcare more like India.

http://m.timesofindia.com/india/27-...of-medical-attention/articleshow/49474537.cms

https://www.theguardian.com/world/2009/oct/04/india-slums-children-death-rate

 

[SurfingDoctor]

This is exactly what I'm talking about. No ones saying take a sick kid off a vent in the PICU. I just think that keeping brain dead people alive in the ICU for weeks is a waste of money. Spending 40k a year on bosentan for an 80 year old with pah who still smokes is a waste of money. Spending 100k on harvoni for a 60 year old ivda with hep c is a waste of money. It's hard to say where the line is exactly but I see some stuff out there that is just not right. If you're a millionaire and you have the money to spend on yourself, sure. But I don't see why people who are putting nothing into the system are getting so much out of it. I see a ton of taxes taken out of my paycheck and none of it is going to me

Futile care is certainly an important issue. What was previously suggested in this thread had nothing to do with futility but just care. Not treating a patient who can't pay is just as unethical as treating a brain dead patient who had unlimited wealth. I agree, there should some limitations on treatment when it comes to end of life, with the exception of palliative care which should be a requirement. Where one draws the line in the sand though is tricky.

 

[vendtex]

Well, best of luck in your quest to make US healthcare more like India.

http://m.timesofindia.com/india/27-...of-medical-attention/articleshow/49474537.cms

https://www.theguardian.com/world/2009/oct/04/india-slums-children-death-rate

Weren't you bemoaning the US infant death rates among the poor just a week or so ago? Ironic really.


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[SurfingDoctor]

Weren't you bemoaning the US infant death rates among the poor just a week or so ago? Ironic really.


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As a pediatrician, you agree with a lower standard of care for poor patients and their children?

BTW, India's infant mortality rate is like 50th worst in the world. Not really something to strive for.

 

[qwerty89]

As a pediatrician, you agree with a lower standard of care for poor patients and their children?

BTW, India's infant mortality rate is like 50th worst in the world. Not really something to strive for.

India is still a country trying to recover from decades (1947-1991) of terrible socialist economic policy that left the country poorer than US-backed Pakistan. Since that time they have made remarkable success. Are you telling me that we should hold all countries, regardless of available resources, to the same healthcare standards? Of course India has a high infant mortality rate since its still a poor country (average GDP per capita).

Not to mention the second article is from 2009, which in a country that grows 5-10% a year in GDP, is a long time ago.

 

[vendtex]

As a pediatrician, you agree with a lower standard of care for poor patients and their children?

BTW, India's infant mortality rate is like 50th worst in the world. Not really something to strive for.

You didn't answer the question, but the follow up would you rather have your infant cared for at any of the countries that supposedly have lower infant mortality rates?.....

I believe that the point the poster was trying to make was that of a two tiered system, which many countries that have "universal healthcare" seem to have like England, Canada and Australia.

 

[giantswing]

I can't wait to tell patients the reason they had to wait 6 months for their GI appointment was because Bernie let 200 homeless people fill up the appointments for the first 5 months.

It isn't our place as providers to pick and choose whom "deserves" care.

 

[vendtex]

As a pediatrician, you agree with a lower standard of care for poor patients and their children?

BTW, India's infant mortality rate is like 50th worst in the world. Not really something to strive for.

It isn't our place as providers to pick and choose whom "deserves" care.

Nor is it the place of the government.

 

[Psai]

It isn't our place as providers to pick and choose whom "deserves" care.

Yes it is. My time is not free. I don't see why I should be forced to see patients without compensation.

 

[bronx43]

Most academic centers provide uncompensated care or "free" care (though nothing is ever free). I suppose the care is low quality to those patients? People don't go wheeling ventilators out of room because patients can't pay. If you think they should, I wouldn't recommended saying it aloud on your ICU rotation. BTW, if I ever heard a trainee suggest that ability to pay would determine the care we provide during their rotation to the PICU, you can bet I would fail them and make it aware to the clerkship director.

http://elischolar.library.yale.edu/cgi/viewcontent.cgi?article=1176&context=ymtdl

Lol.

Anyone who fails a student for disagreeing with him/her politically is intellectually and emotionally weak. Not only that, but this line of "agree with me or else" thinking is deplorable - if not outright dangerous. You would think that the failures of so many "-isms" in the past century would provide a cautionary tale to the groupthink mentality, but I guess those who don't know history are doomed to repeat it. Was the symbol of fascism not fascio littorio and "strength in unity?"

Don't get me wrong - this isn't a response to espouse either position in this health care debacle, since there is no right answer in this. Morality in itself is nothing but a set of opinions. The more you read and actually think about politics, the more you realize that it's rooted in philosophy and prediction of human behavior, neither of which are objective in any way, shape, or form.

 

[username456789]

It isn't our place as providers to pick and choose whom "deserves" care.

*physicians

 

[vendtex]

Well grades on a rotation aren't based solely on fund of knowledge but implementation of ethically principles and professionalism in medicine. Saying people who can't pay should be provided with inadequate care doesn't sound like a passing student to me because clearly there needs to be more education.

First you mentioned the ability to pay "affecting the care" you give then it was changed to "inadequate care." They are different. Maybe in the ICU setting you are more removed from those distinctions and issues, but at least in the outpatient setting, the ability to pay has an impact on what care they get because of what they can afford. It's not ideal but much of it is independent of the physician's influence, unless of course you are going to buy their medications yourself.

 

[SurfingDoctor]

You didn't answer the question, but the follow up would you rather have your infant cared for at any of the countries that supposedly have lower infant mortality rates?.....

I believe that the point the poster was trying to make was that of a two tiered system, which many countries that have "universal healthcare" seem to have like England, Canada and Australia.

Weren't you bemoaning the US infant death rates among the poor just a week or so ago? Ironic really.


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To answer your specific questions, yep I was talking about infant mortality rates as one of many metrics of quality of healthcare as an industry. And to answer your other question, I've had my children hospitalized in the US hospitals and they received fine care. Doesn't mean we shouldn't strive to make it better. If other countries have better outcomes, we should try to learn what they are doing right, not belittle them because we have to think the US is best at everything.