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Old 07-11-2014, 12:49 PM   #21
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I think a transition to a single payer system will be a near impossibility. We already see groups of practitioners and hospital systems opting out of Medicare and Medicaid. In my region, "Concierge Practices" are growing; where physicians provide consultation and care management on a subscription basis and do not deal directly with insurers at all. I only see the schism between those with resources and their healthcare and those at the lower socioeconomic end widening.

The genesis of our predicament lies with the removal of the patient from the payment-decision function. We have created a moral hazard situation because the costs of decisions are not borne by the decision maker (patients and their families). This happens all the time in end of life care where family members demand everything be done despite near futility. The US is the only healthcare system I know of that accepts this wasteful paradigm.

We also have bastardized the primary principle of insurance: the transfer of the cost of a possible loss, shared among a cohort of similarly at risk entities; into a payment plan for expected expenditures. This removal of the patient from the decision making and generations schooled under the idea that healthcare is a right that is paid for by a nebulous insurance company or the government has spurred demand and corrupted market forces.

On top of all this you have the regulation and payment mandates of federal programs which only add to the costs while returning nothing to the patient. Don't get me started about observation days and denials!
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Old 07-11-2014, 02:13 PM   #22
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.....................At the end of the day insurance provides little to benefit individual patients.
One advantage to me as a patient is that the insurance company negotiates a much lower rate for a standard procedure than I would pay as an uninsured patient walking in from the street.
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Old 07-11-2014, 02:21 PM   #23
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I am not unsympathetic to the problems of the OP.

However, the problems with providing healthcare in the USA have been obviously coming for decades. Why do other countries have lifespans equal to or better than our while spending far less of their GDP than we do? Inquiring minds wonder?

The medical profession, like many (education and law come to mind), could have done themsevles a service by addressing these issues earlier, rather than waiting until the pain was so great the any remedy was deemed better than the status quo.
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Old 07-11-2014, 02:58 PM   #24
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I am not unsympathetic to the problems of the OP.

However, the problems with providing healthcare in the USA have been obviously coming for decades. Why do other countries have lifespans equal to or better than our while spending far less of their GDP than we do? Inquiring minds wonder?
Not to derail the thread, but part of the answer to this question is, in some countries, a healthier lifestyle with less food consumption, less chemicals in such food, more exercise, lots of red wine (okay, science has now started to question this ), etc....

As for getting between a patient and his/her doctor, cost will be a determinative factor as long as a 3rd party (whether the government or an insurance company) is paying for the medical care.
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Old 07-11-2014, 08:51 PM   #25
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I think it would be most interesting to hear a perspective from a doctor who after working for a system like Britain's NHS or Canada's to then be offered a position in the US with our fee structure. I wonder if the higher income would offset the added headache of paperwork, and dealing with countless insurance policies, and malpractice. In the end. I wonder which system a doctor would chose, having an adequate dose of both.
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Old 07-11-2014, 09:14 PM   #26
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I think it would be most interesting to hear a perspective from a doctor who after working for a system like Britain's NHS or Canada's to then be offered a position in the US with our fee structure. I wonder if the higher income would offset the added headache of paperwork, and dealing with countless insurance policies, and malpractice. In the end. I wonder which system a doctor would chose, having an adequate dose of both.
I did some of my training in the US (late 80s) so I have some familiarity with the system. I do remember that our small academic department had six full time staffers whose job it was to bill. As a trainee, I had a salary, so I didn't have to worry about chasing bills, and the same could be said for my bosses. It would be a different story in private practice.

I spent all of my attending physician career in Canada. Most of that time was spent in a province where my colleagues and I were paid on a sessional basis for most of our work. We worked in ICU on a weekly schedule, and bills were submitted to the Provincial Department of Health on our behalf. We got paid the same whether it was a busy or a quiet week, because it all evened out in the end. Our physicians' organization negotiated with the Province and we got raises from time to time, often linked to productivity. It worked very, very smoothly and I never had to worry about paperwork. However, I also spent a couple of years working in another Province where the model of care was private practice. This was more onerous with respect to billing, rejected claims, etc. It was, in fact, a PITA. So I think that you have to look at the model of care, not just the country.
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Old 07-11-2014, 10:06 PM   #27
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I am not unsympathetic to the problems of the OP.

However, the problems with providing healthcare in the USA have been obviously coming for decades. Why do other countries have lifespans equal to or better than our while spending far less of their GDP than we do? Inquiring minds wonder?

The medical profession, like many (education and law come to mind), could have done themsevles a service by addressing these issues earlier, rather than waiting until the pain was so great the any remedy was deemed better than the status quo.
Certainly the cost of healthcare in the US is too high. Elements that generate those costs need to be examined closely. When multiple people are employed to generate billing elements, patients and families demand expensive testing, and physicians fearful of malpractice actions order diagnostic tests of marginal if any value, you have waste. Similarly, providing agressive therapy to those at the end of life where other health systems do not offer this interventions lead to excess costs.

Life expectancy in differing countries is a complex metric. In most cases it says more about lifestyles (diet, exercise, drugs, adolescent pregnancy, violence, and automobile accidents) than it does about healthcare. It is also important to understand that the statistics reported from countries vary substantially. What is called a live birth in the US is in many cases not counted as a live birth in other nations, skewing the stats. Examining disease specific mortality rates can be more informative.

Another important factor is the research costs of medicine are largely borne by the US. The rest of the world takes a free ride.

The underlying theme is that much of the inflated costs have little to do with nurses and doctors and more to do with perverse incentives, administrative costs and a system where people spend other peoples money.
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Old 07-12-2014, 10:02 AM   #28
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Certainly the cost of healthcare in the US is too high. Elements that generate those costs need to be examined closely. When multiple people are employed to generate billing elements, patients and families demand expensive testing, and physicians fearful of malpractice actions order diagnostic tests of marginal if any value, you have waste. Similarly, providing agressive therapy to those at the end of life where other health systems do not offer this interventions lead to excess costs.

Life expectancy in differing countries is a complex metric. In most cases it says more about lifestyles (diet, exercise, drugs, adolescent pregnancy, violence, and automobile accidents) than it does about healthcare. It is also important to understand that the statistics reported from countries vary substantially. What is called a live birth in the US is in many cases not counted as a live birth in other nations, skewing the stats. Examining disease specific mortality rates can be more informative.

Another important factor is the research costs of medicine are largely borne by the US. The rest of the world takes a free ride.

The underlying theme is that much of the inflated costs have little to do with nurses and doctors and more to do with perverse incentives, administrative costs and a system where people spend other peoples money.
I agree with most everything you say with the exception of the underlined above. This is rapidly changing and not the case anymore. It is something that has been used (particularly by pharmaceutical companies) but also by others to try and justify our high costs.

The other point I might disagree with is that our inflated costs are not caused by doctor's high fee structure. I don't think that is entirely true, if you are going to compare our medical costs per GDP with other countries. It is definitely a contributing factor. Our doctors get paid very well in most instances. My personal opinion is that they deserve to be well compensated due to their extensive education and sometimes demanding job, depending on their specialty.

However, let's not just be overly polite here. Some doctors (especially surgeons) and some other specialty fields are extremely well paid-even considering their years in school. There are not too many high paying jobs that are stress free. In fact today even low paying jobs are fraught with stress and demands. Again look at teachers. Everyone thinks that is an easy job because they have summers off. They don't realize that teachers today are required to put in a great deal of additional hours after that school bell rings, and then countless hours at home doing lesson planning and grading. I have both doctors and teachers in my family.

Something else to consider. Society is changing. The younger generation are less appreciative, more demanding, and entitled. Ask any teacher who has been at it for a long time. Corporations are changing and becoming more and more demanding of their employees. We have become a very money driven society where individuals are less valued and stock value is paramount.

All of the participants on this board are hoping for those stock prices to continue to climb. Understandable, but just understand that this comes at a price. It is also one of the contributing factors in our problem with health care costs.
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Old 07-12-2014, 02:36 PM   #29
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I have already given notice to do 1/2 time July 1, 2015 and plan to fully ER at end of 2015. However, I have just had it with medicine. And from what I see around me I am not alone.

<snip>

So, if you like your doc, take a moment to say thanks and let he/she know you appreciate their resilience.

As we say, the BS bucket is full. I think we all understand where you are coming from regardless of our current or previous occupation. Good luck with your decision.

The other thing to keep in mind is this:
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Old 07-14-2014, 12:35 AM   #30
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My son-in-law is a family doctor and having similar issues. My own doctor of 17 years is going into concierge medicine, and my husband and I will try it for a year. She's such a great doctor in so many ways. For the past few weeks my husband was trying to find a doctor and discovered most aren't taking new patients, or don't take Medicare (being 63, we have to consider this), or are retiring or going part time. So we will both stay with her for now.


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Old 07-14-2014, 12:54 AM   #31
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The option of concierge practice is only open to a few percent of physicians. It works mainly for internists and family practice doctors. For subspecialist, surgeons, hospital base physicians etc. it does not work. Even in these specialties the physician usually must work for a decade or more to develop a patient base in a relatively affluent community to have long term success. Even affluent communities become "saturated" with regard to concierge practice relatively quickly.

All that said if you have a great doctor and can afford concierge it is often the only way you can get top quality personalized care. Quite a few of the best practitioners in my neck of the woods are going concierge. They are aware that not all their patients can afford to follow them and many find that the main negative.
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Old 07-14-2014, 01:52 AM   #32
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I had way too many bad experience with medical doctors do sympathize with the OP. The last draw was how my dying brother was treated by his oncologist. He DID have God complex and didn't give a !#$!@#4 about my brother's fight against cancer. He only cared about his trial that my brother was in. To him, my brother was another guinea pig. My grandma's death came earlier b/c surgeon made a mistake. When his mistake was known 7 years later, he put the blame on our family. Then, there are doctors whose main interest seem to be fattening their wallet by any means, at the expense of medical, medicare system. I've seen medical bill that charged $700 for 10 minutes my doctor spent with me on a visit (20 mins waiting). US medical system is screwed up and doctors are part of it. Sorry about my tirade but that's the way I see it.
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Old 07-14-2014, 07:03 AM   #33
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Not to derail the thread, but part of the answer to this question is, in some countries, a healthier lifestyle with less food consumption, less chemicals in such food, more exercise, lots of red wine (okay, science has now started to question this ), etc....

As for getting between a patient and his/her doctor, cost will be a determinative factor as long as a 3rd party (whether the government or an insurance company) is paying for the medical care.
These "deniers" are nothing but quacks financed by the bottled water lobby. Keep the wine flowing!
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Old 07-14-2014, 07:13 AM   #34
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At the end of the day insurance provides little to benefit individual patients.
Insurance in its classical form is only intended to share the risk that someone could otherwise not cover on their own. Unfortunately, medical insurance had grown into a system that made it "free" or nearly so to the covered individual. That leads to a totally distorted market since the only real cost of medical care was the inconvenience of going to the doctor. Only now are we moving towards high deductible plans but the press is full of stories bemoaning how the "poor" can't afford the deductibles and copays.

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One advantage to me as a patient is that the insurance company negotiates a much lower rate for a standard procedure than I would pay as an uninsured patient walking in from the street.
The only logic for the high "list price" of medical procedures is to cover the losses provided to people without insurance that later don't pay. My doctor used to just see me and send a bill to cover the copay later. Now, I can't get in until they reverify my insurance and I can't leave without visiting the payments desk. I've never had the need myself but I've talked with several people without insurance that had negotiated excellent rates for paying cash for the OB and delivery room. They all had to pay in full upfront.
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Old 07-14-2014, 07:54 AM   #35
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I think it would be most interesting to hear a perspective from a doctor who after working for a system like Britain's NHS or Canada's to then be offered a position in the US with our fee structure. I wonder if the higher income would offset the added headache of paperwork, and dealing with countless insurance policies, and malpractice. In the end. I wonder which system a doctor would chose, having an adequate dose of both.
A bit off topic but Canadian friends who snow bird in the same area we do tell us that in the Canadian system( a single payer system I believe and also less costly) wait times for appointments and quality of care are significant issues. I gather that those who can, go outside of the system when they are financially able.
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Old 07-14-2014, 08:29 AM   #36
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[QUOTE=Ally;1470856]My son-in-law is a family doctor and having similar issues. My own doctor of 17 years is going into concierge medicine, and my husband and I will try it for a year. She's such a great doctor in so many ways. For the past few weeks my husband was trying to find a doctor and discovered most aren't taking new patients, or don't take Medicare (being 63, we have to consider this), or are retiring or going part time. So we will both stay with her for now.

DH sees a neurologist regularly. His Doc specializes in movement disorders. We live in a low population northeastern state with good access to providers and primary tertiary care hospitals, but the area is not a major urban center. DH's neurologist decided a year ago to "go concierge". We (reluctantly) decided to stay with him as DH likes his doc. Fast forward a year and the doc is retiring......as he put it, this isn't NYC and the "Fee" to join his wellness center was not embraced by his patients. He had indicated back a year ago that he would retire if it didn't work because the time he had to put in in order to meet his patient's needs and generate a decent living were not sustainable and he would not be able to continue under those conditions any longer.

The old doc maintained a one man practice. Today we visit DH's new Doc, fresh out of med school and a one year fellowship in Movement Disorders. This practice is huge and owned by the hospital so we expect a different kind of care, less personal, less hands on, but hopefully a good quality of care. The experience level of the Doc concerns me a bit, but it was pointed out to us that younger docs fresh from fellowships at major research hospitals have been exposed to the latest best practices. We'll see.

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Old 07-14-2014, 08:49 AM   #37
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Golden sunsets what you are experiencing is the new norm for medical care in the US. Medicine is now an overpriced commodity. Old time doctors are retiring at an accelerated rate due to burnout.

The new doctors straight out of fellowship are a mixed lot. They have been trained in a drasticly different economy and culture than the prior generation. On average these physicians are trained with much less on call time, less primary responsibility for a lower number of patients and less "seasoning". They also carry a high average debt from training. Regardless, many I have worked with recently, a majority I think, adapt to the real world of medical practice quickly. Very few though retain and cherish the personal side of medicine and fewer still want to work a fraction as hard as the prior generation of doctors.
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Old 07-14-2014, 10:15 AM   #38
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These "deniers" are nothing but quacks financed by the bottled water lobby. Keep the wine flowing!
What about the "women" and "song"?
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Old 07-14-2014, 10:32 AM   #39
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I sympathize with the OP. Our practice instituted a lot of the "practice improvement" changes and installed an EHR in 2009-2010 and it was hideous (though not "government driven", more "practice administration driven"). I was a software engineer before medical school, strongly pro-EHR and I type super fast and the EHR just made the job so much harder in so many ways that I spent the next two years lobbying the spouse for early retirement. There are parts of the job that I miss, but not many. The 1980s style software designs of these expensive EHRs are just mind-boggling.

Canadian, British, and American docs are all paid about the same by specialty. There are more specialists in the US and fewer generalists.

Canada tracks and manages wait times. No one tracks wait times in the US, so you can't say that wait times are better in the US.
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Old 07-14-2014, 10:46 AM   #40
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What about the "women" and "song"?
DW would kill me if any other women were involved but, fortunately, she likes wine. As for song, the world is better off if this tone deaf, talentless ogre refrains from attempting this in any form.
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