Free market medical care versus the status quo

[disneysteve]

Just to be clear, I'm not saying that the health care system isn't a mess. It is a disaster.

But some of your comments simply aren't true, like saying that shorter stays must mean patients aren't as sick. The exact opposite is true. Hospitalized patients are sicker than ever but reimbursement is awful and they count every penny and watch everything that gets done, or not done. If they decide no hospital-level care happened on a day, they don't pay for that day at all. There is great pressure to squeeze as much care as possible into as little time as possible and then handle everything you can through home care and visiting nurse services.

One downside of this is that readmission rates are an issue since a lot of patients are still quite ill when they are sent home. If home care and outpatient follow up aren't tip top, the patient often bounces back into the hospital. In my old practice, we were actually incentivized to see discharged patients within 48 hours of their release in an effort to cut down the readmission rate. Long gone are the days when people stayed in the hospital until they were pretty much better and could return home without issue.

[Smallsteps]

While I agree with you 100%, the opposition will probably say that 45% (or whatever the number is) don't pay any taxes so those who do pay would still be paying for those who don't.

It's pretty interesting but over the past 2-3 decades, the stance of the medical field (doctors, nurses, med students, etc.) has changed dramatically. 25+ years ago, the medical field was staunchly Republican and conservative and strongly opposed to a single payer system. Today, just the opposite is true. The vast majority of medical folks are Democrats and support for a single payer system has grown tremendously. Even the American Medical Association, which had always vehemently opposed single payer, has had to soften their stance because it was so out of touch with the reality of the field.

In general i too have seen people discharged that many may think too soon. Follow-up care is hit and miss IMO.
Unfortunately the level of care i see is going down. Just yesterday a co-worker told us of a serious condition "missed" by two urgent care / er doctors. Required immediate surgery. This is happening in my own circle, those I meet, and even in news more and more frequently.

I think the elephant in the room is what no one talks about.... the patients.
Data shows a large percentage do not take medication correctly or follow medical advice. like Comparable negligence in car insurance.
How about Tort reform ? Most single payer have very small amounts allowed for malpractice. i guess over testing used for CYA will be curtailed.
People who compare medical insurance to auto or other insurance seem to forget auto can cancel you for being a bad driver ...No insurance and very few doctors fire a patient for self inflicted problems.

One of the first jobs i had with good insurance, we had people who sought out care for every ache or hangnail. This was only slowed or curtailed as our co-pay went up and up. i always felt it was directly due to the hypochondria i witnessed. These were often the ones just looking for a mistake and most likely would sue ..... i would hate to have been a doctor for them.

I worked with a lady who came here from Germany, she told me "there is a different attitude in her former country that you were conscience of your responsibility to use care wisely, NOT it is FREE so test for everything, i must have something wrong."

Many newly insured that paid nothing or almost nothing using the ACA were similar. Many going in for anything and everything and like going to a spa and saying "give me the whole menu of options" of us,

My absolutely favorite interaction was a co-worker whom did not have insurance until the ACA.
The line she told was "we can finally afford insurance". i asked her what was the cost before and she stated "oh we never even shopped for insurance before..... but the news says we can finally afford it" She sent her whole family through top to bottom check everything just because.

Yes, I was amazed. She then told her teenager ( on phone right in front of me).... "he could go do anything he wanted with his friends ( activities she did not let him do before) ....cause if he got hurt, SO what, they have insurance".
She had a family of SIX paying $200 a month with the rest of us picking up the rest.
Both her and spouse when looking for jobs were based on $ per hour not if they offered benefits/ medical. (IMO their lack of coverage was a personal choice)
Completely disconnected so i explained to her the subsidy that made her coverage cheap was being paid by all of us sitting around her.
YET those whom do not feel we should pay for people like this are painted as heartless etc.

Honestly there were many who left practicing medicine after the ACA. the medical personnel I have talked to are not all cheerleaders for single payer.
The plans i have read so far, the reimbursement for all care would drop. How many people would want to go into that career for less pay?
if your income dropped by half you would be happy and approach your job with the same dedication? Or do some think that their income will not drop?
I have read comments on social media regarding plans. The disconnect seems to think "well they are doctors/ nurses they won't just take another job" LOL What about who will go into medicine ??
The devil is in the details of what would even pass.
Americans often do not know the details of these programs some would like to copy in other countries or the taxes ( income/ VAT etc) they pay for that "benefit".

[disneysteve]

Honestly there were many who left practicing medicine after the ACA. the medical personnel I have talked to are not all cheerleaders for single payer.
The plans i have read so far, the reimbursement for all care would drop. How many people would want to go into that career for less pay?

If you interview a bunch of doctors who have left their practices in recent years, as I did, I bet that very few will cite income as the main reason. The reason doctors are jumping ship is the hassles of practicing medicine today. Insurance company issues top the list. As I've said, there are thousands of different plans and every one has their own unique set of rules and regulations and guidelines and processes and quality metrics and reporting requirements and forms and websites and chart audits and more.

Ask any doctor which insurance company is the easiest to deal with and the vast majority will say Medicare. Why? It is a nationwide plan that is the same no matter where you go. It doesn't matter if you are in New York, Nebraska, or Nevada, Medicare is Medicare. It isn't perfect. Nothing is. But it is one set of rules that covers over 44 million Americans. Dealing with that is so much easier than working with the 200 or 300 individual plans that we took in our office.

Obviously, nobody wants to see their income drop, but I think many doctors would be willing to earn less if it meant a huge reduction in the hassles and paperwork and red tape they currently deal with. Part of the problem today is that doctors don't get paid anything at all for a great deal of the work they do since it is non-clinical. In my practice, I would spend a few hours every week doing paperwork and earn nothing for that time. Simplify the system and eliminate all of that paperwork and you make the job much more appealing.

As for new people going into the field, if incomes will be lower overall, then there needs to be some reform of the medical school education system. The median student loan debt for graduating physicians today is $200,000 and many finish with $300,000 or more. There are some proposals (and maybe even some pilot programs) working on shortening the training process to reduce the total cost. But more needs to be done. Nobody wants to come out of school owing upwards of 200K if they will be going into a job that won't earn them enough to support that debt load.

[TexasHusker]

Are you willing to work for what Medicare reimburses for all of your patients? Are you willing to put your future income fully in the hands of Medicare, knowing they can cut your reimbursements at any time, at their pleasure?

[disneysteve]

Are you willing to work for what Medicare reimburses for all of your patients? Are you willing to put your future income fully in the hands of Medicare, knowing they can cut your reimbursements at any time, at their pleasure?

Personally, I don't think we'll see an actual single payer system in my lifetime, if ever. I think there will be a single payer option but still be private options as well for people who want to pay for additional coverage. Heck, Medicare isn't entirely single payer now. 80% of Medicare recipients have supplemental coverage to pick up what Medicare doesn't. But your point is certainly a valid one. Do you want to put all of your eggs in one basket? Do you want to have a service-based business with only one client? In my office practice, we were about 40% Medicaid and 25% Medicare so about 65% of our business was government insurance. I don't honestly know how much difference it would have made to be 100% government insurance.

[Smallsteps]

That is admirable if practice is 65% low reimbursement. Most practices in my area try to never let their % go above 30% total. Many seniors have to search if they want to find a new doctor for whatever reason like retirement etc. I was just talking to a 80 yr old neighbor who is having a terrible time with the Providers she can find as most as NOT even listening to her have prescribed items she is allergic to or can NOT be used with other medicines she is on. Often those on medicare or medicaid end up with the bottom rung of providers in this area.

[disneysteve]

That is admirable if practice is 65% low reimbursement.

Our practice was (still is) in one of the poorest cities in America so it was kind of the nature of the beast. When you are working in a poverty-stricken area, that's what you get.

[LivingAlmostLarge]

I don't either. My mom doesn't understand that her medicare is single payer. It's not comprehensible. She keeps saying I paid for it by working. NOT understanding that it's still being paid for by everyone else. She keeps saying that she doesn't understand why are people arguing if obamacare is working. UGH. More than SS I read that it's medicare that will bankrupt the US government. That SS is a problem and will run out but medicare has a large deficit and bigger issues at play.

[TexasHusker]

As has been mentioned, we already can see the outcome of single payer through Medicare and Medicaid: Often, the providers with good reputations and a lot of patient demand simply opt out of these programs. They aren't worth messing with and they can make a lot more money seeing other patients. Hey if I'm a doctor and trained for 10 years, I am doing the same thing. You see the same in highly-restrictive managed care plans, primarily HMOs. The top doctors opt out because they don't have to play the game. Now the left says "we will make it the law so that providers MUST accept the single payer plans." Think about that ideology for a minute. "We are going to establish the plans, establish the rates, and make it law that you have to accept it." How does that, in any way whatsoever, represent a free country? Do we really want that? What would happen is, reimbursements to providers would spiral downward with the price controls, driving many providers into early retirement, and discouraging potential doctors from going to medical school and residency because the medical school debt is no longer offset by the hopes of high income. That would pave the way to a lot more foreign medical graduates with less training. If you look at the provider lists of a lot of HMOs out there, it is a lot of providers from outside the U.S. That isn't coincidence.

[Smallsteps]

For some reason i cannot get the "quote" option to work but here goes. To disneysteve: The area i am talking about that limits talking medicaid and medicare patients is NOT a wealthy area but they simply lose money taking on too many with low reimbursement. To living almost large and Texashusker: I always think putting real # in front of people in SS and medicare we always hear "i paid into this when working". NO one is arguing that but if one would see that MOST are using FAR more then put in ... simply acknowledge that the money has to come from somewhere. we will have a shortage of doctors but what i am more worried about is the QUALITY not the quantity. Although using PA and nurse practitioners is being touted as the answer it simply is the duct tape of medical care. No offense I have met many great nurses who know a lot but I have also seen far too many that rely on well the book said or i have NEVER seen that i do not know what to do. Medical PRACTICE requires accepting that people are different and many do not always show the same symptoms that were in a book or considered normal symptoms. I for one have had a few personal times where if i had not been lucky to get some excellent diagnosticians, i would be dead. i have had to advocate for good care many times because i had the "i don't know gang" working that day. People always want good care for all....... but i can tell you if you are not a person who questions those who throw out close enough guesses ...... you will get sub-par and then will end up with items getting worse and requiring many more visits and or re-admission. all costing more money.

[TexasHusker]

In a free market economy, we cannot solve all financial problems for all people. By attempting to do so, you kill the golden egg, itself. Life in a free market economy includes risks, and rewards. By attempting to buffer the risks - through “universal” this or that, zero down home loans, guaranteed student loans, etc., we are simultaneously capping tit rewards. That ideology is a fundamental shift in our republic.

[TexasHusker]

for some reason, the edit function isn't working on the forum. Obviously the word "tit" in the above paragraph is supposed to be "the". As a side note, it seems like this forum doesn't work more than it does. Maybe the government needs to take it over?

[james.hendrickson]

Guys - noted on the quote and editing issues. We have a tech on the problem.

[disneysteve]

The site is a total mess and has been since last week. Apparently, there was a virus issue. James says the tech folks are working on it but they clearly aren't going very fast. I actually suggested shutting the site down entirely until it's fixed but so far they haven't gone that route.

[disneysteve]

To disneysteve: The area i am talking about that limits talking medicaid and medicare patients is NOT a wealthy area but they simply lose money taking on too many with low reimbursement.

Well when your practice is in a very poor area, you don't really have a choice. If we had tried to limit our Medicaid population, there wouldn't have been much left. Low reimbursement is better than no reimbursement. FYI, I'm doing my quoting manually since the quote function is part of all that isn't working.