Front Row Seats for the Collapse of the ACA

[Sensei]

One of the great things about working in a large medical center is I get a front row seat to the collapse of the ACA. Make no mistake, it is collapsing despite most people having no clue of the harm being caused. For example, my hospital was yesterday at full capacity, refusing all transfers (including trauma and code STEMI), boarding 15 patients in the emergency room, enjoying an ED waiting room with 40+ pissed off souls and a left without being seen rate of 15-20%. Those are metrics that were unthinkable just 3 years ago when boarding was unheard of and our elopement rate as 2%, but is now almost a daily occurrence. That degree of hospital crowding takes a massive toll on morbidly and mortality that goes under reported in the lay media.

Now that "Tumpcare" is on the back burner, many are wondering what to do. This article, while lengthy, is perhaps the best advice that anyone can give the GOP.

http://www.redstate.com/patterico/2017/03/27/next-step-repealing-obamacare-ted-cruz-answer/

Allowing Obamacare to collapse should be a nonstarter. If this happens, only the richest and most powerful will escape unscathed.

Keep in mind these fundamental truths when reading the article:
1) There is a difference in healthcare coverage and access to quality care. Just ask anyone using the VA or Medicaid if you doubt me.
2) While you can provide everyone with coverage, there are insufficient resources to provide everyone with access to quality care.
3) The only way to control cost of healthcare is to control consumption and market distortion from government interference.

[GardoneVT]

The core problem is this-the number of educated and professional folks qualified to treat people will always be outnumbered by sick people in need of help. The gear and medicine don't come cheap either.

High demand combined with low supply of quality medical care equals high costs. Too much public assistance means more folks using medical services,and then sick people cant get treatment for lines and delays. Too little public assistance means poorer folks can't get treatment. No health plan DC could ever create will repeal the cold laws of supply and demand.

[olstyn]

The core problem is this-the number of educated and professional folks qualified to treat people will always be outnumbered by sick people in need of help. The gear and medicine don't come cheap either.

I work in a hospital (tech support). While replacing an old, worn out computer a few weeks ago, I overheard a pair of surgeons talking about how they don't get paid enough. I'm sure they both make at least mid six figures. The arrogance on display was absurd. (Whining about pay in front of someone whose hourly rate they make in only a few minutes is pretty rude, IMO.) I was also quite impressed at the amount of not working they were doing. I guess when you've convinced yourself that you're very very important, manners and work ethic go right out the window. I'm not suggesting that doctors shouldn't be well paid, and yes, on some level, it's dictated by supply and demand, but there's simply no denying that their salaries are a part of the problem, and for that 15 minutes, at least, those two certainly weren't earning their pay.

[rauchman]

Interesting article. Thank you. I am far from well versed enough on the subject to see any flies in the ointment for what's proposed in the article, but on the surface it makes sense. I do know that what Paul Ryan was proposing was absolutely ridiculous. It seemed to make Obamacare worse. The Republicans needs to be something that works on this issue and have it pass, or they lose big credibility going forward.

[Rich@CCC]

Sensei,
I believe that the "collapse of the ACA", actually the collapse of our established insurance and health care systems was the original and ultimate goal of the badly monikered Obama Care legislation. Obama had little to nothing to do with the actual legislation, he was just the right puppet to help get it pushed through.

That's not to say that I was happy with the system in it's previous state. The insurance system needed cleaned up. No argument from me there, but the ACA just piled worse on top of bad. Again, that was the actual goal of the legislation. This has been an Alynski's Rules styled attack in order to open the field for a State run single payer health care system from the word go. The left didn't even do a decent job of hiding it. In fact they came out and said it on more than one occasion.

olstyn,
I've seen the same level of arrogance from physicians many times. Just keep in mind the kind of person that makes a good(technically speaking) surgeon. Very Alpha personality with a hardcore drive for perfection. Also keep in mind the expense in both money and self sacrifice to achieve the goal of being the best surgeon in their field. Then add to that the constant threat of a malpractice suite from our ridiculously litigious citizenry and legal establishment where frivolous charges are bandied about daily with no regard for the lives destroyed in the aftermath.

That doesn't excuse a lack of empathy or make the arrogance any easier to swallow, but it does go a long way to explain the attitude seen by someone from the outside. Those surgeons probably graduated med school with close to a million dollars in debt. and both have probably been sued many times for outcomes beyond their control.

No, I am not a doctor!

rauchman,
I saw where Newt Gingrich places the blame for the Ryan care garbage squarely on Ryan. He stated that Trump was told Ryan had a plan and it would be taken care of so he could concentrate on other issues. I've always seen Paul Ryan for the RINO he is and never did buy into his pose as a financial conservative. I hope this is true, that Trump was duped and not complicit in this. I know Trump wants to "Replace" the ACA where I'd much rather it simply be scrapped, I just can't see him wanting to replace it with something worse. Maybe I'm being too optimistic?

[shane45]

I work in a hospital (tech support). While replacing an old, worn out computer a few weeks ago, I overheard a pair of surgeons talking about how they don't get paid enough. I'm sure they both make at least mid six figures. The arrogance on display was absurd. (Whining about pay in front of someone whose hourly rate they make in only a few minutes is pretty rude, IMO.) I was also quite impressed at the amount of not working they were doing. I guess when you've convinced yourself that you're very very important, manners and work ethic go right out the window. I'm not suggesting that doctors shouldn't be well paid, and yes, on some level, it's dictated by supply and demand, but there's simply no denying that their salaries are a part of the problem, and for that 15 minutes, at least, those two certainly weren't earning their pay.


Any job that just about anyone can do will not be a high paying job. Any job few can do will likely be a high paying job. I think these surgeons already did the hard work to get where they are. By your logic you should make as much as a CIO, DB engineer, DNOP or Dir of IT perhaps? They certainly can make well into 6 figures and certainly aren't running around. In my view this kind of logic is a BIG part of the problem.

NO I didn't want the budget Neurosurgeon to put my spine back together after my motorcycle crash, I wanted the guy that was highly paid because he was known as a great surgeon. I don't give two F's what he is doing when not cutting on my spine. His value is not measured in the minutes working his shift. Its measured in the results of his work.

[RevolverRob]

I work in a hospital (tech support). While replacing an old, worn out computer a few weeks ago, I overheard a pair of surgeons talking about how they don't get paid enough. I'm sure they both make at least mid six figures. The arrogance on display was absurd. (Whining about pay in front of someone whose hourly rate they make in only a few minutes is pretty rude, IMO.) I was also quite impressed at the amount of not working they were doing. I guess when you've convinced yourself that you're very very important, manners and work ethic go right out the window. I'm not suggesting that doctors shouldn't be well paid, and yes, on some level, it's dictated by supply and demand, but there's simply no denying that their salaries are a part of the problem, and for that 15 minutes, at least, those two certainly weren't earning their pay.

I concur, that the surgeons shouldn't have had an open conversation about pay in front of you. But they were discussing a matter between two peers and likely didn't think anything about it (which is rude and uncouth, but isn't arrogant, per se).

As for the not working part - Are you sure they were not waiting on an OR or patient to be prepped? Or that they hadn't just completed a 6-hour surgery?

Surgeons also may not make as much money as you presume, the average pay is well below mid-six figures and more like low-six figures. When you account for student loan debt, the 5-7 years of medical school + residency, they spent a considerable amount of time working their asses off for minimal (or quite frequently NO) pay. I wouldn't be so quick to judge a person in this tract. Most of the med students and doctors I have met are assholes, type A, very very annoying people to be around on a professional level. But they're really good at their jobs and if I were broken and needed a surgeon to fix me, I'd want them to do it. Because that's the type of mentality and personality that fixes problems the best way, not the cheapest or quickest.

As for the "no denying salaries are part of the problem". I feel like I could say that about 95% of the IT guys I interact with. Most of them can barely diagnose something as broken or listen to directions. They insist upon being arrogant jerks who claim to know everything about everything and rarely can they solve a problem quickly. The exception is that "one guy" who actually does his job...;)

[Mark Housel]

Surgeons also may not make as much money as you presume, the average pay is well below mid-six figures and more like low-six figures. When you account for student loan debt, the 5-7 years of medical school + residency, they spent a considerable amount of time working their asses off for minimal (or quite frequently NO) pay. I wouldn't be so quick to judge a person in this tract. Most of the med students and doctors I have met are assholes, type A, very very annoying people to be around on a professional level. But they're really good at their jobs and if I were broken and needed a surgeon to fix me, I'd want them to do it. Because that's the type of mentality and personality that fixes problems the best way, not the cheapest or quickest.

THIS ^^^^
The well over a decade of your life invested before you are up and running as a hot shot surgeon who commands these salaries where you are in debt but not making the "big bucks" and working your a$$ off none the less is certainly a reason for someone to hope to recoup their investment. There are no guarantees that in the end after the investment that you will actually be good enough to be that high salary commanding hot shot surgeon though.
My wife is a Nurse Practitioner and our potential future son in law is currently a psychiatric resident so we can perhaps sympathize a bit more.

OTOH, the guy who just operated on my eye (detached retina) who has multiple houses, land, toys, planes, a lavish lifestyle**, is GD good at his job seems like a really nice person from my interactions with him. I certainly don't begrudge him any of his success/wealth. The practice he's a part owner of appears to be a F*ING money making machine! Who knows how many surgeries they do a week between the 10+ surgeons on staff. The place looks like a small shopping mall with comparable sized parking lots packed every day.
Both surgeons that I have interacted with at that practice (cataracts & detached retina) have been both skilled, personable at least able to fool me into thinking that they care about their work and I don't begrudge either of them whatever they are making.

**The contractor who is doing our remodel knows him as he's done lots of work on his places. Everyone knows everyone here. This place is "small town America" defined in that regard. We are, and likely always will be, the "outsiders"

FWIW, I've notice in my lifetime that not many (like 0.00%) poor people have ever employed me during my working career (prior to retirement) so I kinda liked the fact that there have been enough rich people to have kept me gainfully employed all my life. :cool:

[RoyGBiv]

Tangent.

One of my kids is planning to go into healthcare, likely physical therapy. We have several friends in that field, who told my kid the following... paraphrasing.

"When I became a PT, you only needed a masters degree. Now you need a PhD to be a licensed PT. It's not worth it. Make sure your Bachelors degree is in something specific, like Kinesiology or Exercise Science so you can get a job working for a licensed PT making almost as much money as they do, with 1/10th the hassle. The insurance company pays for "Mary" (another acquaintance working as a PT assistant) at $60/patient-hour. She gets to her sessions a few minutes early, does her job, and goes on to the next session. The insurance company pays me $70/patient-hour, but I am responsible for the patients treatment plan, scheduling, liability insurance, filing paperwork and hounding the insurance companies for payment and all the post-treatment paperwork and record-keeping. "

An extra 3 years of school and ~$120,000 in debt for an extra $10/hr in pay, with fewer hours in the day to see patients because of all the overhead.

No surprise that the number of providers is diminishing relative to the demand for services.

/tangent

[OlongJohnson]

https://www.youtube.com/watch?v=6qP8Idn8mps

[TAZ]

I work in a hospital (tech support). While replacing an old, worn out computer a few weeks ago, I overheard a pair of surgeons talking about how they don't get paid enough. I'm sure they both make at least mid six figures. The arrogance on display was absurd. (Whining about pay in front of someone whose hourly rate they make in only a few minutes is pretty rude, IMO.) I was also quite impressed at the amount of not working they were doing. I guess when you've convinced yourself that you're very very important, manners and work ethic go right out the window. I'm not suggesting that doctors shouldn't be well paid, and yes, on some level, it's dictated by supply and demand, but there's simply no denying that their salaries are a part of the problem, and for that 15 minutes, at least, those two certainly weren't earning their pay.

I think that the core of the problem is the not many actually understand the true issues affecting the healthcare system. Additionally the fact that we seem to want a single point of attack means we will fail. That complex a system has many issues that need to be addressed, no magic bullet exists.

WRT the whole paid too much comments. You do realize that you made an uninformed judgement call about an entire profession based on a 15 minute snapshot in time. How do you know those guys aren't being raped by the hospital?

My brother is an OB/Gyn and probably makes good cash. Not as great as he used to, but oddly he seems to work more hours. How often do you get up at 0'Dark Thirty to rush to a hospital to try and save a mom and her baby from bleeding out? I've never had to do that, but I can count the number of days my bro gets a full nights sleep a week on 1 finger.. maybe 2 if things are slow. How many places charge you rent for offices you don't want or need just so you can bring them patients to charge $50 aspirins to. So just maybe those guys had a point.

Not saying that there aren't overpaid assholes in the industry, but we should probably point fingers based on facts instead of emotions.

I think Rich hit the nail on the head. Obamacare, RomneyCare, RyanCare, TrumpCare all have the exact same purpose: usher in single payer cause nothing works except more government. Saul Alinsky and the Hegealian principles at work. Establish impossible expectations (affordable care irrelevant of medical history) and then when the current system can't meet it offer a solution. Create the problem and then come along with a solution that involves more government control.

What government in the history of humanity has wanted LESS control over its people? What better control than the life or death levers that medicine offers??

[RevolverRob]

Establish impossible expectations (affordable care irrelevant of medical history) and then when the current system can't meet it offer a solution.

And herein lies the rub. The solution to this problem has and always will be the reality that some folks will live and others will die. Ultimately, when a person cannot afford healthcare, their life expectancy drops and the result is death. Personally? I'm fine with this. You have medical issues, because you drink too much/smoke too much/do too many drugs - Personal choices, personal responsibility. Death is an inevitable result of Life, some of us will get there sooner than later.

Even with tort reform and refined indigent healthcare, the ultimate reality is that some people will die because of a lack of access to healthcare. The problem, to my mind, is when the costs of even reasonable healthcare become out of reach for the majority of the population. That shouldn't be the case and careful regulation of pricing and services is one place where governmental oversight can provide benefit in this sense, but only if done from a common-sense standpoint (and we call know common sense + government = not a fucking chance). But overall, I concur that a single-payer system is untenable and that we, as a society, cannot bear the additional burden, that some of our ostensible fellow society members place on the system.

But then, I'm a callous asshole. I don't think we should spend money curing childhood cancers, nor should we house repeat felony offenders in correctional facilities for extended periods of time (three choices; work on the chain gang/in a factory, volunteer for medical studies, or bullet to the brain), nor should we come to the aid of every person getting their asses beat in public (some folks need beating).

Personal choices, personal responsibility.

[AMC]

I also agree that Rich hit the nail on the head that the ACA was intended to fail. What too few of my conservative friends yet realize is that the Republicans are in on it (at least the majority, and definitely the leadership). This whole Ryancare debacle should wake people up to the fact that they've been lying for years. They don't intend to repeal the ACA. They don't think the plan is wrong. The fact is, we're in worse straits than most realize because there is no real "opposition" to socialist government in government. Ambassador Keyes was right when he said that the mission of the Democrat Party is to establish a socialist revolution, and the mission of the Republican Party is to pretend to oppose it.

[Eric_L]

I also agree that Rich hit the nail on the head that the ACA was intended to fail. What too few of my conservative friends yet realize is that the Republicans are in on it (at least the majority, and definitely the leadership). This whole Ryancare debacle should wake people up to the fact that they've been lying for years. They don't intend to repeal the ACA. They don't think the plan is wrong. The fact is, we're in worse straits than most realize because there is no real "opposition" to socialist government in government. Ambassador Keyes was right when he said that the mission of the Democrat Party is to establish a socialist revolution, and the mission of the Republican Party is to pretend to oppose it.

I think this may be the truth.......

[45dotACP]

One of the great things about working in a large medical center is I get a front row seat to the collapse of the ACA. Make no mistake, it is collapsing despite most people having no clue of the harm being caused. For example, my hospital was yesterday at full capacity, refusing all transfers (including trauma and code STEMI), boarding 15 patients in the emergency room, enjoying an ED waiting room with 40+ pissed off souls and a left without being seen rate of 15-20%. Those are metrics that were unthinkable just 3 years ago when boarding was unheard of and our elopement rate as 2%, but is now almost a daily occurrence. That degree of hospital crowding takes a massive toll on morbidly and mortality that goes under reported in the lay media.

Now that "Tumpcare" is on the back burner, many are wondering what to do. This article, while lengthy, is perhaps the best advice that anyone can give the GOP.

http://www.redstate.com/patterico/2017/03/27/next-step-repealing-obamacare-ted-cruz-answer/

Allowing Obamacare to collapse should be a nonstarter. If this happens, only the richest and most powerful will escape unscathed.

Keep in mind these fundamental truths when reading the article:
1) There is a difference in healthcare coverage and access to quality care. Just ask anyone using the VA or Medicaid if you doubt me.
2) While you can provide everyone with coverage, there are insufficient resources to provide everyone with access to quality care.
3) The only way to control cost of healthcare is to control consumption and market distortion from government interference.

Jeebus. Hate total bypass...Bed management crawls up my ass to get beds open and discharge anybody who has half decent MAP.

We've been at total capacity probably five of my last six shifts as charge on my stepdown unit with the ER holding what runs between 3 to 12 patients for the floors.

Here's my .02 USD from what I've seen working at a hospital with a solid reputation. The more coverage goes up, the further down quality goes. I mentioned above, to admit new patients, a lot of corners get cut and there is huge pressure to discharge current inpatients, many with multiple chronic conditions requiring complex management, but are poorly managed. Bonus points they are just on the ragged edge of medically stable. They get home and before their home health agency checks in, they go into acute on chronic respiratory failure, GI bleed, sudden cardiac death or some sort of ugly complication that rears its head they're back in the ED before their old ID band even came off. All of this happening pisses off patients (and their families) who yell at doctors (and nurses) who burn out like gasoline soaked flypaper and leave the hospital because they can work some nice outpatient clinic where nobody throws poop at them. The hospital has to hire new staff....Leaving the hospital with staff that's been working all of three weeks to see the next wave of Traumas, STEMIs, Code 44s, and strokes....Who need inpatient beds so discharge anybody you can alright?

How could it possibly go wrong?

[Eastex]

This has been enlightening, my daughters majoring in Kinesiology right now. I guess it's the natural response to increased wait times that we are getting all of the "Urgent Doc, Excel Er" type of businesses popping up all over.


"Hell bent on being intentionally anachronistic"

[OlongJohnson]

Ambassador Keyes was right when he said that the mission of the Democrat Party is to establish a socialist revolution, and the mission of the Republican Party is to pretend to oppose it.

Long term, this is a concept I've worried about in the context of gun control.

[Sensei]

Sensei,
I believe that the "collapse of the ACA", actually the collapse of our established insurance and health care systems was the original and ultimate goal of the badly monikered Obama Care legislation. Obama had little to nothing to do with the actual legislation, he was just the right puppet to help get it pushed through.

That's not to say that I was happy with the system in it's previous state. The insurance system needed cleaned up. No argument from me there, but the ACA just piled worse on top of bad. Again, that was the actual goal of the legislation. This has been an Alynski's Rules styled attack in order to open the field for a State run single payer health care system from the word go. The left didn't even do a decent job of hiding it. In fact they came out and said it on more than one occasion.

I find myself fluctuating between thinking that the ACA was some diabolical scheme to usher in single payer vs. just a botched attempt to address what the Dems thought was the problem with healthcare. On days that I find myself prone to the conspiracy theory, I just need to watch 5 minutes Nancy Peloci to realize that these people struggle to walk and chew gum, much less devise a diabolical scheme to collapse insurance.

So, I generally think that Dems simply mistook America's healthcare crisis as a problem of inadequate coverage for the poor and chronically ill, instead of recognizing the real problem of rising cost. Thus, their solution attempted to address the issue of coverage but largely ignored or exacerbated the heart of the problem - rising cost. Here is an excellent article that chronicles the history of rising costs (although I disagree with the author's premise that the ACA is bending the cost curve):

https://www.thebalance.com/causes-of-rising-healthcare-costs-4064878

Addressing this cost crisis is not going to be fun. Any real solution must address the unbridled consumption of healthcare resources and eliminating price controls for selected segments of the population. Both of those equate to a massive downgrade in the healthcare standard of living that we all enjoy.

[AMC]

I get the whole, "Never attribute to malice that which can be explained by stupidity" thing, but applying that here doesn't exactly wash.....Because the Dems in Congress didn't write the ACA, and weren't the "idea people".....They're just the upfront "talent". The folks who wrote the ACA have pretty much admitted that was their intent.

[Wondering Beard]

I get the whole, "Never attribute to malice that which can be explained by stupidity" thing, but applying that here doesn't exactly wash.....Because the Dems in Congress didn't write the ACA, and weren't the "idea people".....They're just the upfront "talent". The folks who wrote the ACA have pretty much admitted that was their intent.

Embrace the power of "and".

[Nephrology]

When you account for student loan debt, the 5-7 years of medical school + residency

FYI, this is actually an underestimate. The total is 4 years of medical school + a residency +/- fellowship, both of variable duration. Residency is 3-4 years on the low end (Internal Medicine, Pediatrics, Family Medicine & Emergency Med programs), 7-8 years on the high end (Neurosurgery, some academic General Surgery residencies w/significant research requirements). Then you can tack on fellowship (subspecialty training), which can vary from 1-5 years, again depending on the subspecialty & nature of the program.

In sum, 7 years after undergrad is the low end. if you're unfortunate enough to want to do Neurosurgery or want an academic career in Colorectal/Cardiothoracic you are looking at the better part of 2 decades of training. And, well, let's not forget those of us who don't think 1 doctorate is enough... add on another 3-4 for that. I think optimistically, assuming I maintain current interests (EM-> Crit Care), I've got another 10 years of training ahead of me. Optimistically.

The debt thing is a really big fucking deal doo and the problem is ramping up rapidly. I am at a state school and out of state students (~1/3 of my class of ~180) are charged a whopping $72,000 per year for tuition. Add on living expenses and multiply x4 and you're talking almost half a million dollars. Never been happier to be an MD PhD student.




So, I generally think that Dems simply mistook America's healthcare crisis as a problem of inadequate coverage for the poor and chronically ill, instead of recognizing the real problem of rising cost. Thus, their solution attempted to address the issue of coverage but largely ignored or exacerbated the heart of the problem - rising cost.

This is one of my biggest frustrations with the Democratic Party. I don't really pretend to have a great solution to our current state of affairs but anyone who thought the ACA was going to fundamentally change the problems in American healthcare was delusional, it drives me bonkers to see so many of my progressive 20-something peers come flocking to its defense when they have no idea what it's actually done. It doesn't help that there is a ton of bloat in the healthcare industry itself, but that doesn't magically get better when you give 20 million more people garbage insurance plans. It's worth noting that the NHS is facing a similar crisis despite their historically successful single payer system, so this problem is not unique to America (even if its presentation is certainly uniquely American).

It's also not particularly helpful that we have gotten really good at keeping prolonging vital organ function in people who are near death at an exorbitant price, something I am sure you are acutely aware of. Ironically, it seems that a huge percentage of the people filling ICU beds in this country could have lived longer and more fulfilling lives if they had just 1) quit smoking 2) eaten something besides McDonalds once or twice a week and 3) remembered to take their metformin/lisinopril/atorvastatin as directed. I would also add 4) never set foot in a SNF to the list but that is sort of an editorial aside...

[Joe in PNG]

The nasty, evil part of me is wondering how our system would benefit if we stopped giving narcan to ODing junkies.

[Nephrology]

The nasty, evil part of me is wondering how our system would benefit if we stopped giving narcan to ODing junkies.

As bad as the opiate crisis is, it wouldn't put a dent in the top causes of morbidity & mortality (https://www.cdc.gov/mmwr/preview/mmwrhtml/su6304a2.htm#tab2) in the US.

[RevolverRob]

As bad as the opiate crisis is, it wouldn't put a dent in the top causes of morbidity & mortality (https://www.cdc.gov/mmwr/preview/mmwrhtml/su6304a2.htm#tab2) in the US.

Yep. The bottom line is

Heart Attacks
Cancers of various types, but especially lung cancer
COPD, aka Emphysema and bronchitis
Stroke

And given that lung cancers, emphysema, bronchitis can be virtually eliminated by not smoking and limiting pollution - and heart disease and stroke risks reduced by not smoking, eating well, and exercising - The long-term solution to have a healthier population is, always has been, and likely always will be - to get thine ass off the couch and to the gym. Skip the McD's for breakfast/lunch, limit your caloric intake, and stop smoking.

[45dotACP]

The nasty, evil part of me is wondering how our system would benefit if we stopped giving narcan to ODing junkies.
What nephrology said...

Not nearly as much impact as if statins or beta blockers had never been invented.

Sent from my XT1585 using Tapatalk

[Nephrology]

What nephrology said...

Not nearly as much impact as if statins or beta blockers had never been invented.

Sent from my XT1585 using Tapatalk

To be fair I think statins and beta blockers (and ACEis & metformin) are probably the solution. I was more thinking of pressors, CRRT and CPAP (or fast food, tobacco products and alcohol; take your pick).

[OlongJohnson]

4) never set foot in a SNF to the list but that is sort of an editorial aside...

Remind us what an SNF is?

[peterb]

It's also not particularly helpful that we have gotten really good at keeping prolonging vital organ function in people who are near death at an exorbitant price, something I am sure you are acutely aware of.

As a society we're not good at dealing with death. The fact that talking about dying and DNRs and advanced directives are considered "difficult conversations" for doctors and patients instead of perfectly normal is just one example.

I supect that a lot of patients and their families would be surprised at how many older doctors and nurses choose to have DNRs or equivalent provisions in their paperwork.

On the cost issue, one problem is that the system is designed to spend money on treatment than prevention. There's a lot of evidence that programs like visiting nurses to see patients at home keeps a lot of those patients out of the hospital, but funding those programs is always difficult.

[Nephrology]

Remind us what an SNF is?

Skilled nursing facility aka nursing home. This is only sort of a joke. There are some SNFs out there that are excellent and do a great job caring for elderly folks with complicated psychiatric/medical problems, but there are also a lot that are frankly borderline criminal... bottom of the barrel employees that neglect their residents and do not tend to the residents until something emergent happens. I once saw a SNF resident who came in with a COPD exacerbation over the weekend. He had an unknown medical history & unknown code status. The "emergency on-call" nurse didn't return our calls for five hours.

All of these facilities are typically very expensive, and like any institution that houses a lot of people in close quarters (prisons, college dorms, military barracks, etc) they are breeding ground for infectious diseases, which are much more devastating in the elderly for obvious reasons.


As a society we're not good at dealing with death. The fact that talking about dying and DNRs and advanced directives are considered "difficult conversations" for doctors and patients instead of perfectly normal is just one example.

I supect that a lot of patients and their families would be surprised at how many older doctors and nurses choose to have DNRs or equivalent provisions in their paperwork.

On the cost issue, one problem is that the system is designed to spend money on treatment than prevention. There's a lot of evidence that programs like visiting nurses to see patients at home keeps a lot of those patients out of the hospital, but funding those programs is always difficult.

Definitely. I think death is a hard conversation for lots of folks and usually one that doesn't happen until too late. I am not even quite 30 yet and I have an advanced directive that basically says "no thanks."

Primary and secondary prevention measures are also very important, but the "lead a horse to water/make them drink" analogy is appropriate here. The medications I listed above (statins, ACE inhibitors, metformin) are used treat chronic conditions like diabetes, high blood pressure and elevated cholesterol. They're relatively well tolerated and super inexpensive - most of them are cheaper than the copay - and are demonstrated to improve survival and quality of life.

Still, for them to work, you need to 1) get a diagnosis and prescription and then 2) take them as directed. I think this was partially the aim of the ACA, and the intent is a good one, but improving access doesn't improve health literacy or compliance with care.

[Sensei]

It's also not particularly helpful that we have gotten really good at keeping prolonging vital organ function in people who are near death at an exorbitant price, something I am sure you are acutely aware of. Ironically, it seems that a huge percentage of the people filling ICU beds in this country could have lived longer and more fulfilling lives if they had just 1) quit smoking 2) eaten something besides McDonalds once or twice a week and 3) remembered to take their metformin/lisinopril/atorvastatin as directed. I would also add 4) never set foot in a SNF to the list but that is sort of an editorial aside...

Yesterday I was taking signout at the beginning of my shift and we eventually came to a patient with metastatic hepatocellular carcinoma (bad liver cancer). He was under hospice care but he and his family had indicated that he wanted to be a "full code." So, the hospice agency sent him to the emergency department as he became acutely weak and shocky, likely from hepatorenal syndrome (accelerated renal failure) and sepsis. The day team had ordered $1000 in diagnostics, and they were waiting on his labs to come back before admitting him to the ICU which would cost about $10,000-20,000 per day.

There was stunned silence from my residents and the off-going attending when I asked why they were admitted a patient with terminal cancer to an ICU. The reply was, "Well, he wants to be a full code and will probably need intubation, central line, etc." My next question to the group was to ask who thinks that offering CPR, central lines, and intensivist services to a terminal cancer patient was a good idea or evidence based? Did they think that these "treatments" were going to change the trajectory of the outcome? If no, then why offer it? My questions were met with the usual, "But, that is what the patient and family wants."

Well folks, we are not in the business of offering dying people a laundry list of expensive but ineffective (and essentially unethical) medical procedures. If we cannot be good stewards of healthcare resources, then expect government to regulate you. The day team was now becoming visibly anxious at this point, and noted that it was hard to have these types of end of life discussions in an emergency department when the patient's oncology team has completely abdicated their responsibilities for setting expectations. I politely thanked the off-going shift for their hard work. After rounds, I took the on-coming chief resident who had inherited this mess into the room and sat down with the patient and his family. I told them in clear terms that he was dying and would die in the next 2 days. I explained their options of taking him home to die, or being admitted to our in-patient hospice service. I never offered CPR, procedures, or even mentioned the so far pending tests that were ordered. Immediately and without hesitation, the family stated they wanted to take him home.

Several minutes after the patient left, the chief resident who accompanied me came up and told me that the labs sent from the day shift had resulted. She wanted to know if she needed to call them to come back because the patient's potassium was 7.1 (a lethal elevation).

That question reaffirms my belief that we are training a generation of robots who only know how to treat what they see as "abnormalities." They order tests to check off items in their differential diagnosis without knowing how to integrate, much less anticipate, the reality of the entire situation. This, along with a society that seems inordinately afraid of death as a defacto bad outcome means that cost-effective solutions will be very hard to come by.

[peterb]

Well after my father's cancer was declared terminal there were still docs ordering tests and scans "to see how it's progressing." Would the results change the outcome? No. Would the results change the treatment? No. He was palliative-only at that point. It made no sense. Peace and quiet and morphine at home was doing more to make him feel better than getting poked and prodded at the hospital.

[Cookie Monster]

deleted

[Nephrology]

Yesterday I was taking signout at the beginning of my shift and we eventually came to a patient with metastatic hepatocellular carcinoma (bad liver cancer). He was under hospice care but he and his family had indicated that he wanted to be a "full code." So, the hospice agency sent him to the emergency department as he became acutely weak and shocky, likely from hepatorenal syndrome (accelerated renal failure) and sepsis. The day team had ordered $1000 in diagnostics, and they were waiting on his labs to come back before admitting him to the ICU which would cost about $10,000-20,000 per day.

There was stunned silence from my residents and the off-going attending when I asked why they were admitted a patient with terminal cancer to an ICU. The reply was, "Well, he wants to be a full code and will probably need intubation, central line, etc." My next question to the group was to ask who thinks that offering CPR, central lines, and intensivist services to a terminal cancer patient was a good idea or evidence based? Did they think that these "treatments" were going to change the trajectory of the outcome? If no, then why offer it? My questions were met with the usual, "But, that is what the patient and family wants."

Well folks, we are not in the business of offering dying people a laundry list of expensive but ineffective (and essentially unethical) medical procedures. If we cannot be good stewards of healthcare resources, then expect government to regulate you. The day team was now becoming visibly anxious at this point, and noted that it was hard to have these types of end of life discussions in an emergency department when the patient's oncology team has completely abdicated their responsibilities for setting expectations. I politely thanked the off-going shift for their hard work. After rounds, I took the on-coming chief resident who had inherited this mess into the room and sat down with the patient and his family. I told them in clear terms that he was dying and would die in the next 2 days. I explained their options of taking him home to die, or being admitted to our in-patient hospice service. I never offered CPR, procedures, or even mentioned the so far pending tests that were ordered. Immediately and without hesitation, the family stated they wanted to take him home.

Several minutes after the patient left, the chief resident who accompanied me came up and told me that the labs sent from the day shift had resulted. She wanted to know if she needed to call them to come back because the patient's potassium was 7.1 (a lethal elevation).

That question reaffirms my belief that we are training a generation of robots who only know how to treat what they see as "abnormalities." They order tests to check off items in their differential diagnosis without knowing how to integrate, much less anticipate, the reality of the entire situation. This, along with a society that seems inordinately afraid of death as a defacto bad outcome means that cost-effective solutions will be very hard to come by.

It is awful that the oncology team did not do their job and unsurprising to hear the resident's reaction re: their hyperkalemia, and it's an attitude that isn't unique. I think very few people have the combined talent, sensitivity and wherewithal to recognize the right thing to do in a situation like that, and then to follow through it it. I don't know if this is unique to any particular generation of physicians but I suspect that the selection criteria we are using - namely performance on exams like the MCAT and USMLEs - doesn't make you a thoughtful or courageous human being. Just a hardworking one that has been trained to find an answer.

Either way, good on you for doing the right thing.

The unwillingness to accept death is another big one. When I was working with my PICU preceptor we had a very sad case of an 18 y/o with acute promyelocytic leukemia (a blood cancer with a usually good prognosis) who suffered one of its devastating complications, DIC (a clotting disorder) that resulted in her bleeding into her head and global cerebral devastation, in addition to kidney failure. She only barely "passed" her brain death exam when she was disconnected from her ventilator and moved her chest (but not air).

At the nearly 3 hour care conference her family insisted that they wanted the full suite of services - including hemodialysis, which it wasn't even clear she could be provided on an outpatient basis due to her dependency on mechanical ventilation - because it was insisted that 'this is what God wants'. Mercifully they did not want compressions or defibrillation, so when she arrested only 30min after the care conference she was allowed to go. Not nearly so many are that lucky.

[Dr_Thanatos]

Yesterday I was taking signout at the beginning of my shift and we eventually came to a patient with metastatic hepatocellular carcinoma (bad liver cancer). He was under hospice care but he and his family had indicated that he wanted to be a "full code." So, the hospice agency sent him to the emergency department as he became acutely weak and shocky, likely from hepatorenal syndrome (accelerated renal failure) and sepsis. The day team had ordered $1000 in diagnostics, and they were waiting on his labs to come back before admitting him to the ICU which would cost about $10,000-20,000 per day.

There was stunned silence from my residents and the off-going attending when I asked why they were admitted a patient with terminal cancer to an ICU. The reply was, "Well, he wants to be a full code and will probably need intubation, central line, etc." My next question to the group was to ask who thinks that offering CPR, central lines, and intensivist services to a terminal cancer patient was a good idea or evidence based? Did they think that these "treatments" were going to change the trajectory of the outcome? If no, then why offer it? My questions were met with the usual, "But, that is what the patient and family wants."

Well folks, we are not in the business of offering dying people a laundry list of expensive but ineffective (and essentially unethical) medical procedures. If we cannot be good stewards of healthcare resources, then expect government to regulate you. The day team was now becoming visibly anxious at this point, and noted that it was hard to have these types of end of life discussions in an emergency department when the patient's oncology team has completely abdicated their responsibilities for setting expectations. I politely thanked the off-going shift for their hard work. After rounds, I took the on-coming chief resident who had inherited this mess into the room and sat down with the patient and his family. I told them in clear terms that he was dying and would die in the next 2 days. I explained their options of taking him home to die, or being admitted to our in-patient hospice service. I never offered CPR, procedures, or even mentioned the so far pending tests that were ordered. Immediately and without hesitation, the family stated they wanted to take him home.

Several minutes after the patient left, the chief resident who accompanied me came up and told me that the labs sent from the day shift had resulted. She wanted to know if she needed to call them to come back because the patient's potassium was 7.1 (a lethal elevation).

That question reaffirms my belief that we are training a generation of robots who only know how to treat what they see as "abnormalities." They order tests to check off items in their differential diagnosis without knowing how to integrate, much less anticipate, the reality of the entire situation. This, along with a society that seems inordinately afraid of death as a defacto bad outcome means that cost-effective solutions will be very hard to come by.
Kudos to you for that.

To give you an idea of how adverse most doctors are to death, I had a terminal metastatic small cell lung cancer patient who died at home that their oncologist refused to sign the death certificate because and I quote "He was doing fine when he left my office." Terminal Cancer and "doing fine" are not equivalent terms. That doctor got two versions of the speech about their duty to their patients and finally in a huff agreed to sign the DC as "Cardiac Arrest". Dumbass.

I stopped asking doctors about when they learned the cure for death. They always cop an attitude right after that. :-)


Sent from my SM-P905V using Tapatalk

[DocGKR]

For those who have not done so, I strongly recommend reading Atul Gawande's Being Mortal.

[JAD]

Being Mortal is a moving and compelling book even for people well outside of the medical profession.

This is a very good topic for the middle of Lent.

[Totem Polar]

If we cannot be good stewards of healthcare resources, then expect government to regulate you.
The whole post was great, but this sentence struck a nerve. Apropos of much, IMO.

[Nephrology]

For those who have not done so, I strongly recommend reading Atul Gawande's Being Mortal.

Another one you've previously recommended that I really enjoyed was When Breath Becomes Air by Paul Kalanithi.

[LostDuke]

It is awful that the oncology team did not do their job and unsurprising to hear the resident's reaction re: their hyperkalemia, and it's an attitude that isn't unique. I think very few people have the combined talent, sensitivity and wherewithal to recognize the right thing to do in a situation like that, and then to follow through it it. I don't know if this is unique to any particular generation of physicians but I suspect that the selection criteria we are using - namely performance on exams like the MCAT and USMLEs - doesn't make you a thoughtful or courageous human being. Just a hardworking one that has been trained to find an answer.

Either way, good on you for doing the right thing.

The unwillingness to accept death is another big one. When I was working with my PICU preceptor we had a very sad case of an 18 y/o with acute promyelocytic leukemia (a blood cancer with a usually good prognosis) who suffered one of its devastating complications, DIC (a clotting disorder) that resulted in her bleeding into her head and global cerebral devastation, in addition to kidney failure. She only barely "passed" her brain death exam when she was disconnected from her ventilator and moved her chest (but not air).

At the nearly 3 hour care conference her family insisted that they wanted the full suite of services - including hemodialysis, which it wasn't even clear she could be provided on an outpatient basis due to her dependency on mechanical ventilation - because it was insisted that 'this is what God wants'. Mercifully they did not want compressions or defibrillation, so when she arrested only 30min after the care conference she was allowed to go. Not nearly so many are that lucky.

Interesting discussion, but isn't this exactly the kind of scenario that lead to the initial accusations that the ACA was setting up "Obama death panels" years ago?

As a a layman who has lived in three continents and has experienced health care abroad I find disconcerting that the fact the countries that have amazing health care services such has France spend less of their GDP's on health than we do.

How does that happen? How is our world so different, our medicines so expensive, our insurance system able only to deliver millions of dollars in bonuses to its executives and practically no savings?

[Nephrology]

Interesting discussion, but isn't this exactly the kind of scenario that lead to the initial accusations that the ACA was setting up "Obama death panels" years ago?


I cannot really comment on the rest of your post as it's beyond what I claim to understand, but I agree that is clear that our healthcare system is very inefficient for a wide variety of reasons. Having the capacity for highly advanced technological intervention obviously does not directly improve our nation's health when so much of it is decided on an incremental, day-to-day basis, well outside of the clinic.

As for the "death panels" thing, from my recollection that was largely a boogeyman with little basis in reality, especially when you consider the actual text of the ACA. I think the contention was that we would have a restriction on the quantity and quality of available resources (MRIs, access to certain surgeons, etc) which frankly can be an issue in some countries with single payer systems.

This is a silly analogy, but for example, when I was at Mayo Clinic - Rochester, I one heard that our campus had more MRIs than the entire country of Canada. Now, whether or not having all of those MRIs actually did patients any good is an entirely different question. However, with the NHS struggling right now with very similar issues (http://news.sky.com/story/nhs-crisis-explained-why-are-services-under-threat-10552564), it is clear that the scope of the problems in healthcare are global in nature and are not magically resolved by a single payer system.

Regardless, the fear that we would somehow have fewer MRIs (or other services) was fairly silly given that the ACA did not create a single payer system and was really about restructuring the health insurance industry. This of course has had all kinds of complex, indirect effects on hospital networks and private practices but again, this is beyond my ken. It's also worth mentioning that there are several services that are in serious regional deficit (i.e. in CO, psychiatric services, certain specialty surgeons like spine) despite our relatively market-driven approach.

All this to say that I think the issues are extremely complex and require a far more nuanced conversation than "obamacare vs trumpcare" or whatever today's headline happens to be. I don't consider myself qualified to weigh in with a proposed solution given that I don't think I fully understand the problem to begin with.

[peterb]

Interesting discussion, but isn't this exactly the kind of scenario that lead to the initial accusations that the ACA was setting up "Obama death panels" years ago?

The proposal that triggered the "death panel" stupidity was simply that doctors be reimbursed by Medicare for time spent in discussions with patients about advanced directives -- just as they are for other office visits.

[45dotACP]

I cannot really comment on the rest of your post as it's beyond what I claim to understand, but I agree that is clear that our healthcare system is very inefficient for a wide variety of reasons. Having the capacity for highly advanced technological intervention obviously does not directly improve our nation's health when so much of it is decided on an incremental, day-to-day basis, well outside of the clinic.

This. So very much this.


Sent from my XT1585 using Tapatalk

[Nephrology]

The proposal that triggered the "death panel" stupidity was simply that doctors be reimbursed by Medicare for time spent in discussions with patients about advanced directives -- just as they are for other office visits.

I would give my left testicle to 1) make our organ donation system "opt out" (vs our current "opt in" system), and 2) require that everyone fill out an advanced directive as a requirement for graduating high school or getting your driver's license.

[DocGKR]

"As a a layman who has lived in three continents and has experienced health care abroad I find disconcerting that the fact the countries that have amazing health care services such has France spend less of their GDP's on health than we do. How does that happen? How is our world so different, our medicines so expensive, our insurance system able only to deliver millions of dollars in bonuses to its executives and practically no savings?"

I can't speak for all of France, but I was just at a surgical conference for several days with a number of French practitioners--all were complaining about patients they could not effectively or completely treat, because of cost considerations...

[peterb]

I can't speak for all of France, but I was just at a surgical conference for several days with a number of French practitioners--all were complaining about patients they could not effectively or completely treat, because of cost considerations...

Yup. Every developed country is trying to find the right balance.....

That's another one of my frustrations with the U.S health care debate: It often seems to end up at "The Europeans have it right, so we should be just like them" vs. "The European systems aren't perfect, so there's nothing we can learn from them."

Sigh.

[GardoneVT]

We have two problems.One is solvable, the other is not.

Problem #1 is outlined earlier, and no government in history has found a way around it. The Law of Supply and Demand is pretty rigid.Demand for quality healthcare will always outstrip supply thereof regardless of the national GDP.

So follows Problem #2- how to allocate the limited healthcare available the most socially and ethically beneficial. There isnt enough resources for everyone poor and rich to have top quality medical care, just like not everyone can own a Ferrari. So should fat people get priority treatment and relatively healthier folks dont? Should younger people be aggresively screened and treated while those above a certain age should be consigned to fate? Should nonsmokers with active gym memberships and good diets take treatment precedence over the overweight smokers?

Truly solving this means deciding who wins and who loses.
From the politicians' seat , theyre pragmatically better off NOT solving it at all. In a country with as high of an obesity rate as ours combined with food production ,food sales and agriculture being major drivers of national industry, really solving healthcare means pissing off Wall Street as well as Joe Public, because its going to require fundamental changes in social behaviors and thus spending patterns. We cant have fair allocation of healthcare and a society of McDonalds addicts at the same time. Which wont be good for McDonald's share prices.

So, like the national debt, since theres no pragmatic way to solve the issue without serious cultural changes , it will remain unsolved.

[Wondering Beard]

So follows Problem #2- how to allocate the limited healthcare available the most socially and ethically beneficial. There isnt enough resources for everyone poor and rich to have top quality medical care, just like not everyone can own a Ferrari.

Scarcity is the nature of material reality. Whether we're talking about healthcare, food, iPhones or oxygen, scarcity is the rule. Nothing in healthcare makes it somehow different than the rest of reality. Moreover, the law of supply and demand is the direct result of the fact of scarcity; if anything isn't scarce (and in this material reality, it doesn't exist) then supply and demand don't apply, or rather the crossing lines in the graph don't move.

The nature of supply and demand means that it changes primarily (but not always) according to cost. Bigger supply comes with lower costs, it can never fully meet all demand (scarcity) but it can meet a much greater level of demand with lower costs (witness modern vs traditional agriculture). Government interference in trade (healthcare being an economic activity between parties is naturally part of trade) has just about always increased costs. When it comes to healthcare, we are trying to get the government to change its past interference into a type of interference that is supposed to lower costs. I don't know enough about the healthcare industry to say how that might be achieved, if at all, but conceptually I find the idea dubious at best.

Nevertheless, whether we like it or not, this whole matter has come under government control and that is what we have to deal with.


Truly solving this means deciding who wins and who loses.

Leaving that in the hands of people whose job is to take money from A and redistribute it to B according to whomever paid for the acquisition of their job sounds like a terrible idea.

There is a system that has been superb at handling these types of choices forced on us by scarcity, it's called free markets; never perfect but excellent at moving the graph for the benefit of most people since, as opposed to politicians, it is the knowledge of millions of individuals, in constant interaction, that is aggregated and thus shows how and what people prefer and benefit from. it's not politically feasible nowadays to apply it to healthcare but getting it closer to free markets would solve a whole lot of problems.

[Drang]

Leaving that in the hands of people whose job is to take money from A and redistribute it to B according to whomever paid for the acquisition of their job is a terrible idea.

My only quibble with your post...

[DocGKR]

1. See Sensai's comments above--we as a Nation need to stop wasting scarce resources on useless invasive expensive medical care which will not alter the outcome of terminal patients at end of life--instead, we need to emphasize compassionate hospice care aimed at making those individuals last days as peaceful and comfortable as possible.

2. People need to start taking responsibility for their lifestyle choices; as noted above, a lot of healthcare resources are devoted to individuals who create their own medical issues. Much like a habitually speeding and reckless driver will eventually loose their license, perhaps similar loss of privileges should be a consequence for those narcissists who continually make poor health choices, fail to head medical advice, and then burden the medical system with their own self-created health crises.

[Drang]

To give you an idea of how adverse most doctors are to death, ...

I stopped asking doctors about when they learned the cure for death. They always cop an attitude right after that.

Been thinking about these posts.

For several generations now we've all been raised on tales of heroic doctors refusing to give in, and miraculously pulling patients back from, or maybe from just beyond, the brink of death. On any given day you can find at least one, probably more, "doctor dramas" on cable. "Oh, look, its that episode where Hawkeye thumps the GI on the chest yelling 'Don't let the bastard win!' and BJ (or Trapper John, don't remember) explains that 'the bastard' is Death." And of course he saves the troop, because it is a Dramatic Necessity.

Bad enough that us peasants buy it, but the medical industry has a vested interest in encouraging it.

I've heard people criticize Hollywood for encouraging weird ideas about warfighting ("John Wayne is the reason troops throw a grenade into a grass hut and flatten themselves against the grass wall...") and law enforcement (Dragnet, Adam 12, CSI, etc.) and lawyers (Ironsides, Matlock) but no one blames Ben Casey for encouraging the Doctor=God belief...

[peterb]

There is a system that has been superb at handling these types of choices forced on us by scarcity, it's called free markets; never perfect but excellent at moving the graph for the benefit of most people since, as opposed to politicians, it is the knowledge of millions of individuals, in constant interaction, that is aggregated and thus shows how and what people prefer and benefit from. it's not politically feasible nowadays to apply it to healthcare but getting it closer to free markets would solve a whole lot of problems.

The problem with a pure free-market approach to healthcare is what happens to the folks at the bottom of the ladder. Think about the kinds of predatory businesses that flourish where there are high concentrations of poor people. Do we really want to subject them to the health-care equivalent?

We're wealthy enough as a country to do better. I wish I knew how.

[TicTacticalTimmy]

We have two problems.One is solvable, the other is not.

Problem #1 is outlined earlier, and no government in history has found a way around it. The Law of Supply and Demand is pretty rigid. Demand for quality healthcare will always outstrip supply thereof regardless of the national GDP.

So follows Problem #2- how to allocate the limited healthcare available the most socially and ethically beneficial. There isnt enough resources for everyone poor and rich to have top quality medical care, just like not everyone can own a Ferrari. So should fat people get priority treatment and relatively healthier folks dont? Should younger people be aggresively screened and treated while those above a certain age should be consigned to fate? Should nonsmokers with active gym memberships and good diets take treatment precedence over the overweight smokers?


(my emphasis)

It sounds to me like you're saying healthcare is a scarce resource, quite the revelation!

If only we had some system that enabled scarce resources to be precisely allocated......

If only there was some system of distributing societies' resources that had a 200 year proven track record of steadily lowering costs and raising quality and availability of scarce resources.....

It would be amazing if this system had no overhead costs, like if it somehow didn't require any tax-funded bureaucrats to make decisions about resource allocation....

Like if there was some magical "invisible hand" that distributed healthcare resources and punished those who use or produce those resources inefficiently...

I guess I'm just daydreaming though, a system like that sounds too good to be true. We just need to have Faith in the Government to lower costs and keep improving quality. That's something that has worked for the allocation of other scarce resources in the past right?

[NEPAKevin]

It would be amazing if this system had no overhead costs, like if it somehow didn't require any tax-funded bureaucrats to make decisions about resource allocation....



What, no love for the IRS?
15565

[Wondering Beard]

The problem with a pure free-market approach to healthcare is what happens to the folks at the bottom of the ladder. Think about the kinds of predatory businesses that flourish where there are high concentrations of poor people. Do we really want to subject them to the health-care equivalent?

We're wealthy enough as a country to do better. I wish I knew how.

Since the economies that became the richest started out with most people at the bottom of the ladder (and those people now have extraordinary wealth compared to their truly poor forebearers), off hand I'd say yes.

While there aren't truly pure free markets anywhere, we do know that greatest beneficiaries of free markets are actually the poor. To quote TiTacticalTimmy somewhat sarcastic comment:"If only there was some system of distributing societies' resources that had a 200 year proven track record of steadily lowering costs and raising quality and availability of scarce resources....." Free markets lower costs which is what benefits the poor much more than the rich. You are mistaken in your assumption that free markets make the poor more vulnerable to predation, when it is the opposite.

[TicTacticalTimmy]

The problem with a pure free-market approach to healthcare is what happens to the folks at the bottom of the ladder. Think about the kinds of predatory businesses that flourish where there are high concentrations of poor people. Do we really want to subject them to the health-care equivalent?

We're wealthy enough as a country to do better. I wish I knew how.

I would argue that government intrusion into healthcare is precisely what has created the risk of non-access to health care resources for poor people.

For example, if I don't have health care coverage and I am poor, I am strongly incentivized to remain without coverage and go to a hospital when my health ailments become acute. The hospital must then provide for me (1986 EMTLA law, among other government interference), spending a similar amount of health care resources on me as if I were a paying customer. In this way I externalize the cost of my health care to the hospital, who adds it to their average costs, which then trickle up to the insurance providers, which then trickle down to all those who choose to purchase health care coverage.
In this way, in our current system, the lack of affordability of healthcare by poor people leads to an increase in all healthcare insurance premiums, thereby increasing the number of poor people who cannot afford health insurance. The cycle repeats itself and as time goes on the cost of health insurance for the average person becomes increasingly higher relative to the average cost of healthcare for the average person, making the purchasing of healthcare insurance an increasingly bad decision.

However, the average person does not have the option of simply avoiding buying health insurance and actually paying for their healthcare as they consume it. If they do so and get an acute health problem, the costs for treatment are typically astronomical.

Why are acute treatment costs so high? It seems to me this is, again, almost entirely due to government interference, for these reasons:
1. Government programs like Medicaid act as middlemen between health care resource producers and consumers in a large plurality of cases. The result of this is that the entire pricing system is geared toward health care producers interacting with these middlemen, to the detriment of consumers who wish to deal directly with health care producers.
2. As a result of (1), consumers cannot competitively price the goods of various "competing" health care producers. For example, if I need some x-rays done and have two local hospitals to choose from, I cannot simply go to each hospitals website and compare their prices like I would for any other product in the market. Someone correct me if I am wrong, but I doubt I can even call them and ask their pricing. Therefore, it is in health care producers interest to charge as much as possible when there is no middleman involved, since they have no fear of price-based competition.
3. Health insurance plans are structured so that they benefit those with who consume extremely high amounts of healthcare.
For example, if I am sick and want to get better, I may require a $100,000 operation. If my deductible is $10,000, I only have to pay $10,000. If there was a $20,000 operation alternative, I would refuse that alternative, since I don't save any money.
This becomes far more pronounced for terminal or end of life care and similar situations. If keeping me alive costs $20,000 per month but I only pay $1,000 per month because I have insurance, I am strongly incentivized to consume $20,000 per month in healthcare resources, relative to my incentive if I were paying out of pocket. The costs of my care do not simply dissapear, rather I externalize them to the other consumers who share my health care insurance provider or to the non-insure clients of the hospital, thereby raising the costs for everyone.
4. Perhaps most importantly, these health care insurance providers are incapable of performing the basic function of an insurance company: namely, analyzing average risk and assessing a price tag equal to this average risk plus a profit margin that is competitive with market profit margins for that industry. The most egregious example of this is the fact that healthcare providers cannot refuse for pre-existing conditions. If an insurance company knows I am terminally ill and will cost $40,000 per year to keep alive, they would not choose to insure me for less than $40,000. Due to the pre-existing conditions law, they must insure me, lets say for $5,000 per year. The other $35,000 must be shared among the insurance companies other clients, thereby raising the average health insurance costs of everyone else well above their average health insurance consumption.

In all of these ways and more, government interference has effectively obliterated all incentives for the market to provide low-cost healthcare, whereas the market has every incentive to provide the most expensive healthcare possible. The end result is that poor, or even working and lower middle class people, cannot afford healthcare without government assistance. This assistance leads to still higher healthcare costs, which means less people can afford healthcare, which means more demand for government assistance, and on and on and on until the system eventually breaks or is replaced with a completely Socialized system.

[Mark Housel]

I would argue that government intrusion into healthcare is precisely what has created the risk of non-access to health care resources for poor people.

For example, if I don't have health care coverage and I am poor, I am strongly incentivized to remain without coverage and go to a hospital when my health ailments become acute. The hospital must then provide for me (1986 EMTLA law, among other government interference), spending a similar amount of health care resources on me as if I were a paying customer. In this way I externalize the cost of my health care to the hospital, who adds it to their average costs, which then trickle up to the insurance providers, which then trickle down to all those who choose to purchase health care coverage.
In this way, in our current system, the lack of affordability of healthcare by poor people leads to an increase in all healthcare insurance premiums, thereby increasing the number of poor people who cannot afford health insurance. The cycle repeats itself and as time goes on the cost of health insurance for the average person becomes increasingly higher relative to the average cost of healthcare for the average person, making the purchasing of healthcare insurance an increasingly bad decision.

However, the average person does not have the option of simply avoiding buying health insurance and actually paying for their healthcare as they consume it. If they do so and get an acute health problem, the costs for treatment are typically astronomical.

Why are acute treatment costs so high? It seems to me this is, again, almost entirely due to government interference, for these reasons:
1. Government programs like Medicaid act as middlemen between health care resource producers and consumers in a large plurality of cases. The result of this is that the entire pricing system is geared toward health care producers interacting with these middlemen, to the detriment of consumers who wish to deal directly with health care producers.
2. As a result of (1), consumers cannot competitively price the goods of various "competing" health care producers. For example, if I need some x-rays done and have two local hospitals to choose from, I cannot simply go to each hospitals website and compare their prices like I would for any other product in the market. Someone correct me if I am wrong, but I doubt I can even call them and ask their pricing. Therefore, it is in health care producers interest to charge as much as possible when there is no middleman involved, since they have no fear of price-based competition.
3. Health insurance plans are structured so that they benefit those with who consume extremely high amounts of healthcare.
For example, if I am sick and want to get better, I may require a $100,000 operation. If my deductible is $10,000, I only have to pay $10,000. If there was a $20,000 operation alternative, I would refuse that alternative, since I don't save any money.
This becomes far more pronounced for terminal or end of life care and similar situations. If keeping me alive costs $20,000 per month but I only pay $1,000 per month because I have insurance, I am strongly incentivized to consume $20,000 per month in healthcare resources, relative to my incentive if I were paying out of pocket. The costs of my care do not simply dissapear, rather I externalize them to the other consumers who share my health care insurance provider or to the non-insure clients of the hospital, thereby raising the costs for everyone.
4. Perhaps most importantly, these health care insurance providers are incapable of performing the basic function of an insurance company: namely, analyzing average risk and assessing a price tag equal to this average risk plus a profit margin that is competitive with market profit margins for that industry. The most egregious example of this is the fact that healthcare providers cannot refuse for pre-existing conditions. If an insurance company knows I am terminally ill and will cost $40,000 per year to keep alive, they would not choose to insure me for less than $40,000. Due to the pre-existing conditions law, they must insure me, lets say for $5,000 per year. The other $35,000 must be shared among the insurance companies other clients, thereby raising the average health insurance costs of everyone else well above their average health insurance consumption.

In all of these ways and more, government interference has effectively obliterated all incentives for the market to provide low-cost healthcare, whereas the market has every incentive to provide the most expensive healthcare possible. The end result is that poor, or even working and lower middle class people, cannot afford healthcare without government assistance. This assistance leads to still higher healthcare costs, which means less people can afford healthcare, which means more demand for government assistance, and on and on and on until the system eventually breaks or is replaced with a completely Socialized system.

Thank you for explaining in clear terms what I fully understand to be true, but have difficulty in articulating.

There is simply no way to make something cheaper by taxing it, more plentiful or readily available by regulating it, more generally affordable or better quality by inserting government run and regulated middlemen into the process of supplying it.

People seem to forget that in the not so dim past none of what is considered the "Health Care Industry" existed. Yet people managed to receive medical treatment for illness and were able to pay for it somehow?

The last cycle of cause and effect explain the increasing and somewhat out of control costs for things like higher education as well.

[Nephrology]

For example, if I don't have health care coverage and I am poor, I am strongly incentivized to remain without coverage and go to a hospital when my health ailments become acute.

There is no "strong incentive" (assuming you meant fiscal) to allow your hypertension & diabetes to progress to heart and/or kidney failure. EMTALA requires that you be given a thorough assessment and stabilized, not that you receive concierge medical treatment. Even if you got the best treatment in the country for free once you hit the doors of the ED, the strongest incentives out there is not in favor of waiting until you have end stage organ insufficiency.

The issue is that humans don't behave like perfect rational robots who constantly price-maximize, especially when their problems (high cholesterol & BP) really don't bother them on a day to day basis (assuming they even know they have these problems to begin with). However when they get sharp radiating chest pain all of a sudden the doctor becomes someone they'd really like to have a chat with...




1. Government programs like Medicaid act as middlemen between health care resource producers and consumers in a large plurality of cases.


This is how all insurance plans work. Medicaid provides health insurance to people with disability, among others. Other health insurance plans function identically but obviously with different clients, plans, and reimbursement structures. I don't really see your argument here. I just saw a long summary of how an insurance company works, and you seem to imply that if we did away with pooled risk that the cost of an ICU stay would magically drop to $99/night. I don't think this argument comes close to holding water.

It's also worth mentioning that most residency training positions are paid for in part or in full by Medicaid.




2. As a result of (1), consumers cannot competitively price the goods of various "competing" health care producers.

Sorry, but this is bullshit. There is little to no way for the average consumer - even a highly educated one - to objectively "competitively price" healthcare. This is because healthcare isn't like apples. For the vast majority of non-elective and/or cosmetic healthcare expenses that cost real dollars (i.e. not your annual physical), you enter the market with a dramatic asymmetry of information and often without the luxury of time to shop around.

For starters, as you mention, many large medical expenses are incurred precipitously. Traumatic injury or acute illness will usually result in admission to wherever the ambulance takes you, and if you're lucky they'll ask what hospital you want to go to and you'll know which one is in network. All of a sudden you (or your loved one) is in the ICU with a blood pressure maintained by norepinephrine and breathing done by a tube. At what point does one stop to shop around? Those X-rays you mentioned that you wanted done? they got shot just after you were RSI'd and intubated in the resuscitation room. Hope you like em!

Or: you or a loved one is diagnosed with cancer. You are being given lots of scary information very suddenly while you/your loved one are collectively experiencing the worst day of probably your entire life. How do you "competitively price" out hospitals, oncologists, chemotherapy regimens, radiation therapies? How do you do that when you're so tired from throwing up at the end of the day that you can barely roll over in bed, let alone evaluate the per-mg costs of vinblastine between local oncology groups? How can you tell which ones are "the best"? How do you put a price on the difference between them and "2nd best?"

Even if you could, the market for specialists simply isn't big enough to really produce much in the way of real competition. Let's take organ transplantation for an example. Assume you need a new kidney and you're willing to shop around. Do you know how many centers in this country do renal transplants? How many transplant surgeons are practicing in America today? Here in CO, the only game in town (than I know of) is University. If you aren't happy with them, well, be prepared to check out prices in another time zone (& to add on all of the associated travel & living expenses on top of that).

Ultimately, in both of the above scenarios, you will be in a massive financial hole no matter what, and this gets at the ultimate truth of why healthcare is not the same thing as buying a car: for most of us, there is no price we are not willing to pay. Even if we assumed perfect information among consumers AND we all had deeply meditated on what care we do and do not want, at the end of the day, if you know that you need something to help you maintain or regain a meaningful quality of life for a meaningful amount of time, odds are rather good that you will do everything in your power to have it.

I write all of this because "free market!" is to me a facile answer that provides little in the way of specific solutions to specific problems and I don't find it any more persuasive than "single payer!" I am also tired of hearing people talk about heathcare like you're shopping for a new SUV. They're fundamentally not the same and I've never read a good argument to the contrary. Some procedures/markets are closer - elective outpatient surgery, finding a pediatrician or internist to do regular physicals for you & your kids - but when it really matters (& costs) most, it's not the same.



People seem to forget that in the not so dim past none of what is considered the "Health Care Industry" existed. Yet people managed to receive medical treatment for illness and were able to pay for it somehow?

The kind of treatments that exist now (organ transplantation, radiation therapy, monoclonal antibodies, ECMO, CRRT, etc etc ) did not exist in the 'not so dim past,' or existed in a crude form that would be entirely unpalatable to patients of today. There are lots of reasons extrinsic to the act of providing medical care that have driven costs so high, but we can't forget that the intrinsic costs have increased exponentially as well. Let's not forget that a little thing called antibiotics didn't reach patients en masse until the middle of WW2...

Returning to the low costs of past medical care would be easy - don't provide any. Old Mr. Murphy has the dropsy? 2 drops of laudanum in his water every day, good sir, that will be 15 shillings.

[Peally]

I'm guessing there is a happy medium between the garbage government-intrusion-into-every-single-facet-of-medicine-because-think-of-the-children system we have now and Thunderdome.

[Nephrology]

I'm guessing there is a happy medium between the garbage government-intrusion-into-every-single-facet-of-medicine-because-think-of-the-children system we have now and Thunderdome.

That's what I'm hoping, and that someone smarter than me can find it.

[TAZ]

I'm guessing there is a happy medium between the garbage government-intrusion-into-every-single-facet-of-medicine-because-think-of-the-children system we have now and Thunderdome.

I'm sure that there is a workable solution out there aside from the whole ponzy schemes .gov manages to concoct. Cause that is precisely what many if these government programs are. SSA, Medicare, and even ACA are ponzy schemes where one generation is paying for the benefits of the previous. It's why they fail when birth rates and employment opportunities drop. No one to pay the bill. That's why they are mandatory and not voluntary.

IMO the best way to help folks with their medics bills is to strengthen the economy. You can't have people making service job salaries and funding advanced health care in addition to their regular spending. Just both mathematically possible. We need more producers and less takers. That can't happen with .gov being the biggest employer if the nation. That can't happen when people are working 20 hrs at Home Depot and 20 hrs at Taco Bell to make ends meet.

Couple an economy that supports folks getting better paying jobs with benefits packages with some tort reform, some regulatory rebalancing...and you may get somewhere.

The question isn't if there are viable solutions out there, but rather will out "leaders" do anything to get there. Real solutions lead to more freedoms and less government involvement. What politician is going to consider reducing their power base??

[Mark Housel]

I'm guessing there is a happy medium between the garbage government-intrusion-into-every-single-facet-of-medicine-because-think-of-the-children system we have now and Thunderdome.

Once you make the productive labor of others a "right" there is no good "happy medium", and by definition a government (at least as ours is allegedly constituted) designed to protect our rights is in to the hilt. :(

[Drang]

I'm guessing there is a happy medium between the garbage government-intrusion-into-every-single-facet-of-life-because-think-of-the-children system we have now and Thunderdome.

FIFY.

[OnionsAndDragons]

I have had a lot of experience being in the healthcare system, and I tend to agree with Nephrology's above sentiments at least in regards to critical and acute care situations.

I do think there are a lot of services that could benefit from some more invisible hand regulation. Day to day stuff, not cancer treatment or you just wrapped your car around a light pole circumstances.

Let's consider childbirth. You know; a thing we have been doing before we figured out how to rub 2 sticks together.

I found the hospital bill for my mothers birth while cleaning out old boxes a couple weeks ago. It was $164. Now, those were 1950s dollars so they were obviously better than the ones we have now; but even adjusted for inflation, that would be a bill of just under $1500 in 2017 script.

In 2012, which was the most recent year in the best vetted study I could easily find no longer having university library access, the average cost of an uncomplicated vaginal birth at a hospital was over $10,000.

That is an indicator of a big fucking problem, and the problem ain't the fucking.

I suppose if you happen to live near a large enough community you have the option of a skilled birthing center at a much more affordable rate of $2500 or so, but that is still significantly higher than what inflation would indicate.

This sort of mundane shit should not cost what it does. Period.


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