Oregon will start forcing doctors to accept Medicaid

[Boatswain2PA]

I'm aware of the many, many statistics and news reports showing how terrible our healthcare outcomes are.  I am also aware of the many author bias' in virtually all of those statistics and reports, and I don't think they tell the whole story.

For example, we are nowhere where we should be in terms of neonatal mortality.  But if you break the numbers down, the high neonatal mortality rates really only exists in one small subsection of our population (which has a lot of neonates).  That problem has nothing to do with our health care ability or system, but rather a cultural issue of getting them to actually come to SEEK care, and protect their children.  This is a cultural problem, not a health care problem.

[EMEDPA]

Based on the reference that you cited, US is #37 in quality and #1 in amount spent. Sweden is #23 in quality and #7 in amount spent. It's a significant difference, but it's not like Sweden is #1 quality with the least spent. At least, it's not enough to revamp an entire system over and attempt to replicate that system.

 

Also, Cuba ranks lower than the US in quality. Of course, they don't spend a lot of money, but they are also third world.

cuba must be slipping. they used to rank higher than us.

[EMEDPA]

I'm aware of the many, many statistics and news reports showing how terrible our healthcare outcomes are.  I am also aware of the many author bias' in virtually all of those statistics and reports, and I don't think they tell the whole story.

 

For example, we are nowhere where we should be in terms of neonatal mortality.  But if you break the numbers down, the high neonatal mortality rates really only exists in one small subsection of our population (which has a lot of neonates).  That problem has nothing to do with our health care ability or system, but rather a cultural issue of getting them to actually come to SEEK care, and protect their children.  This is a cultural problem, not a health care problem.

depends on where you live. in my community even folks with medicaid basically have no health care because no one accepts it. 2 practices in our city of 500,000 people take medicaid. they can't get primary care, they can't get prenatal care, they can't get prescriptions filled that I wrote in the ER because medicaid now has copays for scripts. If there is no primary care there is basically no care except emergency care, leaving me as the pcp for 500,000 people.

[Boatswain2PA]

Agreed, that is a huge problem.  But this problem is an example of the failure of a government run health care program (which allows those neurosurgeons to make $5M a year working 3 days/week).

I don't buy the argument that they can't fill the script because of the $4 copays.  The vast majority of those people have new I-phones or Galaxy 4's and smoke a pack a day.  They can afford the script if they chose to.  If they were actually poor, they could go into virtually any church and ask the pastor for help with their co-pay, and the pastor would help.  

 

By the way, I am not saying we have perfect health care, or a perfect health care system.  However I think we have terrific health care, and the FUNDAMENTAL problem with our health care SYSTEM is the lack of connection between the services a person gets and the amount they pay for it.    I absolutely detest Obamacare, but one good thing about it is that with the enormous deductibles that many people are being surprised with, it actually does shift the cost of care back onto the people who receive it.  This is terrible for the individual, but good for society.

Of course, this is only for the few people who actually pay for their own insurance and deductibles.  More and more people are being shifted into that single payor system (Medicaid/Medicare) that you are advocating.  How's that working for you where you practice?  Oh yeah, doctors won't accept it because it SUCKS!

[rev ronin]

I don't buy the argument that they can't fill the script because of the $4 copays.  

Back to the latino guy with the stent... which TSACs are on the $4 list?  There's a lot of good, solid drugs on that list, but not necessarily the ones married with the most current cutting-edge care.  A current cardiology PA can correct me if I'm off base, but I've heard that drug-eluting stents are essentially reserved for higher socioeconomic classes who can guarantee they will be able to pay for the months-long course of Plavix or whatever it takes to prevent post-placement clot formation.

 

Acute care is one issue, and preventative care is another, but ongoing follow-up care is yet a different facet where challenges can arise.

[EMEDPA]

I agree that medicaid/medicare need to pay providers better. no argument there. that doesn't mean that these folks don't deserve care though. I also have a problem with the subset of folks who smoke, have  a new car and an Iphone6, but won't pay 4 bucks for their kids abx.

I do have a subset of pts who can't afford a 4 dollar copay. I saw a homeless guy last night at 3 am who had all his possessions on his back. guy had not eaten in days. he had an infected wound requiring antibiotics that wasn't bad enough for admission or an IV (yet). one of my colleagues had seen him 2 days earlier and written him for keflex. 4 bucks. couldn't fill it. I saw him, gave him a few from our take home pack supply and set him up with a local free clinic to get his meds. this guy has medicaid. it has failed him.

[Boatswain2PA]

 

Acute care is one issue, and preventative care is another, but ongoing follow-up care is yet a different facet where challenges can arise.

Yet that is exactly what is falling apart FIRST in the federal guv'ment controlled CMS system.

[EMEDPA]

Yet that is exactly what is falling apart FIRST in the federal guv'ment controlled CMS system.

that is a payment issue, not an overall condemnation of the program. if the program covered plavix and f/u appts q month for 6 months this would be a non-issue.

A lot of health care in this country is already govt run as you know: VA, IHS, Medicare, etc. The inefficiencies come up due to the fact that we have so many different systems and so many different payors. one central system with one payor (say like in France-the best health system in the world) would do away with a lot of that inefficiency.

[PAMEDIC]

yeah, just because it works in every other developed nation in the world, all of whom have better health outcomes than us for less money is no reason to try it here....

Even if the outcomes were identical, they still beat us on cost... by a wide margin.

 

Because of strange ideological or partisan myopia, we have a mish mash system where we in America choose to pay for for less.

[Boatswain2PA]

I agree that medicaid/medicare need to pay providers better. no argument there. that doesn't mean that these folks don't deserve care though. I also have a problem with the subset of folks who smoke, have  a new car and an Iphone6, but won't pay 4 bucks for their kids abx.

I do have a subset of pts who can't afford a 4 dollar copay. I saw a homeless guy last night at 3 am who had all his possessions on his back. guy had not eaten in days. he had an infected wound requiring antibiotics that wasn't bad enough for admission or an IV (yet). one of my colleagues had seen him 2 days earlier and written him for keflex. 4 bucks. couldn't fill it. I saw him, gave him a few from our take home pack supply and set him up with a local free clinic to get his meds. this guy has medicaid. it has failed him.

 

My guess is there was also a significant mental health component to his problems.  Our mental health care in America is absolutely terrible.  

 

There will ALWAYS be people who fall through the cracks of any system.  Period.  No system will ever be perfect, and it sucks to see it fail individual people.  

 

I was incredibly frustrated with the VA as I was trying to get that suicidal Iraqi war veteran with an acute PTSD exacerbation into a VA bed.  Voice mail after voice mail, and hours of waiting only to find that "nope, we don't have any beds" and having to start all over again with a VA 6 hours the other direction.  I imagine that THIS is the frustration that the ED docs have in England and other places with guv'ment run health care systems.  Oh, and by the way, I don't think there are "free clinics" in England run by charities (perhaps I'm wrong).  

 

I would not have had a problem admitting this guy for obs.  Give him IV abx for his infection, feed him well, and have social work do their magic in the morning.  I'm glad I work where I do...

[EMEDPA]

Even if the outcomes were identical, they still beat us on cost... by a wide margin.

 

Because of strange ideological or partisan myopia, we have a mish mash system where we in America choose to pay for for less.

my response was sarcastic. I am in favor of universal coverage and one payor.

[EMEDPA]

no way in hell I could have gotten this guy admitted where I work.

I'm sure he did have some (undx) mental health issues. I agree mental health in this country sucks. one er near me recently had a guy in their er psych area for 3 MONTHS because they could not find an inpt bed for him.

as I understand it, the UK doesn't need free clinics because care is readily available for any urgent or emergent problem. the issues folks have with socialized medicine everywhere are waits for elective procedures. many countries like canada allow folks to purchase policies to cover elective stuff faster, however the govt foots the bill for all basic health care needs.

[Boatswain2PA]

that is a payment issue, not an overall condemnation of the program. if the program covered plavix and f/u appts q month for 6 months this would be a non-issue.

A lot of health care in this country is already govt run as you know: VA, IHS, Medicare, etc. The inefficiencies come up due to the fact that we have so many different systems and so many different payors. one central system with one payor (say like in France-the best health system in the world) would do away with a lot of that inefficiency.

If the program covered plavix and f/u appts q month for 6 months it wouldn't be an issue for the patient, but would certainly be an issue for the taxpayers.  You know, the few of us who actually pay taxes.  By the way, June 15th is right around the corner, time to write another huge freaking check to Uncle Sam....

 

Inefficiencies are inextricably linked to government.  Again, the more we turn healthcare over to the government, the more it will look like VA care, or the DMV, or worse yet, DHS.

 

Meanwhile, if we worked to REMOVE much of the government interference (bans on interstate insurance and other restrictions on competition) and allowed people to select the type of medical insurance they WANT we would achieve two necessary things.  #1) Put the responsibility of care back onto the patient, and #2) reduce the cost of insurance (and healthcare).  

[Boatswain2PA]

no way in hell I could have gotten this guy admitted where I work.

I'm sure he did have some (undx) mental health issues. I agree mental health in this country sucks. one er near me recently had a guy in their er psych area for 3 MONTHS because they could not find an inpt bed for him.

as I understand it, the UK doesn't need free clinics because care is readily available for any urgent or emergent problem. the issues folks have with socialized medicine everywhere are waits for elective procedures. many countries like canada allow folks to purchase policies to cover elective stuff faster, however the govt foots the bill for all basic health care needs.

There are no free clinics because, on paper according to the bureaucrats, there are no need for such free clinics when all health care is free.  However, just like the problems you are experiencing with medicaid patients not having access to primary care, ED/urgent care is often not "readily available" in England either.  Look at the average wait times for ED patients in England.  I wouldn't say that is "readily available for urgent or emergent problems."

[PAMEDIC]

I work in community hospital in the Military Health System (not to be confused with the VA). I think the care we provide is pretty stellar at a fraction of the cost that the private civilian market offers. We serve around 40,000 patients with about 1/3 of them being military personel. The majority of people we see are civilian spouses, dependents, and retirees. So contrary to the idea that our population is all healthy, we actually have a wide diverse patient population with all your normal chronic diseases and bad habits.

 

But in this government run system, people get great care. They have access to immediate emergent care. Primary care visits are encouraged along with regular check ups and vaccinations. We have plenty of specialty clinics. We run four operating rooms throughout the day. The people get what they need, and if we can't handle it in house, we still finance their care on the outside.

 

The most amazing thing about this is that the per capita costs for participants in the MHS is about $2k less than the national per capita cost. Sure, the patients may have to share a room. Sure the carpet might be old. Sure, we may not have a big fancy atrium and the latest designer furniture. But we have what we need and we spend our money where it matters - on patient care.

 

But what is it like working as a medical provider in this big governmental beaurocracy? I think it is great. There is actually less intrusion between the medical providers and their patients. Need some imaging? Go ahead. Does you clinical judgement say that this patient would benefit from a procedure or operation? Go ahead and do it. You don't have to worry about some insurance company denying or overriding your clinical judgement based on their desire for profits. There are obvious limits to what the system will pay for, but nobody is locked in to just Tricare. We won't pay for your boob job, but you are welcome to go outside the MHS and pay for it yourself.

 

I am not saying the MHS is perfect. It has some flaws, but I have my military insurance and civilian insurance through my wife's job. I can pick and choose where I want to go (a luxury most Americans don't have) and I almost always choose the MHS route. It is faster, better, and cheaper.

 

This whole partisan or ideological notion that anything related to government will be more inefficient is just not true.

[PAMEDIC]

... bans on interstate insurance and other restrictions on competition...

 

 

I see people bring this up and it always cracks me up. First, any insurance company based out of any state can offer insurance in any other state. They just have to be licensed and officially allowed to operate in that state. My insurance through my wife's work is for a job in one state by a company headquartered in another state. It is actually quite common.

 

The reason you want to make sure that these insurance companies have some sort of established relationship in your state has to do with disputes and arbitration. Most of the contract laws that regulate your relationship with your insurance provider are governed by state law. If there is any dispute about payments or their denying care, you want both entities to be in the same legal jurisdiction. Otherwise, they can deny care and you have no legal redress.

[Boatswain2PA]

I work in community hospital in the Military Health System... I think the care we provide is pretty stellar at a fraction of the cost that the private civilian market offers.....

The military is the exception to the inefficiencies of government because there is, generally, a level of accountability found within the strict military rank structure that you will not find in government bureaucracies.  General Shinseki was a great general and a force to be reckoned with, but not even he could crack the government bureaucracy that is the VA.  

[SocialMedicine]

There will always be a shortage in primary care because of the salary and time sacrifice. Also, many people do not like care coordination it is not why they find medicine science interesting. If you SUPER saturate the market with PA MD NP then you might cover all areas of medicine such as rural and other underserved primary care posts. However this could be at the sacrificie of overall quality and other specialties. Just a thought

[Boatswain2PA]

I see people bring this up and it always cracks me up. First, any insurance company based out of any state can offer insurance in any other state. They just have to be licensed and officially allowed to operate in that state. My insurance through my wife's work is for a job in one state by a company headquartered in another state. It is actually quite common.

 

The reason you want to make sure that these insurance companies have some sort of established relationship in your state has to do with disputes and arbitration. Most of the contract laws that regulate your relationship with your insurance provider are governed by state law. If there is any dispute about payments or their denying care, you want both entities to be in the same legal jurisdiction. Otherwise, they can deny care and you have no legal redress.

 

Glad I made you smile.

 

There is always a "reason" for regulation, however those who write the regulations rarely think about the unintended consequences of the new regulation.  I don't know the specifics of the regulations that restrict competition amongst insurance companies, but I would imagine they are many and varied.  If they were not, then more people would start insurance companies and get the huge paychecks (such as was described earlier in this thread).

[andersenpa]

Poor elderly latino in my ED with NSTEMI.  This guy isn't just in the bottom 85 percentile, he is probably in the bottom 5th percentile economically.  Doesn't speak English.  This guy is the poster child for the "underserved" population.  He was diagnosed with NSTEMI, treated, flown to tertiary care, sent to cath lab, 4 stents placed, post tx echo shows minimal wall motion abnormality, now he's back home working on the ranch (the ranch, of course, owned by one of those evil 1 percenters) and supporting the rest of his family who followed him from Mexico.

 

So, tell me about how the "other 85+%" don't get the best health care?

Because you're looking at it from the ass end.

 

The purpose and goals of many of the supporters of UHC are to ensure/mandate universal primary preventive care. Again, look at populations not individuals. If we are more comprehensive as a system at providing screening and cost effective treatments (lipid and HTN management, preventive ASA in your case example) then we would decrease the burden of end stage care for coronary and cerebrovascular outcomes. But we don't do that, and we end up loading the end of the system with procedure-rich treatment (provided by disproportionately compensated specialists). 

 

On a capitated basis, we could have paid a PCP a fraction of the cost of that PCI to prevent multiple adverse cardiovascular events.

[EMEDPA]

In the UK they have it right. PCPs are highly regarded and compensated based on population outcomes while surgeons and subspecialists are considered necessary, but not the rock stars of the system.

[PAMEDIC]

The military is the exception to the inefficiencies of government because there is, generally, a level of accountability found within the strict military rank structure that you will not find in government bureaucracies.  General Shinseki was a great general and a force to be reckoned with, but not even he could crack the government bureaucracy that is the VA.  

 

The biggest problem with the VHA is not that it is a government bureaucracy, but that it exists at all.

 

You know what the British equivalent of the VHA is? They don't have one. Vets use the NHS.

 

But here in the US we have a strange hodgepodge of different governmental organizations that provide fractional care to little slices of the population and don't play well with one another. We have the MHS, IHS, VHA, CMS, etc...

The beauty of the NHS system is it consolidates all of this. It allows for easier communication and disemination of records. It allows for greater longitudinal care without all the bureaucratic hand offs and incompatibilities. It consolidates administrative costs and is able to provide more care to more people at a significantly lower cost.

And with the NHS, you aren't locked into it exclusively. Everybody is guaranteed a base level of care. If you want something more or different, you are welcome to purchase supplemental or private insurance for private care. Want to get that boob job? Don't want to share a room with someone else? No problem. The government just isn't going to be the one to pay for it.

[EMEDPA]

The biggest problem with the VHA is not that it is a government bureaucracy, but that it exists at all.

 

You know what the British equivalent of the VHA is? They don't have one. Vets use the NHS.

 

But here in the US we have a strange hodgepodge of different governmental organizations that provide fractional care to little slices of the population and don't play well with one another. We have the MHS, IHS, VHA, CMS, etc...

The beauty of the NHS system is it consolidates all of this. It allows for easier communication and disemination of records. It allows for greater longitudinal care without all the bureaucratic hand offs and incompatibilities. It consolidates administrative costs and is able to provide more care to more people at a significantly lower cost.

And with the NHS, you aren't locked into it exclusively. Everybody is guaranteed a base level of care. If you want something more or different, you are welcome to purchase supplemental or private insurance for private care. Want to get that boob job? Don't want to share a room with someone else? No problem. The government just isn't going to be the one to pay for it.

yup. the oregon health plan used to do that. need an appendectomy? 100% covered. want brand name zyrtec on rx because you have a runny nose instead of benadryl? pay for it yourself.

[andersenpa]

That problem has nothing to do with our health care ability or system, but rather a cultural issue of getting them to actually come to SEEK care, and protect their children.  This is a cultural problem, not a health care problem.

Again, that IS PUBLIC HEALTH

You can't tease out what you are describing as "cultural" problems from "health care" problems. Health care involves every factor that leads someone to the examination table- access, ethnic barriers, and economic drivers are ALL part of it.

[Boatswain2PA]

Because you're looking at it from the ass end.

 

The purpose and goals of many of the supporters of UHC are to ensure/mandate universal primary preventive care. Again, look at populations not individuals. If we are more comprehensive as a system at providing screening and cost effective treatments (lipid and HTN management, preventive ASA in your case example) then we would decrease the burden of end stage care for coronary and cerebrovascular outcomes. But we don't do that, and we end up loading the end of the system with procedure-rich treatment (provided by disproportionately compensated specialists). 

 

On a capitated basis, we could have paid a PCP a fraction of the cost of that PCI to prevent multiple adverse cardiovascular events.

Prevention doesn't prevent, it only reduces the incidence (which is a good thing, of course).

 

We cannot "ensure" universal primary preventive care, even with a UHC, and we damn well shouldn't "mandate" it.  Some folks are not going to get care (refer back to the population with highest neonatal mortality rate in the US) even if it is free.  

 

If people were responsible for their own health care (ie: they paid for it), they would take better care of themselves and get the preventive care they needed.  

 

In the UK they have it right. PCPs are highly regarded and compensated based on population outcomes while surgeons and subspecialists are considered necessary, but not the rock stars of the system.

 

We can do the same thing here without forcing everyone into a one-size fits all bureaucracy that stifles medical advancements.  

The biggest problem with the VHA is not that it is a government bureaucracy, but that it exists at all.

 

You know what the British equivalent of the VHA is? They don't have one. Vets use the NHS.

 

But here in the US we have a strange hodgepodge of different governmental organizations that provide fractional care to little slices of the population and don't play well with one another. We have the MHS, IHS, VHA, CMS, etc...

The beauty of the NHS system is it consolidates all of this. It allows for easier communication and disemination of records. It allows for greater longitudinal care without all the bureaucratic hand offs and incompatibilities. It consolidates administrative costs and is able to provide more care to more people at a significantly lower cost.

And with the NHS, you aren't locked into it exclusively. Everybody is guaranteed a base level of care. If you want something more or different, you are welcome to purchase supplemental or private insurance for private care. Want to get that boob job? Don't want to share a room with someone else? No problem. The government just isn't going to be the one to pay for it.

 

What do you think the "base level of care" would be if we nationalized the healthcare system?  It would be somewhere below terrible.  Have you tried to call the IRS lately?  I have, they screwed up my 2013 taxes (yes, I said 2013 taxes).  I have spent probably 9 hours on the phone trying to get it figured out and, on the rare chance I get hold of someone, nothing gets fixed.  

 

I'll again use the example of my recent Iraqi war veteran I was trying to get into the VA.  It was a bureaucratical nightmare.  This is how government works today.  If they take over healthcare, it will be an even bigger mess.

yup. the oregon health plan used to do that. need an appendectomy? 100% covered. want brand name zyrtec on rx because you have a runny nose instead of benadryl? pay for it yourself.

The original Oregon Health Plan, laid out by Kitzhaber, would be a terrific model for a national health care SYSTEM.  While working on my MPH I wrote several lengthy papers on how we should use that model.  Unfortunately, like most government programs, the politicians screwed it up.  Funny how that happens every time.....

 

Again, that IS PUBLIC HEALTH

You can't tease out what you are describing as "cultural" problems from "health care" problems. Health care involves every factor that leads someone to the examination table- access, ethnic barriers, and economic drivers are ALL part of it.

One could say that every single thing in your life falls into the realm of "public health", and therefore is ripe for people to use to impose their will upon others.