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Reforming-Americas-Healthcare-System-Through-Choice-and-Competition

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Interesting read. Pretty much what I would expect from a Republican administration (vice a Democrat administration document that would focus on expanding comprehensive healthcare for everyone).

But it does nothing to fix the inherent problem with our health care system, and that is the demand will ALWAYS exceed the supply, so therefore must be rationed.  We should have an open and honest discussion about how we will ration healthcare.  Until we have that discussion, and come to some sort of agreement, our health care system will be a mess.

It doesn't specifically mention PAs very much, but it talks a lot about maximizing scope of practice and reducing unnecessary government imposed restrictions to practice.

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On 12/15/2018 at 10:36 PM, Boatswain2PA said:

Interesting read. Pretty much what I would expect from a Republican administration (vice a Democrat administration document that would focus on expanding comprehensive healthcare for everyone).

But it does nothing to fix the inherent problem with our health care system, and that is the demand will ALWAYS exceed the supply, so therefore must be rationed.  We should have an open and honest discussion about how we will ration healthcare.  Until we have that discussion, and come to some sort of agreement, our health care system will be a mess.

It doesn't specifically mention PAs very much, but it talks a lot about maximizing scope of practice and reducing unnecessary government imposed restrictions to practice.

You mean we can't have it all for free and without any effort on our part?

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1 hour ago, CAdamsPAC said:

You mean we can't have it all for free and without any effort on our part?

Meaning there is NO AMOUNT of effort that could pay for "having it all for free".

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Competition works well for hardware stores. It doesn't work so easy for medical care, unless you are comparing the exact same (and simple) service, such as an MRI scan or maybe a hip replacement. But when you get to the complexities of primary care or general multiple system complaints it is hard to compare apples to apples. Patients would tend to pay for nice providers or providers with simple, confident answers (as some chiropractors give), even if those answers are wrong. The patient, at least at first, would not esteem providers that really changed the outcome of their disease based on hard work, staying informed on the state of the art care that changes outcome. It's complicated.

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To illustrate what I'm saying, I had to fill in for a vacationing family doctor. He was deeply loved by his patients. When I came in, for one week, I found a total disaster in the delivery of care. His patients were very obese and no one had ever addressed it. They smoked, but that was okay, because, believe it or not, the physician smoked too, right in the office. Many of his patients were on narcotics, often for the indication of things like "insomnia." But I remember seeing an obese, smoking, businessman with a blood pressure of about 180/110 and a A1C of >10. He told me that the good doctor was the best he had ever found, he said that was just the way he was and he promised the patient that he would never be on insulin. They loved this doctor and would pay more to see him, yet, the outcomes don't match what a good doctor could deliver.

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To illustrate what I'm saying, I had to fill in for a vacationing family doctor. He was deeply loved by his patients. When I came in, for one week, I found a total disaster in the delivery of care. His patients were very obese and no one had ever addressed it. They smoked, but that was okay, because, believe it or not, the physician smoked too, right in the office. Many of his patients were on narcotics, often for the indication of things like "insomnia." But I remember seeing an obese, smoking, businessman with a blood pressure of about 180/110 and a A1C of >10. He told me that the good doctor was the best he had ever found, he said that was just the way he was and he promised the patient that he would never be on insulin. They loved this doctor and would pay more to see him, yet, the outcomes don't match what a good doctor could deliver.


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We have lost the art of medicine.  We have let it be taken over by MBAs and profit-seekers, and forgot that the patient matters: Body, mind, heart, and, yes, soul.

We (medicine) are losing business to naturopaths who have not one single effective medical treatment, and yet their patients improve ridiculously often given the level of ineffectiveness involved. Why? Because they LISTEN.  They take TIME.

Where can patients get the care and time, coupled with evidence based medicine?  Seriously, where?  The scylla and charibdes seem to be consumerist/customer-satisfaction-driven nonsense like what Mike (jmj11) notes, or the corporate move-the-meat, efficiency-driven asepticism that may never get sued or go bankrupt, but will never be loved or trusted.

I want to BE the middle way.

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8 hours ago, rev ronin said:

 

Where can patients get the care and time, coupled with evidence based medicine? 

low volume practices. Generally rural, but anywhere that a provider can spend the time with a patient that their condition requires. I saw 7 patients yesterday in 24 hours. I am confident that they all got good care, from the pt transferred to a distant tertiary care facility for a pacemaker to the kid with a uri that I see all the time because his parents are nervous nellies. 

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10 hours ago, rev ronin said:

Where can patients get the care and time, coupled with evidence based medicine? 

I can tell you that in my setting (see recent job availability posting) I have this opportunity and the clear support of my off-site SP's/clinic admin since it's all about patient care.  I have no axes to grind because I'm not their PCP, and it doesn't keep me from offering education and non-biased recommendations for chronic health issues though I won't be the one treating them.  An example, I had an older teen a couple weeks back on multiple meds for hypertension yet according to her hx. no one had looked into a reversible cause!  I gave her some information, went through a differential list to give her ideas as to other causes, and then provided a name for a local cardiologist who I know would work the problem and not just dismiss with a diagnosis of essential HTN.  All this for $10.

Edited by GetMeOuttaThisMess
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5 hours ago, EMEDPA said:

low volume practices. Generally rural, but anywhere that a provider can spend the time with a patient that their condition requires. I saw 7 patients yesterday in 24 hours. I am confident that they all got good care, from the pt transferred to a distant tertiary care facility for a pacemaker to the kid with a uri that I see all the time because his parents are nervous nellies. 

Parents, who consume "healthcare dollars" needlessly for their lack of insight? Exactly what is the treatment for a "URI" and the indication for an office or ED visit? This is a prime example of why so much money is spent "on healthcare" in America. The populace needs to learn and understand the use of resources appropriately and THEIR role in addressing these non-conditions by seeking professional care!

 

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Parents, who consume "healthcare dollars" needlessly for their lack of insight? Exactly what is the treatment for a "URI" and the indication for an office or ED visit? This is a prime example of why so much money is spent "on healthcare" in America. The populace needs to learn and understand the use of resources appropriately and THEIR role in addressing these non-conditions by seeking professional care!  

 

Nevermind. Tapatalk deleted the body with an edit.

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8 minutes ago, GetMeOuttaThisMess said:

Here is my justification for such a visit in our $10 admin fee clinic.  Yes, while it drives me nuts for us to see kids <4 y/o for whom there is not a recommendation for decongestants (age 6 or greater), nasal steroids (age 4 or greater), or an effective medically proven cough suppressant, so all you get is cetirizine for a snotty nose which won't help either because it isn't an allergic response; I justify it with the parent as being a quick "check under the hood" to make sure that the cough isn't a pneumonia.  Son-of-a-gun if I didn't pick one up two weeks ago tomorrow on a kid that was looking/acting just like every other adult/kid with a typical head/chest cold.  Heard the "rice crispies" the moment I put the stethoscope on their chest.  No fever, happy as a clam, it didn't clear with coughing, and was reproducible after moving away and coming back to the LLL.  Normally my initial response is "Why are we seeing them for the 4th time in 12 months for the same thing?"  I guess it pacifies me while I'm waiting to go in.  I know Peds see more than this but it is their bread and butter along with OM but I swear if someone figures out how to keep a eustachian tube open aside from stunting it, many would be out of business.

I understand your logic, my post was in response to     "to the kid with a URI that I see all the time because his parents are nervous Nellies.  " I've lost count on the numbers of "worried well" visits sprinkled with the rare occult sick kid, but there are far too many needless visits for the not indicated antibiotics and specialty referrals "to be sure". There has to be an end point established for these visits.

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last night I gave them a bulb syringe and a dose of ibuprofen and instructions to see the pcp prn. 

 

You can’t do this!!!! A bulb syringe!? “But they don’t like it when we use it!” I hear the chopper blades in my head right now.

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15 minutes ago, EMEDPA said:

they refused the ibuprofen because "he won't take oral medicine, just shots or suppositories...."

there's some pathology going on here.........

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On 12/22/2018 at 2:11 PM, jmj11 said:

To illustrate what I'm saying, I had to fill in for a vacationing family doctor. He was deeply loved by his patients. When I came in, for one week, I found a total disaster in the delivery of care. His patients were very obese and no one had ever addressed it. They smoked, but that was okay, because, believe it or not, the physician smoked too, right in the office. Many of his patients were on narcotics, often for the indication of things like "insomnia." But I remember seeing an obese, smoking, businessman with a blood pressure of about 180/110 and a A1C of >10. He told me that the good doctor was the best he had ever found, he said that was just the way he was and he promised the patient that he would never be on insulin. They loved this doctor and would pay more to see him, yet, the outcomes don't match what a good doctor could deliver.

I recall a study of outcomes based on patient satisfaction scores concluding these scores don't correlate with good care or outcomes. This sounds like this physician's practice is confirmatory data point!

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So I was ruminating on this topic more, and it hit me:

We (medical providers, NOT coroporate medicine) should do a study on length of visits vs. a representative set of long-term outcomes.  Say BMI, BP, and A1c.  Maybe throw tobacco use in, too.  My hypothesis would be that the more time clinicians actually get to spend with patients, the more likely good outcomes will be.  It may not be earth-shaking, but it would be a step in the right direction.

And we already have some subset of brand-new PAs who buy into the urban legend that we get to spend more time with patients.  They're ready, willing, and eager to do this, only to be smacked with the cold, hard reality upon graduation that in most primary care contexts you are responsible for 100% of what an MD does, reimbursed at 85%, and paid at 35%.

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I think patients would also be more likely to comply with tx plans for life style change, med management, etc if clinicians spent more time with them explaining WHY they need to take metformin, and yes, it may cause a little diarrhea for a few days, but that is usually self-limited, etc

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My party line is that I am a conduit of information for the patient to access so they may make informed choices about their health. In Arabic physician and teacher is the same word. We often do not have the time to sit with a patient and v"educate" them about their condition and treatment options. Reality is that we are used for pushing through the masses and maximize billing and Press Gainey scores for our corporate money masters.

 

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53 minutes ago, CAdamsPAC said:

My party line is that I am a conduit of information for the patient to access so they may make informed choices about their health. In Arabic physician and teacher is the same word. We often do not have the time to sit with a patient and v"educate" them about their condition and treatment options. Reality is that we are used for pushing through the masses and maximize billing and Press Gainey scores for our corporate money masters.

Right.  So let's change that.  Not really realistic or reasonable to do so, but as has been pointed out elsewhere, reasonable people don't change the world for the better.

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3 hours ago, rev ronin said:

Right.  So let's change that.  Not really realistic or reasonable to do so, but as has been pointed out elsewhere, reasonable people don't change the world for the better.

or just go to a place with low volume that allows YOU THE PROVIDER to decide how much time to spend with your patients. If enough of us do this and avoid abusive move the meat practices, maybe the culture and expectations will change slowly over time. ditto refusing to take low paying jobs, etc

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11 minutes ago, EMEDPA said:

or just go to a place with low volume that allows YOU THE PROVIDER to decide how much time to spend with your patients. If enough of us do this and avoid abusive move the meat practices, maybe the culture and expectations will change slowly over time. ditto refusing to take low paying jobs, etc

That's what I did when I left the ED.  Got tired of being on the holiday hamster wheel.  Heaven help those of you working New Year's Day with all those looking for work notes so that they don't have to go in the next day.

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1 hour ago, EMEDPA said:

or just go to a place with low volume that allows YOU THE PROVIDER to decide how much time to spend with your patients. If enough of us do this and avoid abusive move the meat practices, maybe the culture and expectations will change slowly over time. ditto refusing to take low paying jobs, etc

Been there, done that, and I'm not having an impact on much outside my sphere.  I seriously do want to pursue EBM-like approach to take back market share from quacktitioners and time per patient from MHAs.

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