Are we imploding?

[ventana]

I sit on a plane going on vacation trying to ponder life and my career. 
 

employer hires new grads at 115k

i make only a little more then this with 20 yrs out functioning as a fully boarded doc

senior people are quitting 

union is being invited in

docs quitting left and right 

company complaining about loosing money but downcoding my visits 

have passed up two job offers from other likely toxic work places 

friends in medicine all dislike jobs and or burnt out

many friends in other fields like engineers lawyers are happy.
 

 i am really starting to think the entire medical machine is approaching melt down.   What happens when enough of us leave medicine, enough rural hospitals get cbought and closed by for profit companies, when there no longer is speciality care anywhere but big cities, and most concerning -when companies blindly think that hiring a new grad to replace a 20+ yr clinician or even a specialist doc is somehow a wise decision. 
 

I am really starting to think our whole system is on the brink of failure.   
but I bet health insurance companies and hospital systems will do just enough to keep going to protect their own future. 
 

sadly part of me hopes the system just implodes and we get a reasonable safety net single payer system because the system we have does not work.  
 

thoughts?  

[EMEDPA]

I think single payer or national health service is where we are headed. Every other devloped nation in the world uses that model and it results in better health care outcomes for the vast majority of people. Yes, you may have to wait for your elective knee replacement, but you won't die because you can't afford your insulin...

[rev ronin]

14 minutes ago, EMEDPA said:

I think single payer or national health service is where we are headed. Every other devloped nation in the world uses that model and it results in better health care outcomes for the vast majority of people. Yes, you may have to wait for your elective knee replacement, but you won't die because you can't afford your insulin...

I completely disagree--that is I agree there's a problem, but would solve it in a completely opposite manner.   I think a DPC model is the way to go, probably paired with Mark Cuban's Cost Plus Drug company. We need LESS bureaucratic interference, not more.  Looking at the FDA's approval process for cancer drugs and alzheimer's boondoggles, it's clear that we need to absolutely reform the approval process, and probably intellectual property laws too. I've gotten so sick of substitute endpoints and "best practices" that aren't. We know how to do EBM, and yet we don't use it. We do things with an NNT of 50+ and get our messaging muddled by whichever company last bought us lunch.

One of my goals is to never again have patients sent to me by their insurance. Rather, I hope to care for only those people who've chosen me for care, knowing my philosophy and approach to care. We need to stop focusing on things just because they can be measured, and instead focus on holistic care that treats patients as bio/psycho/social/spiritual entities, not just BMI, BP, and A1c.

[kettle]

23 minutes ago, EMEDPA said:

Every other devloped nation in the world uses that model and it results in better health care outcomes for the vast majority of people. Yes, you may have to wait for your elective knee replacement, but you won't die because you can't afford your insulin...

I disagree 

Yea wait 3 yrs for knee surgery in Canada and 6 yrs in the UK. Rural medicine in Canada is seeing ERs shut down due to no providers. Seeing an influx of providers and nurses in boarder states moving down from Canada to work for far higher wages here. Friends teen boy broken arm, drive 4 hrs to a hospital because the one an hr away is shut down or wait 4 days just to get xrays. Good friend of mine passed due to not being able to get chemo. Grass is not always greener.  

I wholeheartedly agree no one should die from not getting insulin. 

There is no perfect system or solution.

 

 

[EMEDPA]

Base it on one of these and you are likely to do better than the Canadian system:

https://www.expatriatehealthcare.com/the-top-10-healthcare-systems-in-the-world-2022/

[ventana]

Please go read the world health rankings for the USA.  We are truly terrible. 
 

I think the only way forward is strongly regulated single payor.  
 

two patients this week delayed by >6 months their office visit to Dx breast cancer due to money.  Clinic is always slow in Jan due to deductibles.   
we stink in caring for our citizens but healthcare and big corporations pharma are some of the biggest most profitable on the exchanges.    
 

 

 

what about what the system is doing to the most valuable assets??   The people   The docs, PA, NP,RN, LPN, CNA   
no way I would work as a cna for the same money I could get literally anywhere else   $15/hr (or less) to clean up, feed, scoop poop and all that comes with it is just insane    
burnout is real   Compassion fatigue is real   
 

what are the options   ????

 

[ohiovolffemtp]

I'd like to see a serious factor analysis of the cost of medical care.  Specifically:

• what percent of the cost of medical care is the result of the battles between providers and payers until payment happens.  When I see the number of employees needed for medical billing and the size of the profits of payors, I suspect that there's a way bigger percentage here than is needed.
• what percent of the cost of medical care is the result of the whole medical malpractice system: the cost of med mal insurance, the med mal claims process where at least half of the total $ spent goes to attorneys and the legal system vs compensating patients who actually were harmed.
• what percent of the cost of medical care is the result of bloated healthcare administration.  In any hospital system, what is the ratio of employees providing patient care or relevant ancillary services like housekeeping, dietary, pharmacy, etc, vs managers, educators, etc.
• what percent of the cost of medical care is spent in the last few months of life vs having a process that really promotes having goals of care discussions with patients and their families.

I don't think having a single payer system will address much of this other than lessen the 1st somewhat.

[EMEDPA]

Single payor NHS type arrangements generally cover malpractice unless one was grossly negligent. 

• "what percent of the cost of medical care is the result of bloated healthcare administration.  In any hospital system, what is the ratio of employees providing patient care or relevant ancillary services like housekeeping, dietary, pharmacy, etc, vs managers, educators, etc."

In my doctoral program we talked a bit about the parking lot model of hospital management. Record license plates of all cars in the parking lot every night at 7 pm and every weekend several times a day as well as on every holiday. Also monitor who arrives by bus or public transit during these times. Anyone who never is there after hours, on a weekend, or on a holiday is not an essential worker. They are all the upper level  9-5 admin types and the hospital runs perfectly well without them. Start your cuts there, not with the techs, janitors and food service workers who actually contribute to the running of the facility in a meaningful way. ....

 

[rev ronin]

31 minutes ago, ohiovolffemtp said:

I'd like to see a serious factor analysis of the cost of medical care.  Specifically:

• what percent of the cost of medical care is the result of the battles between providers and payers until payment happens.  When I see the number of employees needed for medical billing and the size of the profits of payors, I suspect that there's a way bigger percentage here than is needed.

The number I've heard for this is 30% of all medical spending. Don't know if that's accurate or not, but it seems right.

[CAdamsPAC]

18 minutes ago, EMEDPA said:

Single payor NHS type arrangements generally cover malpractice unless one was grossly negligent. 

• "what percent of the cost of medical care is the result of bloated healthcare administration.  In any hospital system, what is the ratio of employees providing patient care or relevant ancillary services like housekeeping, dietary, pharmacy, etc, vs managers, educators, etc."

In my doctoral program we talked a bit about the parking lot model of hospital management. Record license plates of all cars in the parking lot every night at 7 pm and every weekend several times a day as well as on every holiday. Also monitor who arrives by bus or public transit during these times. Anyone who never is there after hours, on a weekend, or on a holiday is not an essential worker. They are all the upper level  9-5 admin types and the hospital runs perfectly well without them. Start your cuts there, not with the techs, janitors and food service workers who actually contribute to the running of the facility in a meaningful way. ....

 

"Suits" the highest paid hospital employees who do not contribute to the delivery of patient care need to go! I am still waiting for an accounting of the billions of disaster preparedness funds granted to hospitals over the years, and the adject failure demonstrated during the COVID-19 pandemic! Why didn't the facilities have stockpiles of required items and plans to properly distribute them? We need to get the "B School" folks out of health care! The current focus of nationwide healthcare operations is to comply with governmental policies and regulations.

[kettle]

To touch some on the original post. I do think your wage compared to new grads isn't fair but that is not everywhere. First year out of residency 250k, 125k w2, 125k 1099. I average 180-200 hrs a month predominantly in 48-72 hr blocks. So I have about 22 days off a month. There is good for some of us and lot of it is specialty and location based.

Regarding big pharma, do I think their profits are too high? Yes? We did give them a lot of money recently and for a good cause. Without pharma we wouldn't have nearly the medical advancement, they are profit driven, their results help us and I don't think sole government based research would be as effective. Double edge sword.

[CAdamsPAC]

25 minutes ago, EMEDPA said:

Single payor NHS type arrangements generally cover malpractice unless one was grossly negligent. 

• "what percent of the cost of medical care is the result of bloated healthcare administration.  In any hospital system, what is the ratio of employees providing patient care or relevant ancillary services like housekeeping, dietary, pharmacy, etc, vs managers, educators, etc."

In my doctoral program we talked a bit about the parking lot model of hospital management. Record license plates of all cars in the parking lot every night at 7 pm and every weekend several times a day as well as on every holiday. Also monitor who arrives by bus or public transit during these times. Anyone who never is there after hours, on a weekend, or on a holiday is not an essential worker. They are all the upper level  9-5 admin types and the hospital runs perfectly well without them. Start your cuts there, not with the techs, janitors and food service workers who actually contribute to the running of the facility in a meaningful way. ....

 

I've read far too many reports/stories about the impending collapse of the UK's NHS. I don't think the American public in general is willing to have a significant overhaul in delivery of care which limits, reduces or extends wait times, not to mentions rations care as in no end stage anything ICU admissions or 20-week preemies in the NICU, THA/TKA for 80+ year old pts.

[ventana]

13 minutes ago, CAdamsPAC said:

I've read far too many reports/stories about the impending collapse of the UK's NHS. I don't think the American public in general is willing to have a significant overhaul in delivery of care which limits, reduces or extends wait times, not to mentions rations care as in no end stage anything ICU admissions or 20-week preemies in the NICU, THA/TKA for 80+ year old pts.

Strange perspective.  Instead we tolerate one of the highest mortality rates around north of any first world county.  When you look at population based health we are at the very bottom of first world countries.  Seriously we stink. 
 

this whole “our system is great” is cool aide fed to us by insurance, pharma and hospitals.  Our system is horrible.  Please go read WHO rankings.  
 

Privet insurance runs about 28-30% expense ratio.  
medicare runs something like 2-3%

Last I read some 10 years ago government already pay for some merging like 60% of care in the country. (Adding up Medicare Medicaid VA and other state funded programs.)

 

government is looking into the Medicare advantage plans as she many abuses 

 

I hate to say it but if you are not for a single payor system you are not well informed educated or read.   Did you know the “donut hole” would not exist if they allowed the government to negotiate drug prices?  They would have saved enough to fund the entire donut hole. We know this factually as they compared the VA cost of drugs versus what they paid.   
 

please read WHO rankings of first world national health care rankings.   We are close to or at the bottom in every catagory except one.   Which happens to be per capita spent where no other country was even close. By something like 30-50%a few years ago. 

[iconic]

your employer is starting new grads at a very decent salary. Here in FL they try to lowball new grads at 80k or less. 
 

As for healthcare system imploding, of course it is, and maybe that’s not such a bad thing as it is completely unsustainable the way it is heading

[kettle]

11 minutes ago, ventana said:

 

I hate to say it but if you are not for a single payor system you are not well informed educated or read.   Did you know the “donut hole” would not exist if they allowed the government to negotiate drug prices?  They would have saved enough to fund the entire donut hole. We know this factually as they compared the VA cost of drugs versus what they pay

Hmmm blanket statement implying ignorance if we don't agree? Solid argument.

I am baseing my information on material read as well as first hand knowledge of close friends in both Canada as well as the UK. Yes, I've read the world health rankings both of those countries listed above us in those rankings. 

A perfect example of government run healthcare is on the American Indian reservations in rural America. I drive past an IHS hospital often. They get over 30 patients a day in the ER, and 60 in UC. They have an Xray machine, no CT scanner and no ultrasound. They don't have the funding for a CT machine, which is the standard of care.

There's a lot to America outside of the cities and suburbs and I feel our perspective differs based on this

Edited January 15, 2023 by kettle

[iconic]

2 hours ago, rev ronin said:

I completely disagree--that is I agree there's a problem, but would solve it in a completely opposite manner.   I think a DPC model is the way to go, probably paired with Mark Cuban's Cost Plus Drug company. We need LESS bureaucratic interference, not more.  Looking at the FDA's approval process for cancer drugs and alzheimer's boondoggles, it's clear that we need to absolutely reform the approval process, and probably intellectual property laws too. I've gotten so sick of substitute endpoints and "best practices" that aren't. We know how to do EBM, and yet we don't use it. We do things with an NNT of 50+ and get our messaging muddled by whichever company last bought us lunch.

One of my goals is to never again have patients sent to me by their insurance. Rather, I hope to care for only those people who've chosen me for care, knowing my philosophy and approach to care. We need to stop focusing on things just because they can be measured, and instead focus on holistic care that treats patients as bio/psycho/social/spiritual entities, not just BMI, BP, and A1c.

The wheel doesn’t need to be reinvented. Germany has a lot more boomers and does a better job with healthcare. You can still opt out of the government insurance and continue with your DPC (although it doesn’t have to be limited to primary care). Every country with socialized healthcare still has a private only sector. 
 

I think we are a long way out from single payer, but besides that there are many reforms that could be undertaken to improve the situation such as tort reform. Nowhere else in the world do you have billboards with lawyers advertising how much money they have leeched off from healthcare workers 

Edited January 15, 2023 by iconic

[CAAdmission]

If you go single payer, you are giving some entity a big monopoly over the healthcare system.

My fear is that this entity will be greedy, stupid, or both. 

[CAdamsPAC]

54 minutes ago, ventana said:

Strange perspective.  Instead we tolerate one of the highest mortality rates around north of any first world county.  When you look at population based health we are at the very bottom of first world countries.  Seriously we stink. 
 

this whole “our system is great” is cool aide fed to us by insurance, pharma and hospitals.  Our system is horrible.  Please go read WHO rankings.  
 

Privet insurance runs about 28-30% expense ratio.  
medicare runs something like 2-3%

Last I read some 10 years ago government already pay for some merging like 60% of care in the country. (Adding up Medicare Medicaid VA and other state funded programs.)

 

government is looking into the Medicare advantage plans as she many abuses 

 

I hate to say it but if you are not for a single payor system you are not well informed educated or read.   Did you know the “donut hole” would not exist if they allowed the government to negotiate drug prices?  They would have saved enough to fund the entire donut hole. We know this factually as they compared the VA cost of drugs versus what they paid.   
 

please read WHO rankings of first world national health care rankings.   We are close to or at the bottom in every catagory except one.   Which happens to be per capita spent where no other country was even close. By something like 30-50%a few years ago. 

You are correct, but I feel to truly improve the system major changes in the delivery of care must occur. I do believe that POGO said it best 50+ years ago " we have met the enemy and it is us". What do we want and what are we willing to pay/do to get it? Like so much of this country the people have abrogated their responsibilities and control of our lives to the lawyers, MBAs and career government bureaucrats.

Edited January 15, 2023 by CAdamsPAC

[CAdamsPAC]

6 minutes ago, CAAdmission said:

If you go single payer, you are giving some entity a big monopoly over the healthcare system.

My fear is that this entity will be greedy, stupid, or both. 

Or in reality into it for themselves........No one gives up power in your best interest, they seize it and claim it is for your good!

[SedRate]

4 hours ago, ventana said:

I sit on a plane going on vacation trying to ponder life and my career. 
 

employer hires new grads at 115k

i make only a little more then this with 20 yrs out functioning as a fully boarded doc

senior people are quitting 

union is being invited in

docs quitting left and right 

company complaining about loosing money but downcoding my visits 

have passed up two job offers from other likely toxic work places 

friends in medicine all dislike jobs and or burnt out

many friends in other fields like engineers lawyers are happy.
 

 i am really starting to think the entire medical machine is approaching melt down.   What happens when enough of us leave medicine, enough rural hospitals get cbought and closed by for profit companies, when there no longer is speciality care anywhere but big cities, and most concerning -when companies blindly think that hiring a new grad to replace a 20+ yr clinician or even a specialist doc is somehow a wise decision. 
 

I am really starting to think our whole system is on the brink of failure.   
but I bet health insurance companies and hospital systems will do just enough to keep going to protect their own future. 
 

sadly part of me hopes the system just implodes and we get a reasonable safety net single payer system because the system we have does not work.  
 

thoughts?  

You're not alone.

Glad to hear new grads are getting paid well. Unfortunately, I think it's in part due to naivete of the employer side. Either because A., They're not doing a market analysis, B. They're trying to pay people well, or C. They're unaware that new grads need time, support and training -- instead they're likening PAs to docs who don't usually have much variation in pay with the exception of maybe bigger cut due to partnership, more RVUs due to efficiency, bigger bonuses due to seniority, etc. (I spoke with a surgeon new out of residency recently who was surprised to hear my discontent with getting paid the same amount as a colleague with a fraction of my experience. He said surgeons all get the same call pay and reimbursement whether they're brand new outta residency or 20 years in, so why shouldn't PAs?)

As for your other comments, yes, I think it's imploding. My spouse works in business with an econ background, and we talk about this frequently. Medicine in the US is for-profit no matter which way you look at it (except for perhaps govt programs), and thus, a business. Medical businesses cannot be successfully run the way we medical providers think they should unless perhaps they're a DPC. My spouse advocates a single payer and a private insurance option, byebye insurance companies, and revamp hospitals. I think things need to be controlled/checked to some extent. Medical debt is the biggest contributor to bankruptcy in the US. Things have needed to change for a while now.

I dislike corporatized medicine. I have half the mind to start my own practice but man, there's just so much going on in healthcare right now. And not a lot of positive things...

People also need to be actively engaged in their health and wellbeing and take personal responsibility for their health, and then maybe we wouldn't have such a big health problem... But I digress...

Edited January 15, 2023 by SedRate

[Boatswain2PA]

There is no fix for our system.  Americans demand perfect health, including immediate fixes for problems, despite being immensely overweight, sucking on 44 Oz cooler cups full of Dr. Pepper between drags off our cigarette while riding our "mobility scooter" with the oxygen generator hooked to the back of it.  Now add the cultural components, such as the population with highest fetal/maternal deaths is the same population with lowest education, lowest trust in healthcare system, and one of highest in (hard) drug abuse.  Then add in the ravages of heroin, and the scourge of methamphetamine that is effectively ignored by our criminal justice system.  And top that off with our growing tolerance to near-constant cannabis use that saps the socio-economic drive out of sooooo many people. (But hey, it's MEDICAL Marijuana edibles, so that's okay man....and there is no way THAT is why I just randomly have violent vomiting episodes....cause that HELPS!).

This is a vastly different population from anywhere in the world.

We can try (and are moving towards) single-payor system (with carve outs for upper clasd citizens, as always), but that's not going to fix anything.  It might take away Ascension CEO's $13.5million a year paycheck, but will just spread it amongst 35 new mid-level government bureaucrats who can't be fired.

[iconic]

59 minutes ago, CAAdmission said:

If you go single payer, you are giving some entity a big monopoly over the healthcare system.

My fear is that this entity will be greedy, stupid, or both. 

No more greedier than the insurance companies, big pharma, and C-suites.

I would like to see politicians do ANYTHING useful. I don't expect them to take on insurance companies that they are paid by. But why can't they get the price of insulin down? Someone needs to deregulate the FDA so we can import drugs from abroad ffs..

 

I will say that I am very proud of nurses speaking out and trying to push for some changes. Where are the physicians and where are the PAs in this conversation?? Ultimately, physicians were the ones who sold out control to corporate practice of medicine while being hyper-focused on non-existent issues such "midlevel scope creep"

Edited January 15, 2023 by iconic

[rev ronin]

57 minutes ago, CAAdmission said:

If you go single payer, you are giving some entity a big monopoly over the healthcare system.

My fear is that this entity will be greedy, stupid, or both. 

Or worse, efficient and utilitarian like, you know...

[CAdamsPAC]

1 minute ago, rev ronin said:

Or worse, efficient and utilitarian like, you know...

A system that won't pour good money after bad results?

[rev ronin]

Just now, CAdamsPAC said:

A system that won't pour good money after bad results?

No, one that said the "Lebensunwertes Leben" part out loud.