See The Article: Why? What can we do about it?

[jmj11]

See this new article.

This seems to be the same old story, America spends more on healthcare than any other country, yet our results are not that good. It is a multifactorial problem, but can we do better, and PAs could lead the way ... perhaps?

 

[Boatswain2PA]

1. Close the borders so fentanyl and meth don't come across.

2. Stop glamourizing drug use.

3. Stop glamourizing violence.  (Yeah, rap music).

4. Enforce drug and firearm laws.

5. Don't count the "healthcare expenditures" on botox, etc.

 

 

 

Edited January 31, 2023 by Boatswain2PA

[CAAdmission]

Most Americans are emotionally dysregulated. They think they have a right to be happy all the time and if they are not they demand pills to make them so. They demand a pain free life, again with the pills. They also lack any sense of personal responsibility for their own health and eat and drink themselves to death. Finally, they refuse to accept the fact of their own mortality and spend enormous sums to add a few low-quality days or weeks to the end of their lives. 

The healthcare system cannot fix this. In fact, as a profit driven system, it is set up to encourage it. 

Edited January 31, 2023 by CAAdmission

[SedRate]

Agree that it's an incredibly complex, multifaceted problem. And I'm going to just say it: America needs a complete societal and culture overhaul. Instead of becoming more advanced and healthy, we're declining. Things need to change. 

Suggestions/anecdotes:

Limit ads for fast food, beer/liquor, soda, and excessive portions. High schoolers should be taught basic personal finance. (Hell, I was taught in elementary school and got my first savings account as a child.) The whole concept of the 40-hour workweek; limited sick, PTO, and maternity/paternity leave; and health insurance being tied to employment needs to go. People need more rest, more time to recover from illness, more time being active, more time outdoors (suggested to increase happiness; bonus points for outdoor activity), and more meaningful time with family/friends. Deep social ties and fulfillment/meaning are suggested as some of the important factors to happiness, so we should encourage that. Further, this whole instant gratification and constant stimulus with ads/marketing to consume and waste, Insta-delivery, fast food, everything geared towards convenience, etc, needs to be reexamined. We're all so busy and tired to even begin taking inventory of all these little things that add up. Also, we need to check the use of industrial corn in the meat and food industry. Why are animals being fed food they're not naturally meant to consume, fed super-sized portions, and bred for increased palatability? (Check out The Omnivore's Dilemma: The Natural History of Four Meals.) We need to learn about healthy portions and set examples for our children and peers. This goes for exercise too -- no more sitting on the sideline while kids play their sport. Join! Also, the whole idea of stopping work at 65+ needs to stop being glorified -- a fixed income with an aging and increasingly unhealthy population doesn't go very far. Healthful living should be instituted at an early age, not in our mid-age when inflammation, weight gain, high cholesterol, hypertension, etc, have already started to take effect. 

There's much more to it but I think I'll stop here for now. As for our role as PAs? We can all lead the way and set good examples for our pts, peers, and families. We can encourage and support all to take control and personal responsibility for our lives and health. We can continue to engage with one another and make efforts to improve our work culture and environment. 

As an aside, check out the book Rigor Mortis, which talks about biomedical science and research and the lack of "rigor" which has led to misleading data, lackluster cures, and billions in wasted funding. Definitely a must-read for anyone who reads research articles.

[SedRate]

9 hours ago, CAAdmission said:

The healthcare system cannot fix this. In fact, as a profit driven system, it is set up to encourage it. 

^100%

[ventana]

Single payer

parity in primary care reimbursement.   MD=NP=PA

federal supported 16-18 m fellowships for PA/NP so you can hit ground running 

fixed pricing on all drugs. Set at 150% of the going rate in first world countries 

eliminate out of network billing   
 

establish universal reimbursements for covered procedures    

and all the topics as above. 

[ventana]

Commonwealth fund just released this.  We are the very bottom crept for dollars spent per person and percentage of gdp.  Sad. 

[Boatswain2PA]

Single payor would do nothing to improve our outcomes.  Measurements?  Yes.  Yeah, we would track more A1C and lipid panels for more healthy people, but actual outcomes like maternal health?  Nope.

The population that drives our poor maternal health is the population that wouldn't take advantage of a single payor/universal health care system.  Wanna know why I say that?  Because we already HAVE (near) universal coverage for pregnant women.  (and if that isn't the right term for people born with a uterus and get pregnant...then that is also a prime driver of WTF is wrong with us). 

What would pay parity between FP docs, PAs and NPs do?  Nothing, other than destroy family physician career paths.  Why take the HARD classes in undergrad (physics, Ochem, biochem), then study hard for the MCAT, then 4 years of med school, then years of residency to make the same pay as someone who wrote nursing theory papers for 4 years of undergrad, then another 2 years of online courses part time and 500 hours in their friends botox clinic?  

It would just destroy the leaders in primary care.  Sounds like a Bernie Sanders idea to me.

And let's fix all drug prices.  And if we are going to fix those prices, let's go full on Bernie....and fix that price at $1.  For everything.  Every drug, for everyone in the world.  I mean, come on man.....people need their medications.

And we will then experience a complete and total shutdown of all research and development.  No more new chemo drugs.  No more new MABs for pulmonary fibrosis.  No more new nuthin.  But hey....what we have works well, and it'll only be $1.

Anyone with any understanding of history understands how absolutely screwed up things get when the government comes in and "fixes prices".  It is exactly how we are in the whole "healthcare insurance" mess we are in now.  Unfortunately, most people don't have a clue about history....

Eliminating out of network billing would be an absolute BOON to the health insurance companies (almost as great of a boon as the government requiring everyone to purchase their inflated product).  Imagine if the government told hospitals/docs that they couldn't bill patients for ANYTHING unless their healthcare insurance company said they could.  Insurance companies would then hold literally EVERY card when it comes to negotiating reimbursements.

Yeah....let's not do ANY of those ideas.


 

[ventana]

Boats. You are off the deep end. 
 

not even going to engage as your logic has no logic.  Extrapolation to an extreme endpoint is merely fear mongering.  Nothing more. 
 

 

[Boatswain2PA]

It's emotionally difficult to have ones utopian feelins crushed by reality.

[rev ronin]

12 hours ago, Boatswain2PA said:

What would pay parity between FP docs, PAs and NPs do?  Nothing, other than destroy family physician career paths.  Why take the HARD classes in undergrad (physics, Ochem, biochem), then study hard for the MCAT, then 4 years of med school, then years of residency to make the same pay as someone who wrote nursing theory papers for 4 years of undergrad, then another 2 years of online courses part time and 500 hours in their friends botox clinic? 

I just argued in favor of NP/PA reimbursement parity.  Here's the bulk of my written testimony:

As a physician assistant (PA) who owns a small occupational medicine clinic, I am economically disadvantaged in several ways:

- As a PA, I cannot perform the full range of services a physician can. For example, FAA pilot physicals and permanent disability ratings are restricted by law to physicians. Every week I refer my patients to physicians, especially surgeons, for care beyond my scope of practice. Such physician-only services have an appropriately higher base fee.

- I pay a monthly fee to my supervising physician. PA practice owners regularly pay one to two thousand dollars a month for physician oversight that does not contribute to practice revenue.

- When billing insurers, I am paid a fraction of the physician fee for the same service. With respect to Labor and Industries injured worker care, that fraction is 90%.

- My medical supplies, office space, utilities, and employee expenses do not cost less than that of a physician. On the contrary, as a small practice, I cannot buy in bulk so an economy of scale works against me.

There is no different standard of care for services provided by a physician assistant (PA) rather than a physician. I am held to the same standards by the medical commission that oversees both physicians and PAs, and I carry the same level of malpractice insurance. The public has the right to expect the same level of competence and professional care from PAs as physicians, and I and other PAs deliver that daily, all across this state. Right now, we do that at a discount.

This bill simply requires insurers to provide equal pay for equal work.

 

[LKPAC]

18 hours ago, ventana said:

Single payer

I can't agree.  My most demanding, entitled patients are those who get their healthcare for "free" from the government.

Patients need some skin in the game.

[Reality Check 2]

Bottom line for me - The US is crisis medicine, not preventative medicine and too litigious.

Other cultures and countries promote wellness and prevention - and, yes, universal healthcare plays a big role.

The US works longer weeks, more hours, less benefits, less vacation and less parental leave than all of the countries in Europe. 

We have a societal attitude of Grab What You Can entitlement and complete lack of self responsibility.

The solution will take decades but won't happen with our political climate and divisiveness as well as the wealth disparity. 

I don't know what the answer is or where to start. America has been dumbed down and there is no critical thinking.

 

[EMEDPA]

From a global health perspective I would like to mention a few options that have worked elsewhere. These will be unpopular suggestions here, I imagine

1. Phase out smoking entirely. New Zealand just did it. https://www.nytimes.com/2022/12/14/world/asia/new-zealand-smoking-ban.html#:~:text=The new laws are aimed,number of licensed tobacco retailers.

2. Tax the hell out of cigarettes, alcohol, marijuana (where legal), and foods that are known to be bad for health (high sugar and salt content). At the same time subsidize healthy foods(plant based, lean meats, fish, etc). 

3. Make vaccinations and non-hormonal birth control 100% free. People are going to have sex. Abstinence for the general population is not a viable option. Want to prevent abortion? Prevent conception. 

4. Invest in primary care infrastructure so that providers want to go into primary care. Pay based on outcomes as well as on procedures. A FP physician should make as much as an orthopedist. Yes, this means ortho docs are currently overpaid. 

5. Build and support social infrastructure. Build sustainable communities of small homes.  No one should lack housing and food, heat, etc who has a job. 

6. Support children to become good citizens. Support parents who have just had a child.

7. Support and honor the elderly. We will all be there someday if we are lucky. 

8. mandate pharmacy corporations to sell their meds for the same price here that they do elsewhere. I am not saying $1 RXs across the board, but it is ridiculous that I can buy a case of brand name ventolin albuterol inhalers in Haiti for the same price as a single inhaler here. No one should die because they can't afford their insulin. 

9. Guarantee basic health care for every American. Medical bankruptcy should not be a thing. Someone who works 40 hrs a week should not lose their house over a ruptured appy. 

10. Reform the mental health system. There should be enough providers to help those with real metal health issues or those seeking detox. 

11. Reform the prison system. It should not be a for-profit system. We have too many people per capita locked up.  There should be a pathway for nonviolent offenders to re-enter society and have a chance for a real life. 

12. fix 10 and 11 above and a lot of the homeless issues in big cities take care of themselves. 

13. cap malpractice awards and create a system which weeds out frivolous suits before they go to trial. Perhaps a rotating group of judges reviews cases for merit. Award malpractice only for gross negligence, not missing 1 in a million zebras as long as the provider acted in good faith. Rewards should be commensurate with injury. If you can't work for the last ten years of your career and you made 50 k a year, the max award (not including medical bills) would be 500,000. None of these spilled hot coffee on my lap and get 3 million. 

[rev ronin]

Some thoughts @EMEDPA

1) McDonald's deserved to be punished for its ongoing provision of TOO HOT beverages; my daughter still has scars on her thighs, eight years later, from second degree burns delivered by a spilled McDonald's hot chocolate--a beverage far more appealing to children. This was after that infamous verdict, and they still don't get it. Now, doesn't mean lawyers should get it, nor should anyone be unrealistically enriched, but it would be nice if our insurance company had gotten paid back by McDonald's for the direct financial consequence of their bad actions.

2) Several of the above solutions, especially 5, 6, 7, 10, and 11 require religious solutions. Not "spirituality" solutions, but established, real (e.g., not made up by science fiction authors) religions that demand accountability to God (as understood by each faith) for the care of other human beings. That's a values statement, but a falsifiable one: we can't prove it won't work unless we try it, but the longer we try to solve these issues without religion, the more failures we accumulate.

3) The understanding of what constitutes healthy food has changed over the years. Very little nutrition advice is based on science; most is based on lobbying by industry groups. We have a problem with not using evidence based medicine, or, more properly, endorsing the corruption of EBM by anyone with money. Fixing EBM is among the most fundamental fixes needed for A LOT of medicine, not just nutrition.

https://www.youtube.com/watch?v=5Ua-WVg1SsA
 

4) I agree that intellectual property laws need to be revised, and the FDA needs to be overhauled as well. Right now, we have lame drugs that don't demonstrably work getting approved and costing society a ton of money.  We should set both an NNT threshold and a $ per QALY threshold, and RECOUP MONEY FROM PHARMA if an approved drug is ever proven to have not had the expected benefits (see my EBM comments above)

To that pretty comprehensive and clearly solid list, I'd add a couple of other things:

- Reform disability laws to make it easier for people to work some when they can't work full-time, for disabled people to not need to pay down all their assets before public assistance kicks in.

- Tax social media as a public nuisance, regulate the pro-addiction techniques used to draw people in, and generally keep kids off of screens entirely for the first few years of life. We have no political will for this, and seem hell-bent on innovating faster than Black Mirror can catch up.

 

[EMEDPA]

Agree with most of your points above. Re: the McD verdict: she originally asked for her medical bills to be covered ( $20,000). I have no issue with that and compensation for lost days at work. 3 million is over the top. The jury awarded the verdict based on how much McD made off of coffee sales for 48 hrs. Kinda random. If you want to change the system at McD, don't award 3 million to one person. award 30,000 dollars to each person with a legit medical claim from hot coffee, tea, or cocoa. That would hurt them more and teach them a lesson. One person is an annoyance, thousands are an ongoing flow of money out of their profits. 

[rev ronin]

29 minutes ago, EMEDPA said:

Agree with most of your points above. Re: the McD verdict: she originally asked for her medical bills to be covered ( $20,000). I have no issue with that and compensation for lost days at work. 3 million is over the top. The jury awarded the verdict based on how much McD made off of coffee sales for 48 hrs. Kinda random. If you want to change the system at McD, don't award 3 million to one person. award 30,000 dollars to each person with a legit medical claim from hot coffee, tea, or cocoa. That would hurt them more and teach them a lesson. One person is an annoyance, thousands are an ongoing flow of money out of their profits. 

Yeah, I've been a party to dozens of class action settlements over the years; exactly one of them (tech anti-poaching) made any difference at all in my finances--the rest were equivalent to finding an extra $20 bill somewhere I'd forgotten it.

In general, I think pain and suffering should either be accidental and hence non-compensable, or criminal, and punished by fines (which are paid to the government) and imprisonment.

One of my favorite centrist zingers of all time remains "I'll believe corporations are people when the State of Texas executes one."

[EMEDPA]

21 minutes ago, rev ronin said:

 

One of my favorite centrist zingers of all time remains "I'll believe corporations are people when the State of Texas executes one."

well, there was Enron  

[iconic]

Some of the healthiest countries are least religious. American Christianity is a gun-worshiping abomination. The Justice system is another abomination. We don’t need so many lawyers going after everyone for everything if we in-fact did have a universal healthcare system like every other civilized and uncivilized county. The wheel doesn’t need to be reinvented. Also the Bible Belt is the least healthy part of America.

Edited February 2, 2023 by iconic

[FiremedicMike]

Why does this conversation nearly always devolve immediately into who's paying for it as if it is the actual problem.

 

Access to healthcare is not the primary problem, is the fact that people don't know how to properly utilize it, and zero effort is made to ensure the general public has an even basic understanding on how to take care of them selves on a day to day basis.  For the record, I'm not implying that healthcare workers aren't trying to educate these people once they've entered the healthcare system, but by that point it's generally too late to right that ship.

 

If FiremedicMike ran the country, we'd start healthcare education in elementary school.  Nothing major, I don't expect everyone to be a doctor, but I expect people to have a general idea of what their body does and that eating better and staying at least mildly active is the key to staying healthy, living long, and not being a burden on the healthcare system.  

 

[sas5814]

2 hours ago, FiremedicMike said:

Nothing major, I don't expect everyone to be a doctor, but I expect people to have a general idea of what their body does and that eating better and staying at least mildly active is the key to staying healthy, living long, and not being a burden on the healthcare system.

Our lifestyles are clearly a major contributor and, as stated many times before, healthcare became a business primarily with health care as a secondary concern to profit.

I see , every day, people who proactively destroy their own health. I'm sure most of you do too. My most recent example is a patient whose A1C is 12.5 and has been for years. Stage 4 CKD. Why? He drinks half a dozen sodas a day starting with breakfast and his dietary day just goes from there. I have many many similar patients.

Very few people want to work at their health. They just want a pill or a surgery to fix everything.

The crush to see as many patients as possible make education very difficult. I can't even count the number of diabetics I have seen in the last 2 years that have never heard the word "carbohydrate".

Lets talk the politics of healthcare. Why is tobacco still legal in this country? Kills 500,000 people a year and cost billions in health care dollars. Like always follow the money.

There is a difference between the have's and have nots but that is not limited to us. I was listening to a health care economist this morning explaining that life expectancy in New York City varies by as much as 20 years just in different regions within the city.

 

[iconic]

The issue is obviously multifactorial, however, I have no doubt that the complexity of navigating the healthcare system plays a major role. I cannot navigate the healthcare system for many of my patients. Why is it that I cannot look up the coverage of a medication for patients? You have to first prescribe it and hope that it's covered and if it's not covered submit a PA then go from there. Rinse and repeat for every plan. How incredibly wasteful and frustrating for both providers and patients. I used to work with predominantly Medicaid patients and while it had many issues, I at least knew the formulary of covered medication and never had to wonder whether something would be covered. Then the ones taking Medicaid shoulder a heavier burden rather than spreading the burden among many different providers 

Edited February 2, 2023 by iconic

[SedRate]

6 hours ago, FiremedicMike said:

Why does this conversation nearly always devolve immediately into who's paying for it as if it is the actual problem.

 

Access to healthcare is not the primary problem, is the fact that people don't know how to properly utilize it, and zero effort is made to ensure the general public has an even basic understanding on how to take care of them selves on a day to day basis.  For the record, I'm not implying that healthcare workers aren't trying to educate these people once they've entered the healthcare system, but by that point it's generally too late to right that ship.

 

If FiremedicMike ran the country, we'd start healthcare education in elementary school.  Nothing major, I don't expect everyone to be a doctor, but I expect people to have a general idea of what their body does and that eating better and staying at least mildly active is the key to staying healthy, living long, and not being a burden on the healthcare system.  

 

^100%

I will add, though, that the perception of what constitutes healthy is extremely variable and inconsistent across the board, which makes for a very confusing picture for the average American who is exposed to incessant marketing and advertising. Secondly, we're in the information age so what's the excuse for lack of knowledge or basic understanding. So whose job is it to teach us? Our parents? Government? Educators? Science?

At this point I'm digressing, but back in the day, folks had no real health or food education and they didn't really do any formal exercise, and yet they were arguably in better shape (although not necessarily "healthy"). So is it actually the food that's the problem? Or is it portion size that's the issue? Salt? Lack of an exercise program? Or is it because we drive everywhere nowadays and use the elevator and get things delivered to us? Or is it basal level of inflammation? Elevated stress level? Lack of sleep? These are all really just rhetorical questions. 

"Staying at least mildly active" and "eating better" are those vague things that are commonly said innocently but ripe for interpretation by both the speaker (e.g., PA) and the recipient (e.g., pt). And even nutritionists and fitness experts will vary greatly in their advice on what meets the above criteria. Is it 10,000 steps per day? Is it 150min of vigorous exercise weekly? Is it labor/farming? Is it cardio or is it weight training or is it body weights or is it non-impact activities or it is HIIT or is it something that I can only find at a gym because that's where fit people go? And I'm sure you've experienced this also: I can't tell you how many pts and friends say they're "mildly active" and eat "relatively well" when they're really actually sedentary and eat fast food at least once a day. I love hearing, "I have high blood pressure, high cholesterol, and had some stents for a small heart attack, but otherwise I'm pretty healthy!" SMH... 

Another note, CAD is found in nearly all elderly folks regardless of diet. So what constitutes "better" eating, ya know? And when do people become labeled "unhealthy"? Is weight the endpoint to health? Or it is lack of diseases? Or both? And is it the same for the young, mid-age, and elderly? 

[CAAdmission]

14 hours ago, iconic said:

American Christianity is a gun-worshiping abomination.

Sounds like someone doesn't know how to have a good time. 

[rev ronin]

15 hours ago, iconic said:

Some of the healthiest countries are least religious. American Christianity is a gun-worshiping abomination. The Justice system is another abomination. We don’t need so many lawyers going after everyone for everything if we in-fact did have a universal healthcare system like every other civilized and uncivilized county. The wheel doesn’t need to be reinvented. Also the Bible Belt is the least healthy part of America.

Note that I didn't specify any particular faith tradition, although I would quibble that there is such a thing as "American Christianity" as a sensible and useful category into which things can be lumped.  Catholic v. protestant, mainline v. evangelical, asian v. white v. black v. hispanic... There isn't one American Christianity, although if I had to guess, you'd be primarily critiquing white evangelical protestantism.