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[Medicine In The US]: An American Cluster*@#%
AngelHedgie
Registered User regular
Registered User regular
So, to end the derailing in the primaries thread, let's discuss the utter unholy clusterfuck that is the American medical system. The facts speak for themselves - we spend more, and get less. Payment for medical services is an opaque, Byzantine system of government programs and private insurers that makes it near impossible to determine charges prior to services being billed. We're currently facing a shortage of medical professionals, especially in the front lines, which has been exacerbated by the policies of organizations such as the AMA. And that's not even getting into the political mess revolving around the implementation of universal health care.
In short, it's an absolute fucking mess. And there's no end in sight. But, there are a lot of ideas out there for how we can fix the system. But when there are so many issues, where do we begin in fixing the system?
In short, it's an absolute fucking mess. And there's no end in sight. But, there are a lot of ideas out there for how we can fix the system. But when there are so many issues, where do we begin in fixing the system?
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They unionized.
This. Our system emphasizes treatment rather than prevention. I think the blame may lie at both end, however. Speaking at least for myself, it's difficult to motivate myself to do anything about a potential problem, or one which isn't really bothering me yet. Whether this is a particular American cultural thing, me being lazy, or is true of other places as well, I don't really know. As with most things, I think the solution is education, and a concerted effort to emphasize health (by way of prevention) rather than treatment of acute conditions.
So I could go get knee surgery, or I could finish college, both are not on the menu
Just to give another perspective to this, I think that compensation models that medicare uses (as well as insurance companies) causes quite a few problems.
Most physicians (GPs in particular) lose money for simple office visits. This, combined with the necessity for defensive medicine, increases the number of procedures done.
Add to this the fact that Americans largely expect to get the best level of medical care, regardless of their financial ability to afford it, and you can see why we spend so much on healthcare.
This meme needs to be taken out back and shot. Medicare pays out about $60 for a basic 99213 office visit. Anything that takes longer than 10 minutes can easily be upcoded.
This is also flat out wrong. "Defensive medicine" is a buzzword used to promote tort reform. It isn't an actual "thing". Doctors perform more procedures because they are paid for the amount of procedures they perform. It's the invisible hand of the free market in action.
E: Oh, nevermind. You don't. Just an FYI for you yanks, $60 is exactly twice what GPs get paid here in Canada for a routine visit with no special procedures/referrals. Maybe if you reduced your compensation levels you'd not be spending so much on healthcare, and I say that as a medical student.
I think he means, they lose money relative to what they COULD be making in a more expensive procedure. Doing an MRI earns them a lot more money than a physical.
You can understand why one might feel that a healthcare provider is being disingenuous when they claim they lose money
http://www.aafp.org/fpm/2003/0600/p51.html
There was an article I read about a family practice provider whose reimbursement for some office visits didn't cover overhead. That was anecdotal, but it is what I was reminded of earlier.
First, I absolutely agree that some physicians perform more procedures than they "have" to in order to increase their revenue. It is not, however, the only reason why physicians perform what you perceive to be "too many" procedures. Defensive medicine is absolutely a thing. Physicians are taught from day 1 of medical school to cover their asses. I should know, I am ending my second year of medical school and have several friends attending various medical schools across the country.
Not true. The cost of training a radiologist to read that MRI is quite high.
It's just not as common as it is played out to be, it may not even be statistically significant
It's not just the doctor that gets paid that $60.
It's also the doctor's receptionist, his accounting team, her nurses, and you have to account for all the insurance companies/patients that just refuse to pay after the fact.
Doctors have huge staff sizes in America, with experts trained to interface with the insurance providers. In Canada, we have a unified billing system that doesn't require the services of a whole person to manage. Totally different worlds.
I think the word there is yet. There's nothing stopping Harper from just pulling you guys back a few decades as I understand it
Privatization of Healthcare in Canada is political suicide. The American equivalent would be promoting "soft on crime" policies.
Hope you guys fare better
Actually the American equivalent would be privatization of Medicare.
Something that is a near certainty for anyone under 45
When I say that defensive medicine increases the cost of medical care I'm not only referring to the cost incurred by physicians for malpractice insurance and getting sued. The American physician bases many decisions about care with the mentality that "I must order this test so I don't get sued." Many of these tests are medically necessary, but some aren't. Sometimes you are just ordering a CT scan or doing whatever so you can say you did. This also impacts patient perception on what to expect when they go to the doctor. This creates a cycle, where patients expect exams, procedures, etc. for everything and physicians cover themselves by ordering more procedures. This raises patient expectations and the cycle continues.
I don't really know to what extent this has been studied and to what extent it actually affects market prices of healthcare but it is something that I have noticed.
That said, a lot of the "we lose money for X" things are "compared to if I only did Y", which is the same logic used in major chain stores. Sure, it would be better for Best Buy if all they did was sell cables, but they have to sell the non crazy margin items as well.
I can't really think of a way to put it better than Pi-r8 did. In this case, every aspect of the US medical system has an active incentive to do the wrong thing. Be it due to profit motive,fear of lawsuits or cost of medical care: the path of least resistance is to do shitty things. And everyone involved needs to be reformed. From the doctor pay scales (which would mean both increasing base costs and lowering specialty costs), patient understanding (preventative medicine is important, abuse of the ER because you weren't in the mood to make an appointment for a minor problem, and for the love of GOD stop direct medical marketing to consumers because fuck patients doctor shopping or picking a fight with their doctor to get X drug they saw on TV, to the entire pharma industry's fucked up pricing scheme, and the insurance companies essentially refusing to standardize or hunting for reasons to not pay claims)
Yes. In Canada, it's not just the doctor who gets paid $30, either. He/She still has to pay the staff, rent, etc. There is maybe one less person on the team in Canada, tops.
Except that when pressed, doctors themselves admit that "defensive medicine" is BS:
The only real solution I see is single payer.
The biggest takeaway is how utterly corrosive profit is in healthcare. The final third of the article is the most frightening, frankly.
Flash forward a few years and I was getting struck from a jury in a Vioxx case because too many of my friends and family had been prescribed drugs that had later turned out to be dangerous.
Later on my Grandmother end up being admitted to a hospital after a fall, and I suspect that many of the decisions made about her care were based on pumping as much money as possible out of Medicare. They even ignored a do not resuscitate order she had signed upon admission to keep her on machines in Intensive Care for a few days.
It is discouraging that people take advantage of systems like this, but as others have mentioned it isn't surprising (I even mentioned above that I agree that it happens). I think the fault lies both with physicians who over prescribe treatment and patients who agree to unnecessary procedures (or even demand them). Insurance also plays a role. Putting fault solely one one side of the spectrum, especially when as others have mentioned the system is set up to encourage bad behavior on both sides, is disingenuous. Ultimately, we need to change the system. I have a feeling that based on our past discussions that we would disagree on how to accomplish that, though.
I will say this about defensive medicine, though. It happens. You may say that it's BS, but I've seen it countless times and I've been told stories about it countless times. I don't think it is the biggest factor, but it absolutely plays a role and to discount it entirely is foolish.
"Hey there Dr. Doctor! I noticed you prescribed this unnecessary treatment. Why did you prescribe it?"
Doctor has two possible responses:
"I prescribed it because I got paid to do it and I like money."
"I prescribed it because I wanted to do defensive medicine and cover my bases."
Which do you think they're going to say? I'm not saying they're lying - I'm sure in many cases, they believe that they are doing it totally for the right reason, for the benefit of the patient, etc. But the profit motive is powerful and insidious, and can be an underlying cognitive bias without one noticing it. If there isn't a financial incentive to do defensive medicine (as is the case in examples given in the linked Gawande article), defensive medicine is practiced much less.
I agree that the motive for profit is going to play a much bigger role than that of defensive medicine. There are, however, absolutely instances where a doctor orders a test that he personally doesn't think is necessary but does so to cover his bases. I feel like we are talking in circles.
It's a case of "what is the correct policy solution?" If doctors are over-prescribing because they are actually under threat of lawsuit and they really really do need to cover their bases, then we need tort reform. If they are over-prescribing because they get paid more to do it, we need to change physician compensation schemes from fee-for-service to bundled payments and have the IMAP board get Medicare to stop paying for the unnecessary treatments. My argument is that the second case is in fact true, and that when we craft our policy response we should ignore the defensive medicine excuse, because it's wrong, and not do tort reform.
Yep, this.
And sadly no it hasn't gotten much better.
There's a slow push towards standardized, interoperable EHR systems, but the penetration of such systems isn't that great, and even when a provider and a payer are using systems that support the same EHR format, there's a pretty good chance that (1) they don't know it and (2) they're bound by some bureaucratic requirement to keep using whatever system of transmission (even if it's faxing in paper claim forms) that they've been using.
It also effects continuity of care, which is an area where the US fails hardcore. Managed systems like HMOs and the Veteran's Administration benefit from giving all the providers (limited, granular) access to the same EHR database. That way if a specialist needs to know something about the patient's prior visit to another doctor - say, a medication that they tried that didn't work - you don't need the other doctor to fax in the patient's records and you don't have to rely on the patient's bad memory. Small-practice doctors within a PPO network, though? Ugh.
the "no true scotch man" fallacy.
We have among the best early cancer detection rates in the world.
the "no true scotch man" fallacy.
I'm saying do both. I guess agree to disagree?
In his book, Paul Krugman notes that the added administrative fees for our multi-payer insurance system comprise at least 40% of the per-capita difference between the US and Canada.
The CBO brief available here is a decent place to start on malpractice and defensive medicine data. In short, most studies conclude that defensive medicine doesn't really play a significant driving role in health care costs, even though physicians tend to report that it does; things like compensation or, more importantly, simply the standard of care in the area are more prominent driving forces in service utilization. Their best estimates peg the savings of implementing all of the malpractice reforms being proposed at about 0.5% of annual healthcare spending.