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[Medicine In The US]: An American Cluster*@#%
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HSAs are designed to be tax-free savings accounts for the rich & upper-middle-class.
They're awesome if you're mostly healthy, have disposable income, a high tax burden, and expect your health care costs to rise in the foreseeable future.
They're shitty if you actually have chronic medical issues. I was on an HSA+HDHP for about two years because it's all my employer would offer. My antidepressant alone cost more on that plan than I received in HSA money. Sure, I made contributions to it and deducted those on my taxes, but I still hit the contribution limit, and the above-the-line deduction didn't save me all that much money.
It sure saved my employer a buttload, though.
Don't even get me started on FSAs. What a fucking scam.
the "no true scotch man" fallacy.
Of course, there is not a legal requirement to swear to any version of the hippocratic oath to become a doctor. To Apollo's displeasure no doubt.
So, yeah, there is a financial solution to this specific sub-problem. It isn't as much that we need a huge number of additional doctors, although to some extent that's an issue. There's terrible maldistribution. Folks go through medical schools and rack up a quarter million dollars in debt, maybe more and maybe less, and this does impact what field of medicine they want to enter.
Subsidizing medical education is one option there.
As for building additional pylons, there are actually new medical schools popping up left and right.
However, this is really only changing the proportion of American docs in our country. The real limiting factor is residency positions, which are federally funded and have to be gone through in order to be licensed for independent practice. Right now, any spots not filled by American medical graduates are filled by foreign folks. More schools just reduces that number of spots.
Things which are not a right: your wealth.
One possible conclusion: means-testing can go a lot further. Like, sell-your-house further.
They certainly don't make sense in plenty of situations, and are a good tax shelter for the wealthy if (when?) they were allowed to roll over the previous years contributions into their IRA. However, when I had one (single/young and healthy making a pittance in a startup) it was a nice way for me to get a lower premium on my insurance while getting a bit of subsidization from Uncle Sam for preventative care.
Sure, but it really is one of those ground rules you need to set down along with health insurance does not guarantee health care before you can really look at the problem and understand just how fucked up the situation really is. We have a shortage of doctors. We are currently poaching as many of the worlds doctors as we can to alleviate that, however it is nowhere near enough. Apparently high pay, and decent fringe benefits do not outweigh the long years of training and soul crushing debt required to be a doctor. People have proposed making being a doctor easier, pawning some of their responsibilities off on nurses, cutting their pay to control costs, etc...
However a lot of the solutions are based on the illusion that doctors have to treat you. They don't. Even if you have insurance they can choose not to take it. If a doctor decides he is going to see 50 patients tomorrow. Now he can schedule 50 people with insurance that pays him 10$ for a visit, or 50 patients with insurance that pays 50$ per visit. Who do you think he is going to see?
Moreover lets say we decided that no matter what the doctor can only make 10$ a visit. Nothing is stopping him from saying fuck this I am going to retire/get a job that doesn't deal with patients/Go do something else entirely.
Which all leads back to Atomic Ross quote that I limed previously. We have a major problem, and if we want to enjoy great medical care in the future something has to be done. We can have it good, fast, or cheap. Pick any 2.
I understand your skepticism, seeing as this is the interwebs... but I don't come up here to post bullshit just for the hell of it.. Sorry I can't back it up with the clip I watched. :?
I'm not seeing how the solutions are based on the illusion that doctors have to treat you. Look, economics. Hold doctor pay constant, reduce doctor work. This is suggested to drive away doctors? What?
I just get annoyed when they're held up as a panacea. They most benefit the people who need them the least.
the "no true scotch man" fallacy.
I hate to do this because it has been said over and over in this thread, but doctors are not oil. There is no "peak doctors".
The number of doctors can go up, there's all kinds of ways to do that. The number of nurses can go up. The number of GPs can go up and the stuff a GP does can be expanded.
Realistically, they're best used to make the middle and middle-upper save for their own healthcare, so that funds can be diverted to lower income groups. For HSAs to work, saving must be large enough to begin with, and that is only true for relatively high income earners.
It's one of those schemes which makes sense as long the latter part of "okay, we've done that, so now we can redistribute X" is definitely following it.
That makes sense.
the "no true scotch man" fallacy.
I think it's stupid that people use the ER for illnesses that literally can be treated for $5 worth of Tylenol, but I also think it's ridiculous that hospitals charge $1000 for the same service.
Basically, we insist on training (and paying) medical professionals to personally deal with motherfucking anything, even though it's not really necessary. Of course even then if we didn't allow the AMA to basically say "fuck you" to 95% of the people who want that training we'd be fine. Can you imagine the shitstorm that would ensue if, say, the NEA was given a complete stranglehold on the supply of teachers? It's just a terrible idea to let a professional organization manipulate the labor market like that.
It's not a cure all, but it sure doesn't help.
Yes...but what would we call them?
I know! We could call them "urgent care clinics"!
(facepalm)
Let's also not forget that for a long time, midwives were safer than doctors, thanks to classism and doctoral egos.
We have an abundance of those. The problem is that they're all daytime-only (usually 7:00am to 10:00pm), and few (if any, which I haven't personally seen) accept Medicaid, the recipients of which are the overwhelming control group for ER over-use.
If there was a tenable model for it, I would heartily endorse an entitlements-only hospital run by the government.
This is one of my pet issues in case you haven't seen me talk about it before.
I strongly believe that non-MD objective-medicine-based medical professionals should have reasonable decision-making privileges, but there is so much resistance against it.
the "no true scotch man" fallacy.
I think people are using AMA as a more recognizable shorthand for LCME/ACGME. But the AMA does lobby those groups.
For instance, when trying to get seen for strep throat I was told to gargle salt water, and if that didn't fix it, go to the ER, because fuck if my doctor has time to fit me in before it becomes an emergency. I think the average wait time for my GP was 1-2 weeks depending on when he took his vacations.
So I moved to a health care clinic that is staffed mostly with PAs and RNs that are under the supervision of a doctor and I can get in pretty much the same day.
Urgent care and ERs are the new "Doctor's Offices" and your average clinic is now just for checkups and long term care for people with diabetes and health disease or something.
Well, in many cases its a justified thing to ask of people. Without having the patient in front of them, a doctor can't be reasonably asked to offer a diagnosis; type in nausea, sweating, and lightheadedness into WebMD and you'll get possible diagnoses that range from food poisoning to heart attack to anemia.
If you got a problem and can't wait, go to an ER. The problem arises when people can't be asked to differentiate between "I can't wait" and "I'm well-off and impatient."
One of the horrible paradoxes of the single-payer system is that it works better the fewer people there are who need it.
Actually, the AMA is a sponsor of the LCME.
It's also really fucking risky.
I am well aware of what a crazy person frantically trying to find out that they don't have cancer on WebMD is going to create issues. I am also well aware of the difference between sore throat and a 3 day sore throat with exudates and a rash. I guess we needn't be concerned with the fact that strep throat is a common vector of worse (olol kidney failure!) infections.
I get that you're a nurse, you don't need to remind me.
The other side of all of this is that a lot of people, too many in fact, are just panicky or extremely ignorant of human pathology.
I get people all the time coming in and saying things like, "I just smashed my hand and I think my finger is broken!" Five-thousand dollars worth of tests later, we will confirm that, yes, your finger is indeed broken, and here is the 50-cents-worth-of-aluminum splint to tape over it.
Or, God, all the mothers that run into the ER in a full whirlwind going, "My baby has a fever of 100 degrees!" Have you tried giving them any Tylenol, or taking off the piles and piles of blankets you have them under? No, no you didn't. Your child has a diagnosis of "Stupid Parent Syndrome," that'll be $3500.
The reason I would ask for 24-hour care is that it's the only thing I can think of to prevent the rampant abuse of ERs (and thus escalating ER costs) for non-emergent patients simply because A) it's quicker than waiting for the clinic to open, and
When a Medicaid recipient comes into the ER at 3AM for something low acuity, most doctors will treat them because the low acuity isn't worth fighting the oversight committee over and the reimbursement is guaranteed. So Joe Schmoe with the sore throat gets his antibiotics prescription for free, but the taxpayers are billed $2000 for triage costs, doctors fees, and tests.
Kind of like H/A, only without Internet Fuckwads.
BTW, this is tangentially related. I am very pleased by Target's new ad campaign for their pharmacy services.
They look like this (sorry for the shitty photo, I found it on some guy's blog)"
What I appreciate is that they are positioning their pharmacists as skilled professionals rather than pill counters. "Ask us questions about your drugs! We have answers!" This isn't just promoting Target, but promoting pharmacists in general.
the "no true scotch man" fallacy.
I'm wondering how they'll deal with people who move there just to use the health care there. Like if someone knows that they have a disease which is going to require really, really expensive health care over the next few years. I assume Vermont will have some sort of minimum residency period before you can get health care, but people can still get around that if they can wait it out. Will Vermont screen people for pre-existing conditions?
And you're right. However it's a symptom of the doctors pushing it off to the ER because they can't afford to just leave blocks open for a day for someone to bring in a sick kid. Which is the unfortunate side effect of Insurances.
The inflated cost of healthcare is intertwined with that whole shit storm.
Also, first time parents are stupid, yes, but it is never wrong to be cautious. Especially when a life is potentially on the line. If I could count the number of times I've been pushed away for a medical emergency because it wasn't pants shittingly urgent, I'd probably run out of digits.
Of course it wouldn't have been an emergency if I could see the doctor before the end of the month. But again, it isn't like days of old where doctors could see 5 patients a day and still make profit. Preventative care is okay, but sometimes you need a step just past preventative, but realllllllly far away from urgent or emergency care. Doing so could alleviate emergency services for an actual emergency.
In my experience, most people who abuse ERs routinely are Medicaid recipients or uninsured patients of extremely little means, many of them on government housing or living in cheap rental property.
Outside illegal immigrants, a big portion of ER abuse comes from people with literally nothing to lose. At least having a no-cost/low-cost 24-hour clinic would offset the ER losses, if not actually help those patients.
San Francisco has had a lot of good free/low-cost clinics for a while, and they recently started a program offering free clinic visits to low-income residents.
I wonder how much of an effect this has on ER utilization rates.
the "no true scotch man" fallacy.
It probably greatly depends on whether or not the clinics mandate payment before treatment, whether they're open 24 hours a day, and whether or not they can write prescriptions for narcotics.
If they can't do any of that, I'd gather the ER abuse continues fairly unabated.
I think psychiatry is also a high-loss specialty IIRC.
One of the hospital management consultants I used to work with said that neurology is a high-loss specialty unless you can make up for it with radiological exams.
the "no true scotch man" fallacy.