The Moral Crisis of America's Doctors
June 15, 2023 10:15 AM Subscribe
Military psychiatrists label "moral injury" the soldiers' emotional wounds, when they commit acts- such as raiding a home or killing non-combatants, that transgress their core values. Doctors on the front lines of America’s profit-driven health care system were also susceptible to such wounds, as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession.
It's almost as if functioning as a cog in a machine designed to extract maximum profit from patients — instead of providing the healthcare they need — has long-term effects. See also every Dr Glaucomflecken video about United Healthcare...
posted by fifteen schnitzengruben is my limit at 10:52 AM on June 15, 2023 [14 favorites]
posted by fifteen schnitzengruben is my limit at 10:52 AM on June 15, 2023 [14 favorites]
The Beatles said it best:
The best things in life are free, but the MBAs took them from me. They want money, that's what they want.
posted by Abehammerb Lincoln at 10:56 AM on June 15, 2023 [8 favorites]
The best things in life are free, but the MBAs took them from me. They want money, that's what they want.
posted by Abehammerb Lincoln at 10:56 AM on June 15, 2023 [8 favorites]
I went into the article prepared to be unsympathetic--oh no, the wealthy and powerful feel some fraction of the stress their patients feel!--but...well, I dunno. I found my reactions going back and forth. Doctors feeling injured over being treated like employees? 100 ccs of irony, stat!
But it's true, if you go into a profession to do a good job, and at every turn you're being prevented from doing that job--and watching people sicken and die because of it--that does have to have an impact on you. It's not a broken system, it's an actively malign one, built to funnel money one way, and to filter care from flowing the other way. But they do still have money, power, and political prestige, and they could still use all that to make a difference. The hospital system was so tightly wound and fragile, even before COVID, and now, it just seems to lurch towards some inevitable crisis--it does seem like the doctors could take a stand and force a change. The patients certainly don't have the power to do so. Having some docs, like the rheumatologist, move into directly-supplied care doesn't help at all. You can't correct a system by working from the margins like that. You can only pretend to escape it.
posted by mittens at 11:00 AM on June 15, 2023 [11 favorites]
But it's true, if you go into a profession to do a good job, and at every turn you're being prevented from doing that job--and watching people sicken and die because of it--that does have to have an impact on you. It's not a broken system, it's an actively malign one, built to funnel money one way, and to filter care from flowing the other way. But they do still have money, power, and political prestige, and they could still use all that to make a difference. The hospital system was so tightly wound and fragile, even before COVID, and now, it just seems to lurch towards some inevitable crisis--it does seem like the doctors could take a stand and force a change. The patients certainly don't have the power to do so. Having some docs, like the rheumatologist, move into directly-supplied care doesn't help at all. You can't correct a system by working from the margins like that. You can only pretend to escape it.
posted by mittens at 11:00 AM on June 15, 2023 [11 favorites]
It's kinda crazy to see something you've watched up close described in the NYT. My wife's an EM doc and she's followed the exact trajectory this article describes—brutal residency in a county hospital in a major metro, went to work out in the community, and now burning out on the gap between why she's in medicine and what the actual work entails. It's painful, because she and her close residency friends are some of the best people I've ever met. They're a crazy smart, super ambitious group who easily could have lived comfortable, painless lives working in any of a number of lucrative fields, medical or otherwise. They chose EM because they wanted to do something meaningful, because they wanted to help people, because they hate how many people slip through the cracks of our fucked-up mess of a healthcare system.
Then they graduated into this reality: six figure debt, the only jobs are in suburban hospitals, and a bunch of MBA shitheads are constantly squeezing them and everyone else to turn every room faster, bill more, keep the money flowing. It's enraging and heartbreaking and yeah, it's partially the fault of a generation of doctors who saw themselves as above class solidarity, but there's a new generation being fed into the gears who are at least trying to change things before they all burn out.
posted by protocoach at 11:01 AM on June 15, 2023 [50 favorites]
Then they graduated into this reality: six figure debt, the only jobs are in suburban hospitals, and a bunch of MBA shitheads are constantly squeezing them and everyone else to turn every room faster, bill more, keep the money flowing. It's enraging and heartbreaking and yeah, it's partially the fault of a generation of doctors who saw themselves as above class solidarity, but there's a new generation being fed into the gears who are at least trying to change things before they all burn out.
posted by protocoach at 11:01 AM on June 15, 2023 [50 favorites]
Sorry if my above comment comes across as flippant, but even in my profession I keep running in to situations where some consultant is brought in and profits become more important than doing the right thing, and guess what...the company goes straight to failure. Because it stops doing the right thing and delivering on what it did well and what people cared about...because money.
How the hell is the basic human right of medical care for profit? I mean for the corporate head Republicans, "Life" is enshrined in the opening statement of the goddamn Declaration of Independence.
posted by Abehammerb Lincoln at 11:04 AM on June 15, 2023 [1 favorite]
How the hell is the basic human right of medical care for profit? I mean for the corporate head Republicans, "Life" is enshrined in the opening statement of the goddamn Declaration of Independence.
posted by Abehammerb Lincoln at 11:04 AM on June 15, 2023 [1 favorite]
I mean for the corporate head Republicans, "Life" is enshrined in the opening statement of the goddamn Declaration of Independence.
As far as the modern Republican party is concerned, "Life" begins at conception and ends at birth. After that, you're just pre-dead to them.
posted by We put our faith in Blast Hardcheese at 11:07 AM on June 15, 2023 [36 favorites]
As far as the modern Republican party is concerned, "Life" begins at conception and ends at birth. After that, you're just pre-dead to them.
posted by We put our faith in Blast Hardcheese at 11:07 AM on June 15, 2023 [36 favorites]
But it's true, if you go into a profession to do a good job, and at every turn you're being prevented from doing that job--and watching people sicken and die because of it--that does have to have an impact on you.
I don't even work in medicine and I found myself relating to the moral injury.
posted by jenfullmoon at 11:08 AM on June 15, 2023 [9 favorites]
I don't even work in medicine and I found myself relating to the moral injury.
posted by jenfullmoon at 11:08 AM on June 15, 2023 [9 favorites]
Just a note that 'Doctors on the front lines of America’s profit-driven health care system' is different than 'America's Frontline Doctors', which is a pandemic-spawned grift mill.
posted by Jessica Savitch's Coke Spoon at 11:35 AM on June 15, 2023 [12 favorites]
posted by Jessica Savitch's Coke Spoon at 11:35 AM on June 15, 2023 [12 favorites]
Everyday. Every insurance. Healthcare in the US is absolutely broken.
posted by AlexiaSky at 11:42 AM on June 15, 2023 [13 favorites]
posted by AlexiaSky at 11:42 AM on June 15, 2023 [13 favorites]
I don't have the time to read through the whole article yet, though I'm looking forward to it. This has been a problem for a long time, and Covid made it worse because so many health care workers left the system, putting the ones who remained under even more strain (and making the drivers for profit more rapacious). But while I understand that the piece is focusing on the profit engine as the main source of doctor trauma in the US (and maybe I just missed it since I didn't fully read it through), from what I gathered on my quick skim and the comments here, it looks like it's missing another component that makes things particularly awful, which is the impact that Dobbs is having on so many aspects of womens' health care right now, and how deeply intertwined with the legal system many doctors and hospitals now also have to be when making life-and-death medical decisions. Everyone is putting patients last.
Everything about our system just seems broken from the outside in, and I don't know what it's going to take to get anyone in a position of power to care. To everyone reading this who is still working in health care, just thank you for still being here.
posted by Mchelly at 11:53 AM on June 15, 2023 [5 favorites]
Everything about our system just seems broken from the outside in, and I don't know what it's going to take to get anyone in a position of power to care. To everyone reading this who is still working in health care, just thank you for still being here.
posted by Mchelly at 11:53 AM on June 15, 2023 [5 favorites]
Said from >25 years of practice experience:
There's so many facets of this. Absolutely physicians face moral injury when they are unable to secure services they feel are necessary for their patients. At the same time, few US physicians have worked in any austere environments that force making executive diagnostic and treatment decisions. As long as we continue to graduate residents who go into practice that are more comfortable relying on expensive diagnostics and a round-robin of specialist referrals rather than on their own learned skills and knowledge base it's going to happen.
I'm not suggesting that expensive diagnostics and specialists aren't great resources because they are but educationally we are failing residents because so few have the necessary experience or the confidence to make hard decisions. So often in medicine, there is no "best" solution only a less crappy one. Being able to help patients make the less crappy choice is often what it is to be a doctor.
posted by shagoth at 11:53 AM on June 15, 2023 [17 favorites]
There's so many facets of this. Absolutely physicians face moral injury when they are unable to secure services they feel are necessary for their patients. At the same time, few US physicians have worked in any austere environments that force making executive diagnostic and treatment decisions. As long as we continue to graduate residents who go into practice that are more comfortable relying on expensive diagnostics and a round-robin of specialist referrals rather than on their own learned skills and knowledge base it's going to happen.
I'm not suggesting that expensive diagnostics and specialists aren't great resources because they are but educationally we are failing residents because so few have the necessary experience or the confidence to make hard decisions. So often in medicine, there is no "best" solution only a less crappy one. Being able to help patients make the less crappy choice is often what it is to be a doctor.
posted by shagoth at 11:53 AM on June 15, 2023 [17 favorites]
I'm a software developer on the payment side of the healthcare industry, and I see it up close all the time. It's horrifying on a daily basis. Everything about it, starting with the language they use to talk about patients and healthcare.
For example, any time a health insurance company has to pay a claim, that's called a "medical loss". 100% correct if you read this to mean that the only thing that matters is the fact that the insurance company has to pay out, and that the "loss" is something to be minimized. Care? Patient health? Not part of the discussion.
Another one is about patient contact info. Health care infotech systems are notoriously bad at keeping up-to-date records about patient mailing addresses etc, not to mention email addresses which are still somehow considered to be cutting-edge technology. Even the basic NCOA (national change of address) updating that every direct mailer in the world uses is somehow science fiction to these bozos.
But when they lose track of a patient's correct mailing address, they call the process of trying to correct it "skip tracing". As if the patient is some fugitive that is trying to wear a Groucho Marx mustache and "skip town" to hide from the billing department. When 90% of the time the issue is just that the hospital couldn't be arsed to keep their own database up to date, or there was a transcription error when they tried to enter a handwritten form, or nobody reviewed the info with the patient the last time they came in to the office to make sure it was up to date.
posted by bgribble at 11:56 AM on June 15, 2023 [27 favorites]
For example, any time a health insurance company has to pay a claim, that's called a "medical loss". 100% correct if you read this to mean that the only thing that matters is the fact that the insurance company has to pay out, and that the "loss" is something to be minimized. Care? Patient health? Not part of the discussion.
Another one is about patient contact info. Health care infotech systems are notoriously bad at keeping up-to-date records about patient mailing addresses etc, not to mention email addresses which are still somehow considered to be cutting-edge technology. Even the basic NCOA (national change of address) updating that every direct mailer in the world uses is somehow science fiction to these bozos.
But when they lose track of a patient's correct mailing address, they call the process of trying to correct it "skip tracing". As if the patient is some fugitive that is trying to wear a Groucho Marx mustache and "skip town" to hide from the billing department. When 90% of the time the issue is just that the hospital couldn't be arsed to keep their own database up to date, or there was a transcription error when they tried to enter a handwritten form, or nobody reviewed the info with the patient the last time they came in to the office to make sure it was up to date.
posted by bgribble at 11:56 AM on June 15, 2023 [27 favorites]
I met a woman on the profit side of healthcare -- "I make doctors rich" is how she introduced herself. She also confided that she's "a big fan of survival of the fittest." I think about her often whenever I'm interacting with our healthcare system.
posted by credulous at 12:47 PM on June 15, 2023 [14 favorites]
posted by credulous at 12:47 PM on June 15, 2023 [14 favorites]
At the same time, few US physicians have worked in any austere environments that force making executive diagnostic and treatment decisions.
In many cases, this doesn't show up for patients when their doctor says "We can't treat this illness because it won't be paid for by your insurance", it's a gatekeeping function that is handled by the receptionist. "We don't take that insurance", or "we can't book an appointment without insurance on file", or (common in NYC) "we don't take insurance" (aka, payment in full due at time of service).
The doctor never gets in the position of being forced to make difficult treatment decisions, because they don't even get to see the patients who are underinsured, uninsured, or out of network.
posted by bgribble at 12:59 PM on June 15, 2023 [18 favorites]
In many cases, this doesn't show up for patients when their doctor says "We can't treat this illness because it won't be paid for by your insurance", it's a gatekeeping function that is handled by the receptionist. "We don't take that insurance", or "we can't book an appointment without insurance on file", or (common in NYC) "we don't take insurance" (aka, payment in full due at time of service).
The doctor never gets in the position of being forced to make difficult treatment decisions, because they don't even get to see the patients who are underinsured, uninsured, or out of network.
posted by bgribble at 12:59 PM on June 15, 2023 [18 favorites]
or (common in NYC) "we don't take insurance"
Wait, what
posted by grumpybear69 at 1:02 PM on June 15, 2023 [2 favorites]
Wait, what
posted by grumpybear69 at 1:02 PM on June 15, 2023 [2 favorites]
Okay, I needed a little time to think but really i'll just talk a little about my day.
Things that I've run into today in the world of medical social work
Current consequences of dismantling of the mental health care system with people with severe mental illness
People who have hit the Medicare lifetime limits on psychiatric care.
Consequences of being able too not find a outpatient mental health provider for someone on medicaid bc coverage without a waitlist less than months long
Medicaid payments for rehab in nursing facilities, which basically amounts to nothing so people don't get it
Patients being denied recommended level of rehab ( ltac vs acute vs sub acute vs custodial)
Home aid services income limits and hour limits and referral processes for that
Home hospice company not delivering supplies in a timely manner and delaying carrying out doctors orders
Medication assistance stuff, people not getting meds because they can't afford them, or it was denied.
Non US citizens and their lack of options for care just in general
This isn't even an exaggeration, or even a busy day for me. It's just everywhere.
posted by AlexiaSky at 1:12 PM on June 15, 2023 [20 favorites]
Things that I've run into today in the world of medical social work
Current consequences of dismantling of the mental health care system with people with severe mental illness
People who have hit the Medicare lifetime limits on psychiatric care.
Consequences of being able too not find a outpatient mental health provider for someone on medicaid bc coverage without a waitlist less than months long
Medicaid payments for rehab in nursing facilities, which basically amounts to nothing so people don't get it
Patients being denied recommended level of rehab ( ltac vs acute vs sub acute vs custodial)
Home aid services income limits and hour limits and referral processes for that
Home hospice company not delivering supplies in a timely manner and delaying carrying out doctors orders
Medication assistance stuff, people not getting meds because they can't afford them, or it was denied.
Non US citizens and their lack of options for care just in general
This isn't even an exaggeration, or even a busy day for me. It's just everywhere.
posted by AlexiaSky at 1:12 PM on June 15, 2023 [20 favorites]
Thanks for posting this article, which explains why my brother was billed $7,000 for an MRI after surviving a deadly infection. Here in England, a common experience at the pharmacy counter that never fails to amaze me as an American is this: The pharmacist asks if I am on any special plan for discounted medicine. I go no, I don't think so. Then with almost a regretful sigh the pharmacist is like, OK, in that case you're going to be hit with the full cost of the pills. That'll be £8.
posted by johngoren at 1:31 PM on June 15, 2023 [23 favorites]
posted by johngoren at 1:31 PM on June 15, 2023 [23 favorites]
The American system of healthcare was birthed into this world by doctors, who remain its greatest defenders. Medical insurance is terrible stuff from top to bottom, but insurance doesn't run the hospitals, it doesn't bestow that magical credential, it doesn't set the price of medicine. Insurance doesn't have the clout to prop up and perpetuate the whole system. It's doctors.
When Canada socialized medicine the doctors there fought it. The moral argument of universal care did not persuade them. They were worried about their paychecks. And because it was one of the first systems it wasn't even clear if it would be successful. But now we know socialized medicine is both more efficient and provides better outcomes to society. In addition to providing the service as a basic human right. American doctors know all of this and could lead the charge to enact reform, but they choose not to. Doctors choose insurance over people.
I think the morals of an American doctors are below that of lawyers or MBA, who at least have the honesty to publicly own the fact that making money is their main priority. Irregardless of it's social impact.
Oh, I know these MD's graduated with lots and lots of debt!? So did that airline pilot. But unlike doctors those pilots use checklists and whole systems devised to ensure the safety of their customers. I'm not a patient, I'm just another customer and my provider hasn't updated his actual medical skills in 15 years. And that outdated care is sooo expensive. Medical care remains the primary cause of bankruptcy in the US, so doctors can miss me with their pious act that they are just doing their calling.
If it's not clear, I spent a big chunk of the last decade working in the disability field at an organization housed inside a large medical university.
posted by zenon at 1:43 PM on June 15, 2023 [16 favorites]
When Canada socialized medicine the doctors there fought it. The moral argument of universal care did not persuade them. They were worried about their paychecks. And because it was one of the first systems it wasn't even clear if it would be successful. But now we know socialized medicine is both more efficient and provides better outcomes to society. In addition to providing the service as a basic human right. American doctors know all of this and could lead the charge to enact reform, but they choose not to. Doctors choose insurance over people.
I think the morals of an American doctors are below that of lawyers or MBA, who at least have the honesty to publicly own the fact that making money is their main priority. Irregardless of it's social impact.
Oh, I know these MD's graduated with lots and lots of debt!? So did that airline pilot. But unlike doctors those pilots use checklists and whole systems devised to ensure the safety of their customers. I'm not a patient, I'm just another customer and my provider hasn't updated his actual medical skills in 15 years. And that outdated care is sooo expensive. Medical care remains the primary cause of bankruptcy in the US, so doctors can miss me with their pious act that they are just doing their calling.
If it's not clear, I spent a big chunk of the last decade working in the disability field at an organization housed inside a large medical university.
posted by zenon at 1:43 PM on June 15, 2023 [16 favorites]
> or (common in NYC) "we don't take insurance"
Wait, what
Yep, many doctors in NYC don't take insurance at all.
In most cases it's just that they have weighed the cost-benefit and figured out that (a) there are a lot of rich people in NYC who will pay out of pocket for a good doctor, (b) there is a big cost associated with staying in-network and managing the relationships with the N major insurers in the area and submitting/fighting for claims (c) depending on specialty, they may be spending a lot of time fighting and get peanuts reimbursed anyway. There are probably other less savory reasons too.
posted by bgribble at 1:56 PM on June 15, 2023 [6 favorites]
Wait, what
Yep, many doctors in NYC don't take insurance at all.
In most cases it's just that they have weighed the cost-benefit and figured out that (a) there are a lot of rich people in NYC who will pay out of pocket for a good doctor, (b) there is a big cost associated with staying in-network and managing the relationships with the N major insurers in the area and submitting/fighting for claims (c) depending on specialty, they may be spending a lot of time fighting and get peanuts reimbursed anyway. There are probably other less savory reasons too.
posted by bgribble at 1:56 PM on June 15, 2023 [6 favorites]
Wow, I sure am glad that I moved away from NYC well before I needed a lot of healthcare on a regular basis.
posted by Halloween Jack at 2:01 PM on June 15, 2023
posted by Halloween Jack at 2:01 PM on June 15, 2023
I have fond memories of a pharmacist in the grottiest corner of England giving my non-fittest ass free Xanax. However, the English doctor also told me to "take a steamy shower" when I was coughing up this clumpy nasty mucus, which I was disappointed in even if it technically was good advice and good for the earth and antibiotic resistance and so on. I expected at least one prescription for my trouble in making the appointment.
It looks like a Labour government is finally about to get its turn in the UK, so I suppose they're going to really get into another round of privatization of the NHS. Those motherfuckers won't know what hit them... brutal scenes...
Anyway I will defend American doctors as they have to pay for their medical education out of pocket and all the other doctors get it for free or almost free, so I can't blame them for being greedy as fuck because they start out $400k in the hole. Nobody's making education any cheaper so I will just expect my doctor to swindle me a little bit longer...
posted by kingdead at 2:01 PM on June 15, 2023
It looks like a Labour government is finally about to get its turn in the UK, so I suppose they're going to really get into another round of privatization of the NHS. Those motherfuckers won't know what hit them... brutal scenes...
Anyway I will defend American doctors as they have to pay for their medical education out of pocket and all the other doctors get it for free or almost free, so I can't blame them for being greedy as fuck because they start out $400k in the hole. Nobody's making education any cheaper so I will just expect my doctor to swindle me a little bit longer...
posted by kingdead at 2:01 PM on June 15, 2023
The American system of healthcare was birthed into this world by doctors, who remain its greatest defenders.
Which doctors are you talking to? For that matter, which historians? Theodore Roosevelt and the broader Progressive movement don't seem like medical doctors to me. You know, generally the federal government don't either, and I mean Henry Kaiser was a fucking shipbuilder, so I have some concerns about the idea that he was a medical man himself...
Seriously, you are directing your ire at the wrong people. Not to say doctors are perfect--lol fucking no--but they are not the people who devised our current asinine system of medical insurance, and they are by and large not the people who are profiting from it.
posted by sciatrix at 2:06 PM on June 15, 2023 [9 favorites]
Which doctors are you talking to? For that matter, which historians? Theodore Roosevelt and the broader Progressive movement don't seem like medical doctors to me. You know, generally the federal government don't either, and I mean Henry Kaiser was a fucking shipbuilder, so I have some concerns about the idea that he was a medical man himself...
Seriously, you are directing your ire at the wrong people. Not to say doctors are perfect--lol fucking no--but they are not the people who devised our current asinine system of medical insurance, and they are by and large not the people who are profiting from it.
posted by sciatrix at 2:06 PM on June 15, 2023 [9 favorites]
Hospital systems are not run by doctors. The CEOs and Presidents are not MDs. The insurance companies set prices and decide what doctors you see and what hospitals you can go to and even what treatments they will pay for. The systems and insurance companies are working on establishing vertical and horizontal integration. Private equity has now joined the game and is buying up doctor's practices and making them employees who must meet a quota of patients seen a day or suffer a loss of income.
posted by Alcedinidae at 2:08 PM on June 15, 2023 [12 favorites]
posted by Alcedinidae at 2:08 PM on June 15, 2023 [12 favorites]
Groups of doctors, such as the R.U.C., can strongly influence payment rates for Medicare.
Payers routinely reimburse health-care providers for specialized procedures at high rates, but primary-care visits—which might include chronic-disease management, routine vaccinations, or smoking and diet counselling—generate lower revenues. This imbalance is due, in large part, to the Relative Value Update Committee (R.U.C.), an extraordinarily powerful group of doctors that advises the federal government on reimbursement rates for physicians. The R.U.C. consists of thirty-one doctors convened by the American Medical Association; it’s structured such that each specialty has an equal say. On the R.U.C., urology, thoracic surgery, and head-and-neck surgery have, individually, about the same representation as all of pediatrics. The Centers for Medicare and Medicaid Services (C.M.S.), which has final authority to set payment rates for Medicare, has in many years accepted the R.U.C.’s recommendations nearly ninety per cent of the time.
posted by bodywithoutorgans at 2:19 PM on June 15, 2023 [6 favorites]
Payers routinely reimburse health-care providers for specialized procedures at high rates, but primary-care visits—which might include chronic-disease management, routine vaccinations, or smoking and diet counselling—generate lower revenues. This imbalance is due, in large part, to the Relative Value Update Committee (R.U.C.), an extraordinarily powerful group of doctors that advises the federal government on reimbursement rates for physicians. The R.U.C. consists of thirty-one doctors convened by the American Medical Association; it’s structured such that each specialty has an equal say. On the R.U.C., urology, thoracic surgery, and head-and-neck surgery have, individually, about the same representation as all of pediatrics. The Centers for Medicare and Medicaid Services (C.M.S.), which has final authority to set payment rates for Medicare, has in many years accepted the R.U.C.’s recommendations nearly ninety per cent of the time.
posted by bodywithoutorgans at 2:19 PM on June 15, 2023 [6 favorites]
I work at a community college with a nursing program. Recently the director of that program gave a presentation and one short portion has really stuck with me; she said: "The patients our students are seeing are so much sicker than they used to be. It used to be years ago that we could put student nurses with patients who were ready to walk out but now by the time they get to the hospital they're so sick that they will be there for weeks."
I don't know about you, but while I'm not at all surprised, I am chilled to the bone by that statement. Of course they're sicker. Even with gold standard insurance nowadays it costs a lot to go to the doctor, if you can even find a doctor, if, if, if and eventually you end up in the ER or dead. Or both.
posted by mygothlaundry at 2:44 PM on June 15, 2023 [16 favorites]
I don't know about you, but while I'm not at all surprised, I am chilled to the bone by that statement. Of course they're sicker. Even with gold standard insurance nowadays it costs a lot to go to the doctor, if you can even find a doctor, if, if, if and eventually you end up in the ER or dead. Or both.
posted by mygothlaundry at 2:44 PM on June 15, 2023 [16 favorites]
It's a good idea not to generalize about doctors. But it's true that doctors' groups like the American Medical Association have historically strongly opposed single-payer health care plans like Medicare.
Still, there are signs of change at the AMA.
posted by Artifice_Eternity at 3:02 PM on June 15, 2023 [8 favorites]
Still, there are signs of change at the AMA.
posted by Artifice_Eternity at 3:02 PM on June 15, 2023 [8 favorites]
I'll go ahead and generalize about doctors. Most of them didn't study the liberal arts in college and it shows. They don't understand Capitalism and it's lack of concern for any metric but how much profit is made or how the late stage is monopoly. They dont understand that they are essentially workers. They think their high salaries are a reward for working hard. They could have actively advocated for Universal Health Care or Medicare for All during the health care debates but they did not. Most doctors, despite their often weird affect, really care about their patients well being. Their moral injury is real.
posted by Alcedinidae at 3:39 PM on June 15, 2023 [10 favorites]
posted by Alcedinidae at 3:39 PM on June 15, 2023 [10 favorites]
It's not simple, but here's some rallying points to work for the collective-us and not the individual.
Any MD's want to form a co-operative and find economies-of-scale for the collective populace without losing patient services to profit?
Any medical instructors interested in joining the collective co-operative to train medics without charging $$$ and incurring a lifetime of debt?
Any disruptors want to fund this with the goal of having lowest overheads for best patient outcomes and an exit strategy of selling out to the federal government?
posted by k3ninho at 3:40 PM on June 15, 2023
Any MD's want to form a co-operative and find economies-of-scale for the collective populace without losing patient services to profit?
Any medical instructors interested in joining the collective co-operative to train medics without charging $$$ and incurring a lifetime of debt?
Any disruptors want to fund this with the goal of having lowest overheads for best patient outcomes and an exit strategy of selling out to the federal government?
posted by k3ninho at 3:40 PM on June 15, 2023
Insurance doesn't have the clout to prop up and perpetuate the whole system. It's doctors.
is this backed up by gut feeling, a vendetta, or what? because the AMA very recently fought to reduce cuts to Medicaid, fought to get rid of the prior authorization hold insurance companies place on certain medications, and extend Medicare coverage to telehealth, and the AMA is known, at least to my left-leaning physician partner, as a kind of centrist organization that she pays no fees for and refuses to support because they're not radical enough
this centrist org has also been historically very pro-ACA and expanding the ACA
her, all of her co-residents, other doctor colleagues I've spoken to - they're all very interested in greatly expanding and reforming healthcare access. when I talk about socialized medicine, a lot of them are like 'yes, that would be so much better for all of us.' the ones who aren't are all surgeon and ortho bros but that group has always historically sucked in terms of their politics since the field itself is seen as prestigious (ie full of clout) and well-paying (ie way overpaid compared to PCP/EM/Psych/etc)
to blame the nightmare hellscape of American healthcare on doctors is to say that they actually really love minutely having to document everything they do so they have a complete bill of sale that insurance companies will always fight them on approving. I doubt most doctors are that masochistic even if they are an actual asshole
posted by paimapi at 3:55 PM on June 15, 2023 [16 favorites]
is this backed up by gut feeling, a vendetta, or what? because the AMA very recently fought to reduce cuts to Medicaid, fought to get rid of the prior authorization hold insurance companies place on certain medications, and extend Medicare coverage to telehealth, and the AMA is known, at least to my left-leaning physician partner, as a kind of centrist organization that she pays no fees for and refuses to support because they're not radical enough
this centrist org has also been historically very pro-ACA and expanding the ACA
her, all of her co-residents, other doctor colleagues I've spoken to - they're all very interested in greatly expanding and reforming healthcare access. when I talk about socialized medicine, a lot of them are like 'yes, that would be so much better for all of us.' the ones who aren't are all surgeon and ortho bros but that group has always historically sucked in terms of their politics since the field itself is seen as prestigious (ie full of clout) and well-paying (ie way overpaid compared to PCP/EM/Psych/etc)
to blame the nightmare hellscape of American healthcare on doctors is to say that they actually really love minutely having to document everything they do so they have a complete bill of sale that insurance companies will always fight them on approving. I doubt most doctors are that masochistic even if they are an actual asshole
posted by paimapi at 3:55 PM on June 15, 2023 [16 favorites]
I agree on the doctors lobbying against socialized healthcare - dentists in Australia also fought bitterly against their inclusion in socialized healthcare in order to preserve their high salaries and managed to win. As a result you get free healthcare in Australia, except for your teeth, which leads to many poor results (cavities, decay, gum disease, which then lead to many other health problems).
But did dentists make the right choice? General Practice doctors had their pay "frozen" by the government between 2013 and 2020, with fully qualified GPs today earning about $A17 ($US12) per patient.
posted by xdvesper at 4:13 PM on June 15, 2023 [1 favorite]
But did dentists make the right choice? General Practice doctors had their pay "frozen" by the government between 2013 and 2020, with fully qualified GPs today earning about $A17 ($US12) per patient.
posted by xdvesper at 4:13 PM on June 15, 2023 [1 favorite]
If it's not clear, I spent a big chunk of the last decade
I work medical front office, so I'm literally the one having to cause the moral wound of not scheduling due to insurance, or explaining away delays due to terrible staffing numbers.
Even as bad as that is, I'm really glad I don't have to work at the place where literally all the doctors are so I can form an opinion on them as a monolith. Must be exhausting to keep track of that, what between all the axe grinding and sweeping generalizations.
posted by Jarcat at 4:25 PM on June 15, 2023 [4 favorites]
I work medical front office, so I'm literally the one having to cause the moral wound of not scheduling due to insurance, or explaining away delays due to terrible staffing numbers.
Even as bad as that is, I'm really glad I don't have to work at the place where literally all the doctors are so I can form an opinion on them as a monolith. Must be exhausting to keep track of that, what between all the axe grinding and sweeping generalizations.
posted by Jarcat at 4:25 PM on June 15, 2023 [4 favorites]
About doctors who don't take insurance... I remember some articles from a few years ago about how some family doctors were doing it in order to be able to spend more time with patients and less on paperwork. Let's see what a Google brings up to refresh my memory...
Some family doctors ditch insurance for simpler approach (archive)
I'd be curious to know how it has worked out for those doctors and patients since then.
posted by clawsoon at 4:49 PM on June 15, 2023
Some family doctors ditch insurance for simpler approach (archive)
I'd be curious to know how it has worked out for those doctors and patients since then.
posted by clawsoon at 4:49 PM on June 15, 2023
- The American system of healthcare was birthed into this world by doctors
-- Theodore Roosevelt and the broader Progressive movement don't seem like medical doctors to me
America's terrible healthcare system has several culprits. To combat inflation, the 1942 Stabilization Act was passed [in part] to limit an employer’s ability to raise wages to attract workers when the labor pool was scarce. But the actual outcome of the law saw employers turning to alternate incentives, such as health insurance. Since health benefits could be considered part of compensation, but did not count as income, workers didn’t have to pay income tax or payroll taxes on those benefits.
Tax-exempt premiums, increased enrollment and interest, and tax subsidies for third-party insurance further reinforced the new system and laid the foundation for employer-sponsored insurance today.
We end up with shit like:
What's not covered by Medicare Part A & Part B?
Eye exams (for prescription glasses)
Most dental care
Hearing aids and exams for fitting them
Routine physical exams
Long-Term Care (also called custodial care)
What's more, the Centers for Medicare & Medicaid Services provides the bulk of the funding for hospital residencies. Hospital residencies are positions for recent medical school graduates to work in a clinical setting – usually at a hospital or doctor’s office – treating patients and continuing their training in a particular subfield. Residency durations vary by specialty. Even after medical school, an MD cannot obtain a license to practice medicine without at least one year of residency. The number of residency slots directly determines the number of licensed doctors entering practice.
Physician shortages are growing, exacerbated by caps on the number of Medicare-funded residency slots.
It's a deliberate, vicious cycle, with much sicker (and, ultimately, fewer) patients cared for by overburdened (and, ultimately, fewer) doctors.
posted by Iris Gambol at 4:56 PM on June 15, 2023 [5 favorites]
-- Theodore Roosevelt and the broader Progressive movement don't seem like medical doctors to me
America's terrible healthcare system has several culprits. To combat inflation, the 1942 Stabilization Act was passed [in part] to limit an employer’s ability to raise wages to attract workers when the labor pool was scarce. But the actual outcome of the law saw employers turning to alternate incentives, such as health insurance. Since health benefits could be considered part of compensation, but did not count as income, workers didn’t have to pay income tax or payroll taxes on those benefits.
Tax-exempt premiums, increased enrollment and interest, and tax subsidies for third-party insurance further reinforced the new system and laid the foundation for employer-sponsored insurance today.
We end up with shit like:
What's not covered by Medicare Part A & Part B?
Eye exams (for prescription glasses)
Most dental care
Hearing aids and exams for fitting them
Routine physical exams
Long-Term Care (also called custodial care)
What's more, the Centers for Medicare & Medicaid Services provides the bulk of the funding for hospital residencies. Hospital residencies are positions for recent medical school graduates to work in a clinical setting – usually at a hospital or doctor’s office – treating patients and continuing their training in a particular subfield. Residency durations vary by specialty. Even after medical school, an MD cannot obtain a license to practice medicine without at least one year of residency. The number of residency slots directly determines the number of licensed doctors entering practice.
Physician shortages are growing, exacerbated by caps on the number of Medicare-funded residency slots.
It's a deliberate, vicious cycle, with much sicker (and, ultimately, fewer) patients cared for by overburdened (and, ultimately, fewer) doctors.
posted by Iris Gambol at 4:56 PM on June 15, 2023 [5 favorites]
I'd be curious to know how it has worked out for those doctors and patients since then.
Ah, I see that the OP article also gets into this subject. Interesting that the American system has made itself so demoralizing and so full of profit-driven parasitism that going back to a time when it didn't exist has resulted in an improvement for some doctors and patients.
posted by clawsoon at 5:19 PM on June 15, 2023
Ah, I see that the OP article also gets into this subject. Interesting that the American system has made itself so demoralizing and so full of profit-driven parasitism that going back to a time when it didn't exist has resulted in an improvement for some doctors and patients.
posted by clawsoon at 5:19 PM on June 15, 2023
They dont understand that they are essentially workers.
They weren't always. At one time, a doctor had independent power. The article does a good job of talking about how they are turning into cogs in a private equity machine, and gradually waking up to that fact.
posted by clawsoon at 5:25 PM on June 15, 2023 [6 favorites]
They weren't always. At one time, a doctor had independent power. The article does a good job of talking about how they are turning into cogs in a private equity machine, and gradually waking up to that fact.
posted by clawsoon at 5:25 PM on June 15, 2023 [6 favorites]
Any MD's want to form a co-operative and find economies-of-scale for the collective populace without losing patient services to profit?
From my very limited experience interacting with the healthcare system (in Texas and Georgia), as well as anecdotal evidence from the family and friends who work in the industry, both in the care side and the office/admin side: those doctor-owned hospitals and doctor-owned co-ops tend to be the most expensive in the area. It seems that the patient-centered care is better, but they are just soo much more expensive than the other Corporate hospitals. Its like the difference between economy and first-class, you pay alot more and you get alot more.
posted by LizBoBiz at 5:27 PM on June 15, 2023
From my very limited experience interacting with the healthcare system (in Texas and Georgia), as well as anecdotal evidence from the family and friends who work in the industry, both in the care side and the office/admin side: those doctor-owned hospitals and doctor-owned co-ops tend to be the most expensive in the area. It seems that the patient-centered care is better, but they are just soo much more expensive than the other Corporate hospitals. Its like the difference between economy and first-class, you pay alot more and you get alot more.
posted by LizBoBiz at 5:27 PM on June 15, 2023
Am I off track to think of what's being described in the article as the beginning of the "adjunctification" of doctoring, where the goal is to have as much of the work as possible done by people who are highly educated, poorly paid, deeply indebted, and precariously employed?
posted by clawsoon at 5:57 PM on June 15, 2023 [3 favorites]
posted by clawsoon at 5:57 PM on June 15, 2023 [3 favorites]
Capitalism.
posted by AlSweigart at 6:07 PM on June 15, 2023
posted by AlSweigart at 6:07 PM on June 15, 2023
Part of the cost now is that every ancillary service, device, and consumable has set a price with the insurance payouts kept in mind.
No idea wtf the country does if Doctors go the way of Teachers and just... stop being Doctors en masse. There's no substitute and mortality is a far more immediate indicator than illiteracy.
posted by Slackermagee at 6:22 PM on June 15, 2023
No idea wtf the country does if Doctors go the way of Teachers and just... stop being Doctors en masse. There's no substitute and mortality is a far more immediate indicator than illiteracy.
posted by Slackermagee at 6:22 PM on June 15, 2023
Clawsoon, my sister and her husband recently left faculty positions in family medicine (at a hospital that was owned by private equity) to open a direct primary care clinic. They are both extremely happy with their decision. Neither were able to keep working there- it was eating them alive.
posted by rockindata at 6:59 PM on June 15, 2023 [2 favorites]
posted by rockindata at 6:59 PM on June 15, 2023 [2 favorites]
No idea wtf the country does if Doctors go the way of Teachers and just... stop being Doctors en masse. There's no substitute and mortality is a far more immediate indicator than illiteracy.
Nursing shortages show no signs of slowing, survey finds, Axios
US faces 'perfect storm' nurse staffing crisis, USA Today
Why the U.S. Nursing Shortage Keeps Getting Worse, Time
We're running out of nurses even faster than we'll run out of doctors.
It's the moral injury suffered by doctors but vastly worse; it's the unrelenting overload from both criminal cost-cutting and Covid; it's the structural brutality of the system utterly intertwined with the desire to help people who are hurting, so you can't stay but you can't leave until it breaks you.
We need to treat all health care workers like the life-saving, life-rebuilding carers that most of them are, which means money and time off and autonomy and just treating valued humans like valued humans. And then, y'know, teachers and child care workers and sanitation workers and food service workers and administrative workers and everybody else.
I can't imagine how someone can do a good job of diagnosing my symptoms or helping me form healthier habits when they're under attack from a sick system.
posted by kristi at 7:03 PM on June 15, 2023 [10 favorites]
Nursing shortages show no signs of slowing, survey finds, Axios
US faces 'perfect storm' nurse staffing crisis, USA Today
Why the U.S. Nursing Shortage Keeps Getting Worse, Time
We're running out of nurses even faster than we'll run out of doctors.
It's the moral injury suffered by doctors but vastly worse; it's the unrelenting overload from both criminal cost-cutting and Covid; it's the structural brutality of the system utterly intertwined with the desire to help people who are hurting, so you can't stay but you can't leave until it breaks you.
We need to treat all health care workers like the life-saving, life-rebuilding carers that most of them are, which means money and time off and autonomy and just treating valued humans like valued humans. And then, y'know, teachers and child care workers and sanitation workers and food service workers and administrative workers and everybody else.
I can't imagine how someone can do a good job of diagnosing my symptoms or helping me form healthier habits when they're under attack from a sick system.
posted by kristi at 7:03 PM on June 15, 2023 [10 favorites]
I remember in the early days of the pandemic, hospitals stopped doing elective surgeries, then pointed to the lost surgery revenue to justify layoffs.
posted by ryanrs at 10:52 PM on June 15, 2023 [4 favorites]
posted by ryanrs at 10:52 PM on June 15, 2023 [4 favorites]
> hospitals stopped doing elective surgeries,
One of the things that still sticks in my craw about that, is that word "elective" sounds like the right choice there but is actually super-broad.
Like my mother, a Stage 4 cancer patient, had a procedure repeatedly cancelled, that (if done in a timely manner) would have spared her many, many months of completely unnecessary excruciating pain. But I guess because it was not curing the cancer itself, but only dealing with a life-altering downstream effect of it, it was considered "only elective"?
Meanwhile my own surgery to remove a massively infected gland was postponed as "elective" because I guess you can continue dealing with by taking like 3 courses of antibiotics a month while your actual life grinds to a complete halt because you feel like dogshit all day every day, essentially indefinitely.
Because is no one single day where you can say, "if we do not operate today he will die," then that is considered elective?
Having some reasonable criteria to open up a certain percentage of hospital beds for dealing with Covid would have been very, very reasonable. But making "elective" the criterion seems, in hindsight, to have been pretty dumb.
Also, a really severe shutdown for like several weeks while things get sorted out, made plenty of sense. But, for example, in my mother's case we went along for months and months and months and months with no movement in that single flawed criterion "elective".
My frustration is a bit like when I got down to our kid's elementary school and neither the teachers nor the administrators seem to know anything at all about super-well researched and understood basic facts of child development. I understand why Random Joe on the street doesn't understand this stuff, but you are supposed to be educators by profession.
If there is one thing you would thing hospitals could get right, it would be making decisions about medical priorities in a public health emergency. This is like - supposedly! - right down the center of the alley of their exact area of greatest expertise.
The Covid/hospital decision making reminds me of the situations outlined in the OP's linked article in the sense that, in the health care system there are surely many individuals with the knowledge and expertise needed to make a good decision. But the system is set up in such a way that this sort of hard-won expertise is shunted to the side while the ideas of dunderheads and ignoramuses wins the day.
posted by flug at 12:55 AM on June 16, 2023 [3 favorites]
One of the things that still sticks in my craw about that, is that word "elective" sounds like the right choice there but is actually super-broad.
Like my mother, a Stage 4 cancer patient, had a procedure repeatedly cancelled, that (if done in a timely manner) would have spared her many, many months of completely unnecessary excruciating pain. But I guess because it was not curing the cancer itself, but only dealing with a life-altering downstream effect of it, it was considered "only elective"?
Meanwhile my own surgery to remove a massively infected gland was postponed as "elective" because I guess you can continue dealing with by taking like 3 courses of antibiotics a month while your actual life grinds to a complete halt because you feel like dogshit all day every day, essentially indefinitely.
Because is no one single day where you can say, "if we do not operate today he will die," then that is considered elective?
Having some reasonable criteria to open up a certain percentage of hospital beds for dealing with Covid would have been very, very reasonable. But making "elective" the criterion seems, in hindsight, to have been pretty dumb.
Also, a really severe shutdown for like several weeks while things get sorted out, made plenty of sense. But, for example, in my mother's case we went along for months and months and months and months with no movement in that single flawed criterion "elective".
My frustration is a bit like when I got down to our kid's elementary school and neither the teachers nor the administrators seem to know anything at all about super-well researched and understood basic facts of child development. I understand why Random Joe on the street doesn't understand this stuff, but you are supposed to be educators by profession.
If there is one thing you would thing hospitals could get right, it would be making decisions about medical priorities in a public health emergency. This is like - supposedly! - right down the center of the alley of their exact area of greatest expertise.
The Covid/hospital decision making reminds me of the situations outlined in the OP's linked article in the sense that, in the health care system there are surely many individuals with the knowledge and expertise needed to make a good decision. But the system is set up in such a way that this sort of hard-won expertise is shunted to the side while the ideas of dunderheads and ignoramuses wins the day.
posted by flug at 12:55 AM on June 16, 2023 [3 favorites]
I will add - there are undoubtedly many significant waypoints along the road to our dysfunctional health care system. But without question, one of the largest was the mass movement of hospitals and insurance companies away from non-profit organizations to for-profit businesses.
There are problems with every type of governance system, and I'm sure that is true of the non-profit health care & insurance models as well.
But the for-profit business model is fundamentally at odds with the goals of any reasonable health care system.
posted by flug at 1:00 AM on June 16, 2023 [3 favorites]
There are problems with every type of governance system, and I'm sure that is true of the non-profit health care & insurance models as well.
But the for-profit business model is fundamentally at odds with the goals of any reasonable health care system.
posted by flug at 1:00 AM on June 16, 2023 [3 favorites]
But the for-profit business model is fundamentally at odds with the goals of any reasonable health care system.
Non-profit doesn't automatically mean cheap, considering the average net margin for private hospitals in the US is about 5%, take that away most people couldn't tell the difference. I have a family member who volunteers at a non-profit hospital and during Covid it was common for even the non-profits to require a huge cash deposit upfront (equivalent to 4 years minimum wage) before they would even admit you for Covid treatment, because they have no idea how long you'd be occupying an acute care bed.
posted by xdvesper at 1:09 AM on June 16, 2023 [1 favorite]
Non-profit doesn't automatically mean cheap, considering the average net margin for private hospitals in the US is about 5%, take that away most people couldn't tell the difference. I have a family member who volunteers at a non-profit hospital and during Covid it was common for even the non-profits to require a huge cash deposit upfront (equivalent to 4 years minimum wage) before they would even admit you for Covid treatment, because they have no idea how long you'd be occupying an acute care bed.
posted by xdvesper at 1:09 AM on June 16, 2023 [1 favorite]
Because is no one single day where you can say, "if we do not operate today he will die," then that is considered elective?
It sucks, but: yes. That is what elective means. Anything that is not emergency (you're in an ambulance, full sirens, rushing to the ER) or urgent (you will die if we don't operate either today or tomorrow).
posted by Dysk at 1:33 AM on June 16, 2023 [1 favorite]
It sucks, but: yes. That is what elective means. Anything that is not emergency (you're in an ambulance, full sirens, rushing to the ER) or urgent (you will die if we don't operate either today or tomorrow).
posted by Dysk at 1:33 AM on June 16, 2023 [1 favorite]
Non-profit doesn't automatically mean cheap, considering the average net margin for private hospitals in the US is about 5%, take that away most people couldn't tell the difference.
Am I correct to assume that being a non-profit institution embedded in a for-profit industry, where most of your income comes from for-profit insurance companies, limits the gains you'll see from being non-profit?
I'm still amazed that y'all manage to spend twice as much per-person as anyone else in the world on healthcare.
posted by clawsoon at 5:09 AM on June 16, 2023
Am I correct to assume that being a non-profit institution embedded in a for-profit industry, where most of your income comes from for-profit insurance companies, limits the gains you'll see from being non-profit?
I'm still amazed that y'all manage to spend twice as much per-person as anyone else in the world on healthcare.
posted by clawsoon at 5:09 AM on June 16, 2023
Am I off track to think of what's being described in the article as the beginning of the "adjunctification" of doctoring, where the goal is to have as much of the work as possible done by people who are highly educated, poorly paid, deeply indebted, and precariously employed?
I am trying to think of how to make this comment without sounding like a free-marketeer, which I am not. But there are a lot of artificial constraints in the supply of doctors--Iris Gambol's comment about residents above is a good example--where you could imagine the restrictions being lifted and letting the market do some of its work, resulting in, not adjunctification really, but more normalization of being a doctor. Like, just make medical school free. Period. Removing the debt would allow many more people to become doctors, and would allow those doctors to choose traditionally less-lucrative specialties. A higher supply of doctors should tend to lower the price of seeing them, which would be good for patients. (One idea Dean Baker has talked about for years, is allowing doctors from other countries to practice in the US without the burden of having to go through residency here. This article explains, as well as describes the doctor-supply bottlenecks and their political/economic motivation.)
I'm not sure any of that will happen. It seems more likely that the supply of doctors will shrink further, with higher expectations put on nurse practitioners and physician assistants, and those numbers will continue to shrink as well. And...then what? Dr. ChatGPT? A program that will never complain about the burdens of documenting care in the EMR? Care doled out by CNAs reading off a screen? I don't like to imagine how bad this will get, and prefer to imagine at some point, we'll take the money out of medicine...but we just had the perfect opportunity during COVID, and we all see how well that worked out.
posted by mittens at 5:28 AM on June 16, 2023 [6 favorites]
I am trying to think of how to make this comment without sounding like a free-marketeer, which I am not. But there are a lot of artificial constraints in the supply of doctors--Iris Gambol's comment about residents above is a good example--where you could imagine the restrictions being lifted and letting the market do some of its work, resulting in, not adjunctification really, but more normalization of being a doctor. Like, just make medical school free. Period. Removing the debt would allow many more people to become doctors, and would allow those doctors to choose traditionally less-lucrative specialties. A higher supply of doctors should tend to lower the price of seeing them, which would be good for patients. (One idea Dean Baker has talked about for years, is allowing doctors from other countries to practice in the US without the burden of having to go through residency here. This article explains, as well as describes the doctor-supply bottlenecks and their political/economic motivation.)
I'm not sure any of that will happen. It seems more likely that the supply of doctors will shrink further, with higher expectations put on nurse practitioners and physician assistants, and those numbers will continue to shrink as well. And...then what? Dr. ChatGPT? A program that will never complain about the burdens of documenting care in the EMR? Care doled out by CNAs reading off a screen? I don't like to imagine how bad this will get, and prefer to imagine at some point, we'll take the money out of medicine...but we just had the perfect opportunity during COVID, and we all see how well that worked out.
posted by mittens at 5:28 AM on June 16, 2023 [6 favorites]
IDK if anyone will read this far, but one thing I haven't seen mentioned in the historical discussions is the extent to which doctoring in the US was originally an entrepreneurial occupation. Doctors were small businessmen, whatever else they also were, and until very recently all of their national organizations were dominated by people for whom the independent businessman/doctor was the ideal. I think this is one of the roots of the crisis, and the more doctors there are who get paid a salary for working 40 hours/week the better off society will be.
posted by Aardvark Cheeselog at 6:10 AM on June 16, 2023 [2 favorites]
posted by Aardvark Cheeselog at 6:10 AM on June 16, 2023 [2 favorites]
I don't believe the 5% margin thing, there's no citation and it can't be the sole loss to profit if also per-person spend is double other collectively-insured nations.
LizBoBiz: those doctor-owned hospitals and doctor-owned co-ops tend to be the most expensive in the area. It seems that the patient-centered care is better, but they are just soo much more expensive than the other Corporate hospitals.
I can imagine they are, but I also imagine that scoring on patients outcomes rather than price -- when really survival and quality of life are what's meaningful whatever the price -- allow you to make a compelling case that outcomes are worth the price and they deliver profit-making workers into society sooner with more people making preventative-type visits to healthcare services.
That aside, I also said "collective" and "economy of scale" so that those raw price numbers can deliver good quality of life for lower price points, cutting out the lost services which must be given up to pay profits.
posted by k3ninho at 7:56 AM on June 16, 2023
LizBoBiz: those doctor-owned hospitals and doctor-owned co-ops tend to be the most expensive in the area. It seems that the patient-centered care is better, but they are just soo much more expensive than the other Corporate hospitals.
I can imagine they are, but I also imagine that scoring on patients outcomes rather than price -- when really survival and quality of life are what's meaningful whatever the price -- allow you to make a compelling case that outcomes are worth the price and they deliver profit-making workers into society sooner with more people making preventative-type visits to healthcare services.
That aside, I also said "collective" and "economy of scale" so that those raw price numbers can deliver good quality of life for lower price points, cutting out the lost services which must be given up to pay profits.
posted by k3ninho at 7:56 AM on June 16, 2023
posted by bodywithoutorgansEpony-terrifying
posted by pulposus at 8:46 AM on June 16, 2023 [1 favorite]
I don't believe the 5% margin thing
Data is publicly available for publicly listed companies - anyone can pull up listed company reports which by law they are required to publish. It's rare for companies to earn outsized net margins (since competitors will enter the market) - if it happens consistently over several years it's most likely where one company has a monopoly type stranglehold on the market. In the short run, economic fluctuations can lead to outsized margins - right now banks, financial services, semiconductors and oil and gas are making a killing. Healthcare isn't where you want to be in right now if you're looking for profit.
Here is one dataset source, the average net margin for the 34 biggest private hospital conglomerates in the US is 5%. This page contains the file listing the 34 companies used.
For-profit companies have an incentive to cut costs and return more profits to investors. Not for profits aren't under that sort of cost pressure and will likely have higher expenses per patient as they pursue other goals such as patient outcomes.
Am I correct to assume that being a non-profit institution embedded in a for-profit industry, where most of your income comes from for-profit insurance companies, limits the gains you'll see from being non-profit?
The hospital I was talking about operates within a country with free universal healthcare. In fact, in Australia, where I live today, the private and public health systems and insurance providers operate alongside each other. Having a free alternative definitely puts a downward pressure on what private providers are able to charge, but there is always a minimum price dictated by the cost of provision.
posted by xdvesper at 9:00 AM on June 16, 2023 [1 favorite]
Data is publicly available for publicly listed companies - anyone can pull up listed company reports which by law they are required to publish. It's rare for companies to earn outsized net margins (since competitors will enter the market) - if it happens consistently over several years it's most likely where one company has a monopoly type stranglehold on the market. In the short run, economic fluctuations can lead to outsized margins - right now banks, financial services, semiconductors and oil and gas are making a killing. Healthcare isn't where you want to be in right now if you're looking for profit.
Here is one dataset source, the average net margin for the 34 biggest private hospital conglomerates in the US is 5%. This page contains the file listing the 34 companies used.
For-profit companies have an incentive to cut costs and return more profits to investors. Not for profits aren't under that sort of cost pressure and will likely have higher expenses per patient as they pursue other goals such as patient outcomes.
Am I correct to assume that being a non-profit institution embedded in a for-profit industry, where most of your income comes from for-profit insurance companies, limits the gains you'll see from being non-profit?
The hospital I was talking about operates within a country with free universal healthcare. In fact, in Australia, where I live today, the private and public health systems and insurance providers operate alongside each other. Having a free alternative definitely puts a downward pressure on what private providers are able to charge, but there is always a minimum price dictated by the cost of provision.
posted by xdvesper at 9:00 AM on June 16, 2023 [1 favorite]
It's one thing for the margin for the companies that are officially labeled hospitals to be around 5%.
But American health care is deep in coasian hell and there are also the margins for the ER physician group they contract with. And the margins for the neurology group they contract with. And the company that provides the nurses. And the company that provides the supplies. And the company that does the cleaning. And the company that manages the nurses. And the company that and the company that and the company that and the company that manages the companies...
posted by GCU Sweet and Full of Grace at 10:36 AM on June 16, 2023 [2 favorites]
But American health care is deep in coasian hell and there are also the margins for the ER physician group they contract with. And the margins for the neurology group they contract with. And the company that provides the nurses. And the company that provides the supplies. And the company that does the cleaning. And the company that manages the nurses. And the company that and the company that and the company that and the company that manages the companies...
posted by GCU Sweet and Full of Grace at 10:36 AM on June 16, 2023 [2 favorites]
where you could imagine the restrictions being lifted and letting the market do some of its work
the market currently dictates that prestige professions that cater specifically to the illnesses of the ultra-rich are prioritized (ie super expensive, time consuming, difficult to do surgeries that take up a lot of space, R&D, talent, etc) meaning plastic surgery, ortho, cardiology, urology, and gastro, in that order. at the bottom of that list? public health, pediatrics, family med, diabetes/endocrinology, and infectious disease. coincidentally, diabetes incidence rates is strongly correlated with socioeconomic status
fun fact - the only reason why Grady Healthcare, a non-profit, govt funded safety net hospital in Atlanta that bleeds money and forgives a lot of medical debt, happens to be a level 1 trauma center and has world class stroke care is because one of the cofounders of Home Despot was traumatized by one of his employees suffering a stroke in front of his eyes
the other city which has world class stroke care? Boca Raton, which is the other city that Bernie Marcus happens to spend a lot of his time
it is literally by the whims of billionaires that so much of our healthcare system exists and is able to innovate and provide care to a general population
see also the 'luxury hospital suites' that Emory has for its clients with more capital
posted by paimapi at 12:32 PM on June 17, 2023 [4 favorites]
the market currently dictates that prestige professions that cater specifically to the illnesses of the ultra-rich are prioritized (ie super expensive, time consuming, difficult to do surgeries that take up a lot of space, R&D, talent, etc) meaning plastic surgery, ortho, cardiology, urology, and gastro, in that order. at the bottom of that list? public health, pediatrics, family med, diabetes/endocrinology, and infectious disease. coincidentally, diabetes incidence rates is strongly correlated with socioeconomic status
fun fact - the only reason why Grady Healthcare, a non-profit, govt funded safety net hospital in Atlanta that bleeds money and forgives a lot of medical debt, happens to be a level 1 trauma center and has world class stroke care is because one of the cofounders of Home Despot was traumatized by one of his employees suffering a stroke in front of his eyes
the other city which has world class stroke care? Boca Raton, which is the other city that Bernie Marcus happens to spend a lot of his time
it is literally by the whims of billionaires that so much of our healthcare system exists and is able to innovate and provide care to a general population
see also the 'luxury hospital suites' that Emory has for its clients with more capital
posted by paimapi at 12:32 PM on June 17, 2023 [4 favorites]
As with soldiers, I fear it's only the most humane who suffer, here. I was on medicaid for about 9 months thanks to emergency covid procedures and my own mental health crisis. I've been dealing with the same crisis for over 20 years, scraping to get any type of coverage when I lost a job or moved and begging to see any type of help. Usually, that looked like 3-4 months of fighting depression to secure a meeting with a nurse practitioner to get my old prescription reinstated, maybe partially covered.
For the 9 months I had medicaid, my psychiatrist insisted on checking in with me every month via zoom to ensure that the medication was, yes, still working. She charged medicaid $550 for every 15 minute zoom call. This all while I was regularly seeing a therapist, so it's not like this was in anyway necessary to check on wellness. This is also about what I made in a week of work, being paid a bit above the minimum wage in the state.
So to me it clearly looks like my healthcare 'crisis' was a simple result of a non preventative system which BLATENTLY incentivizes doctors to treat patients with good coverage like cash cows and patients without coverage as non-existent. Did I miss anything major from this experience?
posted by es_de_bah at 4:36 AM on June 18, 2023 [2 favorites]
For the 9 months I had medicaid, my psychiatrist insisted on checking in with me every month via zoom to ensure that the medication was, yes, still working. She charged medicaid $550 for every 15 minute zoom call. This all while I was regularly seeing a therapist, so it's not like this was in anyway necessary to check on wellness. This is also about what I made in a week of work, being paid a bit above the minimum wage in the state.
So to me it clearly looks like my healthcare 'crisis' was a simple result of a non preventative system which BLATENTLY incentivizes doctors to treat patients with good coverage like cash cows and patients without coverage as non-existent. Did I miss anything major from this experience?
posted by es_de_bah at 4:36 AM on June 18, 2023 [2 favorites]
" ... MD's graduated with lots and lots of debt"
I get so tired of this. Decades ago, I attended a lecture given by a prominent physician at Northwestern Hospital. The upshot was that medical education was so expensive that he would not advise any of his children to go into medicine as a career. This was, like, the early 80's. Something about the guy rankled me, so I did a little, very superficial, research. My findings were pretty much that you would have to be one godawful doctor, or one majorly unlucky one, or a doctor carrying some sort of massive employ-ability red flag, not to be able to live a relatively comfortable life while paying off that massive debt in a reasonable 3 to 5 years. I say this while feeling that doctors are all we have left, the lawyers and Indian chiefs having gone into politics and casino management. I revere the medical profession. Headline: "Grade-Grinders Find Productive, Useful Life-work".
posted by Chitownfats at 7:21 AM on June 18, 2023
I get so tired of this. Decades ago, I attended a lecture given by a prominent physician at Northwestern Hospital. The upshot was that medical education was so expensive that he would not advise any of his children to go into medicine as a career. This was, like, the early 80's. Something about the guy rankled me, so I did a little, very superficial, research. My findings were pretty much that you would have to be one godawful doctor, or one majorly unlucky one, or a doctor carrying some sort of massive employ-ability red flag, not to be able to live a relatively comfortable life while paying off that massive debt in a reasonable 3 to 5 years. I say this while feeling that doctors are all we have left, the lawyers and Indian chiefs having gone into politics and casino management. I revere the medical profession. Headline: "Grade-Grinders Find Productive, Useful Life-work".
posted by Chitownfats at 7:21 AM on June 18, 2023
my partner had about 600k in student loan debts if you count the masters program she went to
we've now paid it down to about 400k and that's under the deferred payment program active under Covid
she is burnt out as hell - psychiatry work for people who care about others and aren't just pill milling it is emotionally exhausting. she just can't turn off the 'let's do a little free psychotherapy with your consult' instinct when she sees someone suffering
she very much wants to quit her job. with our mortgage, we have about 800k left to lay down. with both of our combined salaries and cutting out all huge expenses (we're the Aldi shopping, coupon clipping, clearance sale + promo code + cashback bonus type when it comes to all purchases who fly Spirit once a year and only vacation in places where we can stay with friends) it will take us 20 years to pay the remaining down and that's if we continue loving our relatively frugal lifestyle and continue contributing at least 10% of our income to charitable causes (much of which isn't written off since it goes to mutual aid programs)
perhaps it's possible that the cost of schooling, debt, and pay scales for doctors like for everyone else may have changed since your brief foray into the economics of MDs / DOs of the 80s? who knows! I'm sure pcp docs earning 180k annual starting wage who are forced into the grinder of 15 min visits with dozens of patients a day are loving life
posted by paimapi at 10:33 AM on June 18, 2023 [1 favorite]
we've now paid it down to about 400k and that's under the deferred payment program active under Covid
she is burnt out as hell - psychiatry work for people who care about others and aren't just pill milling it is emotionally exhausting. she just can't turn off the 'let's do a little free psychotherapy with your consult' instinct when she sees someone suffering
she very much wants to quit her job. with our mortgage, we have about 800k left to lay down. with both of our combined salaries and cutting out all huge expenses (we're the Aldi shopping, coupon clipping, clearance sale + promo code + cashback bonus type when it comes to all purchases who fly Spirit once a year and only vacation in places where we can stay with friends) it will take us 20 years to pay the remaining down and that's if we continue loving our relatively frugal lifestyle and continue contributing at least 10% of our income to charitable causes (much of which isn't written off since it goes to mutual aid programs)
perhaps it's possible that the cost of schooling, debt, and pay scales for doctors like for everyone else may have changed since your brief foray into the economics of MDs / DOs of the 80s? who knows! I'm sure pcp docs earning 180k annual starting wage who are forced into the grinder of 15 min visits with dozens of patients a day are loving life
posted by paimapi at 10:33 AM on June 18, 2023 [1 favorite]
I'm sure pcp docs earning 180k annual starting wage who are forced into the grinder of 15 min visits with dozens of patients a day are loving life
Sure beats doing something just as soul destroying for minimum wage!
posted by Dysk at 12:36 AM on June 19, 2023 [1 favorite]
Sure beats doing something just as soul destroying for minimum wage!
posted by Dysk at 12:36 AM on June 19, 2023 [1 favorite]
« Older The Façade, Not the Perversions | e-zee stuff Newer »
This thread has been archived and is closed to new comments
my partner was a psych resident and one of her psychotherapy-track mentors has been in a legal battle with the US govt. for... almost two decades now? and what did she do to deserve tens of thousands of dollars plus time spent in court that continues to dog her to this day?
she was the former President of the APA and longstanding member who had started an investigation into how the APA basically greenlit torture techniques
isn't that so cool, what our govt does
posted by paimapi at 10:46 AM on June 15, 2023 [26 favorites]