Healthcare Reform

Off Topic Politics & World Issues
21

[quote]BostonBarrister wrote:
The AMA can argue all it wants about only letting the best, most qualified people in, but they’ve moved well beyond the point of “protecting” the public from the possibility of bad doctors – especially when this protection leads to an artificial shortage that makes good doctors practice poorly.[/quote]

Many countries in the world relaxed their rules and dramatically increased the number of people that managed to get into med school. The result? Complete disaster: skyrocketing problems with malpractice and negligence, with much worse consequences than the lack of people they began with.

As I mentioned on my post above, there is a fundamental lack of people who would indeed make good doctors or nurses. Personally, I believe the reason is mostly cultural, but others can argue most of us are wired to be dumb, selfish bastards. But the bottom line is that it doesn’t matter if it’s cultural or genetic – it’s reality, and proven all over the world, not only in the US.

What we need to do is a much better job of managing the people we have – namely, decrease demand by curbing the “ER-abuse” by enabling cheap – or, even better, free – preventive and routine care away from ER departments of hospitals, possibly performed by people that don’t necessarily have a medical degree. There are already hundreds of cheap colleges with basic degrees in healthcare that are teaching people to a level that would be enough for that kind of preventive and maintenance care. That would dramatically reduce the demand and the burnout of the people who do have the talent to be ER doctors and nurses.

Of course, those programs (for prevention / maintenance) should be properly audited, since even though mistakes in those areas are not usually lethal, it’s important to still guarantee a certain level of scientific quality.

Now, there is one clear thing that needs to be changed in Med Schools, but that has nothing to do with AMA: financial aid. The current Financial Aid (scholarships and loans) is absurdly insufficient to cover tuition costs (which cannot possibly be reduced, it is extremely expensive to train a doctor). The consequence of insufficient financial aid is that many talented people don’t even apply because they know they cannot afford it. THAT, my friend, is unfair.

22

[quote]mica617 wrote:
It’s not that there aren’t enough good techs/nurses/etc out there, it’s that the hospitals won’t pony up the money to create new hire positions for them. [/quote]

Huh? Heck, get them to move to the Bay Area then – just in a 15 mile radius from where I live, in between the hospitals there’s about 50 ER nurses positions open, about 150 (yes, you read it right) tech positions open, and 30 MD positions open. Just check the hospital’s website. If you take the whole CA state, it’s several hundreds of positions open, ready to hire tomorrow. And in the next 10 years, it’s projected that it will double every year (as Baby Boomers retire).

23

EMT, kewl. You guys see it all!

[quote]swiperfox wrote:
I understand, having worked a summer as an EMT I came across MANY situations in which the 911 call was unnecessary. The situation I was reffering to was an incident in which, while attempting to chip tile off my bathroom, I missed a hammer strike and caught my finger on the head of a chisel. I struck hard enough to have my finger explode out the side, opening a large gaping wound and turning it completely purple. I could have well bandaged it by myself, but was unsure if it would even close without stitches and thus I was brought to the ER (it was ~11pm on a saturday, so I’d have had to wait a day to see anyone otherwise). Ironically, the only concern I drew was due not to my injury, but a resting heart rate of 32 :slight_smile: (and that only lasted for about a minute)

I also think that often times patients are unaware of how critical or not their situation is, and fearing the worst head straight to the ER. Stomach pain was probably my most common ambulance call.[/quote]

24

[quote]hspder wrote:
BostonBarrister wrote:
The AMA can argue all it wants about only letting the best, most qualified people in, but they’ve moved well beyond the point of “protecting” the public from the possibility of bad doctors – especially when this protection leads to an artificial shortage that makes good doctors practice poorly.

Many countries in the world relaxed their rules and dramatically increased the number of people that managed to get into med school. The result? Complete disaster: skyrocketing problems with malpractice and negligence, with much worse consequences than the lack of people they began with.

As I mentioned on my post above, there is a fundamental lack of people who would indeed make good doctors or nurses. Personally, I believe the reason is mostly cultural, but others can argue most of us are wired to be dumb, selfish bastards. But the bottom line is that it doesn’t matter if it’s cultural or genetic – it’s reality, and proven all over the world, not only in the US.

What we need to do is a much better job of managing the people we have – namely, decrease demand by curbing the “ER-abuse” by enabling cheap – or, even better, free – preventive and routine care away from ER departments of hospitals, possibly performed by people that don’t necessarily have a medical degree. There are already hundreds of cheap colleges with basic degrees in healthcare that are teaching people to a level that would be enough for that kind of preventive and maintenance care. That would dramatically reduce the demand and the burnout of the people who do have the talent to be ER doctors and nurses.

Of course, those programs (for prevention / maintenance) should be properly audited, since even though mistakes in those areas are not usually lethal, it’s important to still guarantee a certain level of scientific quality.

Now, there is one clear thing that needs to be changed in Med Schools, but that has nothing to do with AMA: financial aid. The current Financial Aid (scholarships and loans) is absurdly insufficient to cover tuition costs (which cannot possibly be reduced, it is extremely expensive to train a doctor). The consequence of insufficient financial aid is that many talented people don’t even apply because they know they cannot afford it. THAT, my friend, is unfair.
[/quote]

Hspder,

It may indeed be true that other countries relaxed standards and achieved poor results, but that doesn’t tell us anything unless we know how those countries compare with us in terms of the quality of applicants they were turning away before hand and the level of their standards before they were lowered.

In any case, I rather think there should be more medical schools, and you should enforce the rigor in the standards at the level of practioner exams, i.e the medical boards.

25

W/r/t observations on incentives, insurance companies and health care, I think we should actually try a market system before we decide it doesn’t work.

We have a very strange “market” system, in that the consumers aren’t the purchasers, and the tax code makes it that way by essentially penalizing individuals economically who don’t want to (or can’t get) employer-provided health insurance.

It still wouldn’t be a real market, as you’d still have customers going through middle men (insurers), but at least the middle men would be answerable to the actual health-care consumers if individuals purchased their own policies. Getting a market akin to car insurance would be an improvement compared to what we have now with employer-provided health insurance.

Of course, if you “unpooled” individuals from the aggregation provided by employers, you’d run into thorny issues concerning incentives for the young and healthy to opt out (not unlike there already are, actually, but probably more pronounced) – especially as we’d need to decide moral questions such as whether insurers would be required to offer insurance to everyone, regardless of risk.

But I still think it would be an improvement overall from the current system.

26

[quote]BostonBarrister wrote:
It still wouldn’t be a real market, as you’d still have customers going through middle men (insurers), but at least the middle men would be answerable to the actual health-care consumers if individuals purchased their own policies. Getting a market akin to car insurance would be an improvement compared to what we have now with employer-provided health insurance.[/quote]

Health insurance is fundamentally different than car insurance because of two things: one, the fact that car insurance companies are allowed to recoup their losses by increasing the premiums of bad drivers; the other is that car insurance is much more widespread and health insurance, i.e., a lot more people have it, which basically increases the ability of health insurance companies to “spread the cost”.

If you removed the barganing power of collective clients, while at the same time reducing the number of people with health insurance even more (I’ll bet you that would happen!) the insurance companies would probably severely punish people that have history of disease, even when it’s not their “fault” (i.e., it’s not because of risky behaviors, but rather because of poor genetics). That presents a fundametal moral dillema: is it fair that people that simply are unlucky with their genes pay a lot higher health insurance? For example, my colleague who spends $300 a month on medication for his severe acne, or my friend who has severe hypothyroidism? How about people that have asthma? Should they foot the bill and shut up too?

You can’t play market rules with health insurance. Insurance companies don’t play by classic market rules, i.e, they don’t play by the “charging what people are willing to pay” rule. They play by risk management rules, i.e., they charge whatever they think is proportional to the risk of taking on a customer. That is fundamentally unfair.

I honestly believe that there is a middle-of-the-road system that is the least bad compromise and can be made to work: health insurance is kept in the hands of private companies BUT the Government establishes the rates and the rules – making sure that EVERYBODY gets health insurance, and gets it at the same rates, except for people with risky behaviors (like smoking, over-eating, etc.) – but not bad genes – that should definitely pay more until they clean up their act.

27

Has anyone mentioned that part of the problem is that medicine is now practiced to avoid getting one’s ass sued rather then based on what is strictly necessary? This is a huge issue that many outside may not be aware of (luckily this affects me only indirectly).

28

ScottL is absolutely right. And this kind of practice is an absolute necessity in this litigious society. The physicans who don’t practice this way get bitten in the ass much more often than those who don’t, in the form of frivolous lawsuits and complaints against them.

It is a kinda sad fact, and sad statement about our society, that the consumers do drive the market, and the consumers of healthcare themselves created this.

Many of us in healthcare have seen some of the best, most conscientious and upstanding physicians get in trouble because they practice medicine in what is ideally a credible manner; and some of the worst physicians get into no trouble because they really practice what I call “legal medicine”, which can be very costly for the consumers, the physicians and the system.

So practicing “legal medicine” is merely a matter of career survival for doctors, and this form of duress upon already taxed physicians is only compounding the coexisting problems in healthcare.

[quote]ScottL wrote:
Has anyone mentioned that part of the problem is that medicine is now practiced to avoid getting one’s ass sued rather then based on what is strictly necessary? This is a huge issue that many outside may not be aware of (luckily this affects me only indirectly).[/quote]

29

Perhaps a little off topic, but I find it rather disturbing that the pharmeceutical industry advertises directly to the public. I’m daily bombarded by ads for drugs which have dancing puppies and smiling people playing with rainbows, but in all that gibberish it is rare to even find out wtf the drug is for.

Why the hell would I ask my healthcare professional if suchandsuch is right for me when I don’t even know what it is. You have consumers demanding to be medicated, and if doctors don’t comply patients will just find one that will.

Why is it that doctors are educated about available medication by the very companies pushing their meds? Does this not seem like a conflict of interest?

30

[quote]ScottL wrote:
Has anyone mentioned that part of the problem is that medicine is now practiced to avoid getting one’s ass sued rather then based on what is strictly necessary? This is a huge issue that many outside may not be aware of (luckily this affects me only indirectly).[/quote]

Unfortunately, this statement is applicable much more broadly than to medicine… But you’re definitely right, and I think a couple of general reforms to legal systems would help immensely: damage caps, elimination of contingency fees (or at least a large reduction in the lawyer’s allowable percentage of any award), and adopting a “loser pays” system with respect to legal costs, like the British have.

31

[quote]hspder wrote:
What we need to do is a much better job of managing the people we have – namely, decrease demand by curbing the “ER-abuse” by enabling cheap – or, even better, free – preventive and routine care away from ER departments of hospitals, possibly performed by people that don’t necessarily have a medical degree. There are already hundreds of cheap colleges with basic degrees in healthcare that are teaching people to a level that would be enough for that kind of preventive and maintenance care. That would dramatically reduce the demand and the burnout of the people who do have the talent to be ER doctors and nurses.

Of course, those programs (for prevention / maintenance) should be properly audited, since even though mistakes in those areas are not usually lethal, it’s important to still guarantee a certain level of scientific quality.
[/quote]

After I started seeing patients at the beginning of my second year of acupuncture school, I was amazed at how well we treated certain conditions. It was rewarding to see patients get better without needing surgery, and also to see patients reduce or get off their meds. We were an example of a cheap modality with a near zero side-effect profile effectively reducing the need for more expensive interventions. However…

Eventually I realized that, while we did recieve more western science and medicial training than most other acupuncture schools (at Bastyr University), it still wasn’t enough for us to ethically act as gateway providers. This was unfortunate because for the cost-effectiveness of acupuncture to be maximized, the patient would see the acupuncturist first instead of being referred to one after an exhaustive number of tests were done to rule out any major organic factors.

So I decided to apply for an advanced masters level nurse practitioner program. I know there have been very few cases of an acupunturist failing to respond correctly to an emergency situation, but the possibilty of does exist. Hopefully at some point the amount of training in these areas will increase for acupuncturists. I had the pleasure of taking the first-ever biomedicine module for my national boards, so I am confident that we are moving in the right direction. But for now, I feel I need to supplement my knowledge with western medicine to ethically practice as a gate-keeper provider.