Throwaway05
1yr ago
You do realize the AMA primarily lobbies in support of lower salaries for doctors right?
Throwaway05
1yr ago
And yes, the idea that you need over a decade of training to do the majority of what people are paying for in the healthcare industry is absurd and broken.
Just so so wrong. Even in other countries with faster tracking the thing that gets cut down is undergrad (which is fair but hard to do in America, has its own significant problems, and is logistically unfeasible without completely uprooting our system in a way that isn't happening, and only shaves off two years anyway). We have some good evidence for this in the highly limited care given by providers - the NP lobbying groups best data says that NPs outcomes in simple cases is about equal with physicians outcomes in complicated cases (of course they jazz it up but that's what their data says, never mind the MD studies). Keep in mind that doctors are also the only ones getting that much training, everyone else is considerably less....and it shows. Ask any psychiatrist off the record about how the NPs and PAs are doing and they'll be able to convince you to never send a loved one to either.
As for your other point, flow chart care just doesn't work, no matter how much the MBA types may want it to. Decision support tools are miles off, for some godforsaken reason you can replace artists with an "AI" but the EKG autoread (which is one of the most computationally simple tasks imaginable) would get people killed if put in charge.
In addition to the always underestimated medical complexity, you have the human element - patient entitlement these days is sky high (as exhibited in this thread), people are always demanding things that are not indicated or are outright bad for them (ex: antibiotics for viruses) and your flowchart clinic would be immediately going off the chart or burned down.
That's not taking into the account the unacceptability of failure and legal environment, as soon as someone dies because of an edge case (which happens all the time) flowchart clinic would get sued into oblivion.
If you accepted upfront that 10% of people are going to have an unnecessarily bad outcome and 1% of people are going to die unnecessarily you'd be able to do as you say, but nobody is signing up for that. We (rightly so) value human life too much for that.
Throwaway05
1yr ago
Negotiating prices for services is not "extracting" money unexpectedly, being unaware of what the insurance will cover is not "surprising fucking over," the insurance knows what they will pay for and we often don't and have to fight them, even for clearly necessary stuff.
Hospitals can't know (as in knowing and changing your decisions as a result is illegal, specifically for emergency medicine) what the insurance is going to do, the agency is extremely limited.
In response to this sort of fuckery places have literally closed their EDs. Hospitals are going out of business at record rates and posting record lows for profit. Meanwhile the insurance companies are posting record highs.
What are they supposed to do? Break the law and not treat the guy? Just not get paid and then go out of business? Stop victim blaming.
And that's completely ignoring the other layer of this which I can't verify with the details OP provided, but the PA is probably owned by a third party - a private equity group that does enjoy the revenue associated with skull fucking patients and everyone in healthcare would love for that behavior to get banned but we don't have any control...
I don't know how the fuck the scummy companies won the psyop where they blame everything on doctors who have zero administrative or financial control.
Throwaway05
1yr ago
Surprise billing legislation (while superficially well meaning seeming) is a scam invented by insurance companies as a negotiating tactic, which is part of why its implementation is limited.
Throwaway05
1mo ago
That attitude leads to things like the opioid crisis where the rest of society is left cleaning up the mess left behind by people making questionable decisions.
A huge chunk of healthcare costs these days are associated with lifestyle related problems. That's going to get worse if you have 100k people fuck up their kidneys and need dialysis.
Negative externalities are a thing.
Throwaway05
2mo ago
Accept that you have a blind spot and give up, or choose to believe those who disagree with you on this have a blind spot and give up.
It's been explained to you simply, at length, and with repetition over the course of years and has never landed and therefore will likely never land.
I gave up years ago and Dean seems to have updated his mental model of you to figure that you are liar*.
I repeat that your model of how we perceive your behavior on this should be as a Darwin* - discussion will get nowhere and time will be wasted with pointless demands for more engagement.
*Apologies Dean if you disagree with these characterizations.
Throwaway05
1yr ago
Do you believe health systems should be forced to provide care for someone who has no willingness and/or ability to pay? (They are - if you walk into an emergency room and say I will not pay for any care you provide me they are legally required to give you the same shit as anyone else).
If your response is "you know what I don't want any medical care" then my complaint is withdrawn, but otherwise it sounds like you want to "steal" because you don't like how the process works and don't have a lot of information about healthcare economics.*
*From your other post it sounds like you've been on the receiving end of a practice called surprise billing, which is controversial and legislated against in some jurisdictions but exists for a complicated and justifiable reason but is still annoying, as is usual the problem is health insurance companies being pretty much straight up evil and then blaming everyone else.
As for your frustration with medical debt, if people refuse to pay their medical bills all the hospitals go under and nobody gets medical care. I can understand you're frustrated but these things exist for a reason.
Throwaway05
8d ago
If you are willing to explore changing medications (may not be safe depending on your situation) some of the medications in that class are more weight neutral than others.
Additionally depending on the pathology an alternate medication class might be available, especially if you haven't really revisited it in the years since you started (some things will require that type of med though).
Medicaid may cover a dietician which is better than nothing.
Your primary care may have some routine health suggestions (again a statin, some preventative care etc) or maybe even something like Ozempic.
Throwaway05
1mo ago
People fuck this up constantly. Educated people. Smart people. People believe in antibiotic stewardship until they have a cold and demand antibiotics "just in case." People take medications and are told "no really tell me if you start supplements or something really bad could happen" and then something really bad happens. People are told "don't eat before your expensive, time sensitive, maybe life saving surgery" and then they eat. Sometimes they die because they eat and we can't do surgery.
See front page of meddit today for a discussion on colonoscopies.
People can't be trusted to do a good job of this, and that includes health care professionals (including doctors). Thus the waves of verification.
Throwaway05
1mo ago
Being an excellent PCP is possibly the most difficult and cognitively demanding job in medicine. On top of that pay is shit, prestige is shit, so great people don't go into it but great people are needed.
Corporate pressure and increasing health problems means they have less time with patients but more to do than ever before.
It's a mess and I understand why patients feel mistreated but they also have no idea whats going on.
As for the specifics in the U.S. IM or FM can be a PCP after completing a relevant residency, with (some?) states having a process for being a "GP" with more limited scope of practice after completing certain levels of residency.
The U.S. is weird because all docs can technically do anything in medicine (unrestricted practice) but getting permission to do that in a particular facility, malpractice insurance, and getting patient's insurance to cover what you do is all complicated. Certain kinds of ethically challenged people manage.
Throwaway05
3mo ago
Yeah again saying I don't really agree with OP, but I do find it very plausible that American culture is significantly informed by immigrant communities that had a problematic relationship with addiction (ex: Irish, Borderers, Puritans (in the sense they hated that shit, would need evidence that such things were for cause)) and that generated and informed our toxic attitudes.
As an example, American pain and discomfort tolerance is overall pretty low with respect to seeking pharmacological intervention (notoriously noted in the opioid crisis but you can also see it with our OTC pain killer usage).
Throwaway05
1yr ago
My understanding is that the needing CPR twice was a miscommunication (likely because of something like "he was initially triaged in a resuscitation bay at the trauma center" which is a different kind resuscitation).
However even if he did have CPR twice that isn't evidence against commotio cordis, damage from "down time" (even with prompt high quality CPR) can lead to other problems like anoxic brain injury (likely avoided it seems), pulmonary damage (seems present), and issues with perfusion to other parts of the body that can lead to PT/OT needs. If your heart gets fucked up it fucks shit up. Not out of the woods after initial ROSC is obtained.
If you look at some of the initial medical social media discussion of this you'll see that some people were confused, commotio cordis is rare (and is more common in pediatric populations for physiology reasons) but that's what it looked like, pretty much slam dunk (ex: initial continued perfusion allowing to stand followed by sudden collapse). So we were wondering if it was an atypical presentation of something more "common" in this setting like hypertrophic cardiomyopathy.
I haven't seen a diagnosis released yet but cordis is most likely at this point and is pretty much a freak accident and has nothing to do with COVID.
Throwaway05
1yr ago
Nurses are leaving bedside nursing in droves and while some specialties are keeping up with retirement rates we are slipping behind our overall healthcare needs.
My problem is not that OP has a moral requirement to pay a bill no matter how stupid it is, it's that he doesn't know if it's stupid or not in this case, he (and everyone else) is blaming the wrong parties (the PA has no idea what's being charged and has no control over it, blame the insurance company or the hospital/practice management group that owns the PA). He also went to an inappropriate level of care and was surprised that costs were excessive. If you get admitted and demand to be in the ICU instead of on the floor it'll be your fault when the bill is an order of magnitude higher.
Throwaway05
1yr ago
Is this for real? The person billing OP wasn't even a doctor, and no PA, NP, or doctor is getting paid that much for that type of work. Blame the admin and the billing people for the number, the PA has no control over it and is making 1/10 of that sticker price.
Again, as stated elsewhere doctors have been lobbying for their own competition for years, who proceed to do the same job for cheaper, with less training, and do a demonstrably worse job.
I'm always flabbergasted at how little people seem to know about this in relation to how enthusiastic their beliefs are.
Also the NHS is collapsing.
Throwaway05
1yr ago
-Hospitals can't tell you how much things are going to cost because they don't know and insurances won't tell them they how much they'll reimburse. Insurance rules are complex, constantly changing, and do so with no notice, if a place says "it will be 500 dollars after insurance" they have no idea if that's accurate or enough, and that's when needs are static. And that's if you pretend cost of delivering care is static. It isn't. If a surgery costs on the median X a specific instance could be 0.8x (healthy thin young adult, 1.2x (obese 50 year old), or literally 100x (patient has a complication, crashes, ends up in the ICU). Is the hospital supposed to charge everyone 1.5x to cover for the one person who explodes? That's like involuntary insurance. Places will offer elective and simple procedures in a fixed price fashion but they are very very cautious with that.
-Healthcare in the U.S. is collapsing, many disciplines are moving out of public insurance (most OP specialties) or private insurance (psych, in a limited fashion). Hospitals and facilities are going under with enough frequency it is approaching a full blown crisis, but most of us live in big cities with a famous name brand academic hospital that just put up a 500 million dollar building and has a million billboards. Easy to miss the crisis.
-This process is not designed to extract money unnecessarily from patients, the insurance company is refusing to provide the paid for service and instead of refusing to pay the insurance company for sucking balls the patient is fucking a different victim who is also legally prohibited from retaliating. I don't understand how the hospital/practice management group (and keep in mind that no clinician at any point is involved with any of this) is the villain because the insurance company refuses to provide insurance.
-As is usual for legislation, surprise billing stuff has a tendency to be written by corporate interests that have a financial interest in making the stroke attending and the ED fast track PA the same situation on paper.
Throwaway05
1yr ago
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You should get insurance, this is what it is for. If you have a plan but it has a super annoying deductible....well yes that's how it works (if you don't and you were cash pay you should call the billing department as the other user pointed out, and then get insurance).
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I'm not sure if this will help but you should consider that (while it may appear superficially similar) medicine is not going to be like going to a mechanic. When you go to your dealership the work of analysis and diagnosis is often not paid for, then they'll tell you how much it is to fix the issue and you can take it or leave it. The cost is the labor and parts and replacement and repair. When you go to the emergency room you are paying the staff for the time and resources it takes to figure out what is going on. The treatment is often cheap (medicine, a splint, whatever) but the imaging, labs, and professional fees are time consuming and expensive. As a layman you aren't going to know what is going on under the hood (for instance in this case adults generally don't get nosebleeds that are bad enough to bring them to the hospital, so it could be because it's hella cold and dry outside, or it could be because the patient is having issues with clotting blah blah).
If you have chest pain and go to the ER, and after talking to you they give you tums and tell you to avoid spicy food the bill isn't for the tums it's for making sure you didn't have a heart attack.
Throwaway05
5d ago
It's also worth keeping mind that mental illness almost always impairs insight - your ability to understand and read your mental state may be hampered (not that the average person is truly good at this, but it can be more important in someone who struggles).
Many borderline patients hear the diagnosis and its description and go "thank god, that's me! it all makes sense now." Many go "no that's bullshit I AM TOTALLY FINE LALLAALAL................."
Throwaway05
1mo ago
Malpractice is heavily dependent on state and specialty, can be as low as 5k-10k or as high as well into six figures (OB). Some states have caps on malpractice payouts, some everyone get sued constantly.
Loans are for 4 years undergrad + 4 years of medical school. After that you get paid while working 60-80+ hours a week (but the pay is 50-70) while in residency. Residency lasts like 3-7 years depending on the speciality, and to do some disciplines (like Cardiology) you have to do additional years of poor pay training on top of the residency.
Once an attending most jobs are 40-60 hours a week but some stay higher than that. Depending on the field you may also work weekends, nights, holidays, 24+ hour shifts, 2 weeks without a day off etc. even as a senior doctor.
Throwaway05
5mo ago
Nah it was a historical problem back in the days of handwriting but these days communication is almost all by electronic medical records, sometimes people will give out hard prescriptions but it is easy for doctors to dial in and make it legible. More than spelling you used to have issues dosages and frequencies in the handwritten days though.
Incidentally many medications are either super easy to spell (often brand names) or absolutely fucking impossible without external help.
Throwaway05
5mo ago
My understanding is that several school districts across the country have periodically rolled out (and then revoked) what amounts to an "immersion" program for English grammar. It becomes popular, people try it and they realize it is crap, take it away....and then bring it back out years later. If you are raised during one of the rollouts...it fucking sucks.
Throwaway05
1yr ago
Short version: costs are weird, sometimes outright unknown (the accounting for some stuff gets bizarre), charges are generally inflated as a result an annoying dance with insurance companies and the federal government to get things paid for (ex: for a lot of stuff medicaid and medicare pay less than cost so things get...creative and the insurance company goes "we'll pay you 1.05 times the cost...").
Professional fees are like likely to do this because it's a little more obvious to pay out a portion of a staff members salary based off of how long the encounter is supposed to go (very doctors, NPs, or PA are self-employed these days, almost everyone is "owned" sometimes by a hospital but also by....).
Based off the absurdly inflated price and and the lack of willingness to negotiate (most health systems will be flexible with cash pay) (and also the fact this is the ED) the PA was probably owned by a practice management group which is when a PE firm buys a physician group and does things like cut salaries, raise prices, and be an asshole (and give the money back to whoever is invested in it). It's a huge problem right now.
It is also possible that this primarily driven by what happens when your insurance company just refuses to pay for things but that's less likely.
Throwaway05
1yr ago
Again, the entity extracting more money and surprise fucking over the patient isn't the hospital or the healthcare provider it's the insurance company.
OP paid the insurance company for a service (covering healthcare needs) and then the insurance company was like lol nah we aren't going to do that, and instead of refusing to pay the insurance company or complaining about the insurance company they take it out on essentially a third party with no control.
If I wire transfer some money to 419 scammers and then walk into a bank and punch an employee in the face for allowing me to get scammed then I'm the asshole.
The ED is literally required by law to provide care regardless of insurance status, ability to pay, or appropriateness of that level of care. There's literally nothing the ED can do to stop this, it's OP's job to go to an appropriate level of care, think critically about whether an ED visit is required, investigate his insurance, or get new insurance.
OP and the Hospital are both victims of the insurance company being an asshole.
Throwaway05
1yr ago
Pretty normal to sign a document that says you are financially responsible for accrued charges.
Consider that when you walk into the ED with chest pain you can end up with a million dollar suite of cardiac surgery or thirty cents of tums and everyone has limited idea to predict which it is going to be ahead of time.
Throwaway05
1yr ago
Ah you took this a different angle than everyone which is a better one.
-Restrictions on open immigration are not unique to medicine, no field wants to import competition and generally countries don't want to fuck over their knowledge workers. While the U.S. is notable for you needing to redo residency, that doesn't mean it's actually possible to move over (Canada and Australia will happily take U.S. docs but Germany is incredibly hard) for other reasons.
-Related to that, most countries aren't excited about this because in many countries a lot of people want to move to the U.S. because it's the U.S. or because salaries are higher. If you offered everyone in the NHS the chance to move to the U.S. healthcare in England would collapse instantly. So both the push and pull are blocked.
-Despite this if you wanted to import family medicine doctors (the only area that has true real need) from other countries I don't think anyone would complain, including the family care doctors.
-Training is strictly controlled in the U.S. and is better than elsewhere (mostly by being harder, potentially for no reason) but is also very much so less variable. You picked good countries but you couldn't do this with say India because of the training programs are absolutely U.S. grade and some are incredibly deficient.
-We don't have much of a shortage of doctors in most specialties, we have an allocation problem. Most doctors want to live in a relatively small number of urban areas so those places are flooded and everywhere else is lacking. The reasons for this are complex but increasing supply is unlikely to fix it, but doctors for clamoring for an increase in supply (in the form of residency spots) ANYWAY and have zero control it - blame the government.
-Physician political influence is abysmal right now, we've spent decades propping up our own competition, everyone hates us (because of envy of salaries, political involvement with covid, accusations of racism etc etc) and what lobbying we do do is just left wing politics.
-Physician pay is not unbelievably excessive. The average family care doctor makes 220k. That's a lot of money, but the ceiling is low and it comes with unbelievable sacrifices to that point. When people think of ridiculous pay they think of the orthopedic surgeon making 750k but those guys are less than 1% of doctors, over 90% of doctors are in primary care in some form and those people aren't making the "real" money.
-Medicine in general can be described as a skilled trade, that's what nurses are. Physician work cannot. In the U.S. doctors get training in (and are expected to use these skills) teaching, leadership/management, and research science. Depending on the field soft skills vary from mandatory to almost all of the job (as in Heme/Onc, Psych, and Palliative). On top of that some fields do have the manual skills. That is not an upscale plumber. In the U.S. we've made many attempts to drop in people with less training and skills and they do a demonstrably worse job and unlike in emergency plumbing people actually die.
Tylenol would not be approved as an over the counter drug if discovered today because of how easy it is to kill yourself accidentally (or intentionally) with it.
The average person has no idea how badly many drugs can interact with each other, recreational substances, and with medical comorbidities.
And that's ignoring other problems like the people who would give themselves antibiotics for viral infections etc.
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