Happy New Year!
Do you have a dumb question that you're kind of embarrassed to ask in the main thread? Is there something you're just not sure about?
This is your opportunity to ask questions. No question too simple or too silly.
Culture war topics are accepted, and proposals for a better intro post are appreciated.
Jump in the discussion.
No email address required.
Notes -
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If your response is "you know what I don't want any medical care" then my complaint is withdrawn, but otherwise it sounds like you want to "steal" because you don't like how the process works and don't have a lot of information about healthcare economics.*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.
Having read through this whole thread, I wanted to say that I consider myself a strict capitalist in most things, but the whole industry of medical billing is so ridiculous for so many inscrutable reasons with everyone pointing fingers at each other that I find I'm unwilling to make any moral judgements at all for anything any particular patient chooses to do.
It is indeed pretty incredible that the situation is seen as ridiculous universally enough that the credit bureaus are now ignoring medical debt.
I don't know that I'm inclined or qualified to really defend any particular party in this mess. But I do notice that everyone seems to love to make the insurance companies the boogiemen. Aren't they all publicly traded though? If they're wildly profitable, can I invest in them and get some of that sweet healthcare cheat money? If not, well where's all the money going? What if they're just struggling to eke out some tiny profit while being constrained by an ever-changing maze of legislation and trying to juggle the conflicting demands of a dozen different groups, as the sole party with some responsibility to actually make the books balance somehow with the totality of everything that's going on?
Nothing about a market this regulated can really be described as capitalist. I don't understand how hard it is for people to draw the, to me, obvious line between level of regulation and dysfunction. Do people just think it's a coincidence that housing, medicine, schooling and banking are the industries everyone seems to constantly have problems with and costs seem absurd?
I agree, and that's why I don't consider the overall American healthcare market to be meaningfully capitalist from a consumer's viewpoint, and so in that case the morality of a capitalist system does not apply, in so far as owing the person doing a job for you a fair wage for the work that they performed.
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That's only if one believes that capitalism and regulation are somehow opposite to each other.
This so where the scope creep of what counts as "capitalism" makes the conversation impossible. The previous post seemed moderately in favor of "capitalism" so I interpreted as "relatively free markets". If we're going to switch to using the "cabal of capitalists control everything" then the response is "of course that's bad but it's never existed and no one would ever claim to be usually in favor of that".
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Everyone has an opinion about healthcare, almost nobody expressing this opinion has the slightest idea what's going on and that often includes people in healthcare, often this is downstream of politics (ex: docs foaming at the mouth at anti-vaxxers, or advocating for "socialized" healthcare without knowing what that means) or arrogance (the "medicine isn't hard or complicated" crowd you see here frequently).
Yes follow the money. Some high resource health systems are doing well, but many health systems are being bailed out or going under. Salaries are decreasing relative to inflation (or just overall), burnout is increasing and we've had a bunch of major major strikes/threats of strikes over poor pay and working conditions (like unsafe nursing staffing ratios). Meanwhile:
"The nation's largest insurers, UnitedHealth Group and Elevance Health, reported profits that were 28 percent and 7 percent higher than the same period last year, respectively. UnitedHealth raked in $5.3 billion, while Elevance took in $1.6 billion.
In contrast, some of the nation's largest health systems, HCA and Tenet, saw their profits fall dramatically compared to the third quarter of 2021. HCA reported $1.13 billion in profits, a decrease of 50 percent. Tenet took in $131 million, which is down 70 percent since last year."
Notably HCA and Tenet are both pretty evil companies (large for profit health systems) that will do WHATEVER to make a buck (and have been in legal trouble over it).
Medical billing isn't "ridiculous" okay well it is, but it makes sense and is a well defined system that a lot of people don't understand... but again people don't understand it but everyone is forced to interact and therefore has opinions. Providers become the punching bag for appropriate medical decisions patients don't understand and administrative/billing decisions that providers have zero control or influence over (having being pushed out of medical leadership and admin for decades, sometimes by complicated government mandate).
Speaking of which why is this shit so expensive? People like to blame salaries and labor shortages but that's a lack of understanding at best and jealousy at worst. Our population is getting less healthy (and other countries are catching up in costs as they become like us) and care is getting more complicated and expensive for good reasons. Additionally regulatory and administrative burden means lots of extra hands sucking at the teat. It's similar to academia (think professor to admin ratios, self-inflicted wounds like DEI staff etc).
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"these things exist for a reason"
so what? whether something has a reason doesn't mean the reason is good or justifiable; you don't describe any of those reasons or justifications so there isn't anything to respond to here
trying to portray this as some sort of moral choice binary where you either never seek healthcare or you're stealing if you refuse to pay any bill any random biller in any random medical black box decides to send you empty moralizing and a bad argument
anyone who has legitimately tried to find out what services are going to cost in the medical industry knows how incredibly and intentionally dishonest and obfuscatory it is
lots of people refuse to pay their medical bills now (especially the full amount) and yet more healthcare is delivered now than ever before
the user isn't claiming no one should pay medical debts, but that at most people shouldn't pay ones which are the result of asinine practices intentionally designed for this outcome which is asinine
if more people refuse to abide by these asinine practices, then the practices would end not that no one would provide medical care to anyone else anymore as is the case in states and countries which ban this practice
If you have your car repaired and drive off without paying you are going to get reported, and you certainly don't get to come back and demand the next issue be fixed. It's absurd. Even in outpatient land you can't fire a patient (even with just cause like total refusal to pay or blatantly abusive behavior) without jumping through a ton of hoops.
Rural hospitals and suburban/urban hospitals with poor payor mix (in a lot of areas/for a lot of types of care medicare and medicaid pay less than cost) are going under left and right, and other places are closing their EDs in an attempt to stem the bleeding associated with most of the people least likely to pay. It's not getting a terribly large amount of attention outside the field because it's mostly poor whites and the media/left feels awkward about leaving healthcare out to hang after so much superficial support during the pandemic.
This specific practice (this explanation is abbreviated)* is driven by insurance companies refusing to negotiate with physician groups and just say lol I'm going to underpay you, fuck you. When providers try and negotiate the insurance companies label this "surprise billing" and lobby jurisdictions to ban, knowing that the result is professionals have to just not get paid or accept the lowball offer. It's a negotiating tactic. In the last few years providers and low resource health symptoms have seen total crashes in economic health while high resource systems and insurance companies are doing fantastic, but they don't replace the resources that are closing and retiring.
About half of the psychiatrists in the country are able to retire and they are just fucking right off instead of staying and during a time of sky rocketing mental health crisis. We have limited ability to train replacements if we even wanted to (for a number of reasons) and the stopgap (Psych NPs) are uniformly terrible and create more work for the leftover physicians (psychopharmacology is a lot more complicated than most management, as in diagnosis).
*Their are other explanations, you have stroke and the one neurologist on call doesn't take your insurance. Either they let you die, or work for free/try and bill your insurance anyway.
Do you think billing for car repair is in the same zipcode as medical billing? When I ask for how much something is going to cost to a car mechanic, they tell me how much it's going to cost. I don't find out a month later that, actually, a ringer car repair guy which costs $10,000 flew in town overnight and did the work. This isn't an appropriate comparison and it's why your attempt at moralizing in this way falls flat. When a person is complaining about a specific reason why this practice makes nonpayment justifiable, your analogy need to address that specific aspect of the justification.
the healthcare sector at every level delivers more care at higher prices and higher pay than ever before
given that context, a claim that people refusing to pay bills in situations the OP described is going to result in no services being offered is a stretch
Are places which ban the above practice more likely to suffer the effects you're talking about? If not, I don't really understand the relevance beyond a general criticism for nonpayment.
when a patient criticizes a practice which is intentionally designed to extract more money in dishonest ways from patients, your response is to tell the patient they are morally obligated to either pay whatever bill is sent to them or not seek medical care at all and the real bad guys are those darn insurance companies
an easy response is for patients also not to pay, this is just "the system," tell you to whine into the wind at your congressperson, and blame those darn insurance companies
"we're getting screwed so we're going to screw someone else" doesn't magic some moral obligation on the part of the last screwed anyway
this justification is that you have more negotiating power over patients so you're going to use it to extract more money because you don't have that negotiating power against insurance companies; this aspect of the argument is even more true in the case of the individual patient vis-a-vis anything
okay, so what does this have to do with a physician's assistant in a non-emergency situation?
-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.
so how is this similar to the car mechanic bill situation?
besides, all sorts of other professions delivering all sorts of other services with non-fixed costs and complications manage to present agreed upon, known costs and estimates up front and don't send a surprise bill with an absurd amount attached
I've received healthcare at countries all over the world; there, despite the complications you describe w/re pricing, they're able to tell me an estimate which aligns with the bill I receive later. Even when there are complications. Even when a mechanic while looking at the drivetrain notices the transmission needs to be replaced. As far as I know, there is a single industry which does this and only in a single country in the world.
I am sure there are parts of the US which really struggle with medical services and have the problems you're describing, but on net no it is not or else it wouldn't be delivering more total healthcare, with higher salaries, and higher prices than ever.
Are places which ban the above practice more likely to suffer the effects you're talking about? If not, I don't really understand the relevance beyond a general criticism for nonpayment.
"Unnecessarily" doesn't have much explanatory weight, e.g., I promise to pay any bill I think is "reasonable," and I won't unnecessarily refuse to pay any bill I think it reasonable. This statement doesn't really mean anything.
Nothing about this is strictly "necessary" because if it was then it would be done in places which banned the practice except they don't and medical care is still delivered there. An accurate statement would be that they do it because they're trying to extract more money from the patient or their insurance, they don't have negotiating power with the insurance company, and so they're going to go after the weaker position patient.
no one has to be the villain here, but it also doesn't mean by default it's just the patient who has some moral obligation to get screwed and fork over whatever amount some derp bureaucrat decides to send them
I don't doubt that. Judging by the ACA, insurance company lobbying groups will find a way to make it even worse. If the legislation is similar to efforts in my field, it may help some random person like the OP accidentally in certain situations but will mostly be used by megacorps to put them in better negotiating positions.
Healthcare provision outside the U.S. is structurally different in a number of ways that fundamentally change the feasibility of what you describe like:
-Rates of nonpayment being orders of magnitude lower (a huge chunk of ED care is just not paid for by anybody, in most countries some combination of less recalcitrant insurance and single payor takes care of this).
-Our population is sicker and requires more care and more complicated care and more variable care (the number of patients with BMI over 70 in most countries is close to zero and that kind of stuff is more expensive to deal with and more variable than diseases of poverty).
-Other countries can ration and not engage in heroic care
-Related to that most countries don't have the legal environment. Malpractice related stuff is a huge driver of U.S. costs and complexity.
-You don't know what's going on under the hood with your bill, does the health system automatically write off most of the encounter for tourist patients because it's easier than trying to send a bill to another country? Is that care funded by something specific?
-The type of care where this likely to be relevant is stuff I'm doubting you are getting (how are you getting operated on in multiple countries????).
-Where are you getting this impression of U.S. healthcare? Costs are skyrocketing and health is plummeting but that's not a sign of health. Physician salaries have been decreasing relative to inflation for decades, not sure where you think higher salaries are coming from.
-Shockingly people are not willing to work at places which underpay or have a risk of not getting paid at all, this is doubly a problem because it's incredibly hard to get physicians and to a lesser extent midlevels to work outside of a major metropolitan area. Increase the risk of you not getting paid and nobody wants to work there. A hospital can't exist without providers. This is one of the causes of the death spirals leading to hospital closures recently.
-So is your claim that wanting to get paid for doing work "unnecessary?" That kind of attitude is why people are leaving medicine in droves. Not just doctors, nurses too.
-The villain is the health insurance company for not providing the agreed upon service, but if you say "no I'm just going to steal from someone else and demand the right to continue stealing" than the villain includes you. Again we aren't talking about a heart attack here, we are talking about care that shouldn't be initially triaged by an ED.
Yes, I agree healthcare provision is different in many ways, but that also sets the context for this entire discussion and criticism. Your argument is the end-user has a moral obligation to pay whatever $$ bill is sent to them (if you have some restricting condition, you have not yet mentioned it although I would assume you have some sort of "reasonableness" limit). You justify this by saying healthcare providers cannot refuse to provide services.
The main issue I have with this argument is you're using situations which do not account for the overwhelming vast majority of healthcare in order to justify practices and moral obligations. An example is your ringer neurologist to a patient having a stroke with other examples being almost entirely focused on ED care, but this is not representative of the majority of healthcare expenditures. Healthcare providers can and do refuse non-emergency care to people who they know will not pay for it. Perhaps in the context of megacorps and hospital systems, it is true individual doctors cannot de facto refuse care due to billing.
You set this context by essentially requiring the end user who is being screwed to think of it in situations which aren't representative and about individual doctors and other providers who have limited choice with pay structures likely irrelevant of whether or not each individual pays any bill sent to them.
But then, so what? This would be a systemic criticism, not a moral obligation on the final screwed person. The enduser can simply respond with your same moralizing back at you.
One, not a tourist. Two, your claim is that the healthcare system may automatically writes off tourist patients (I wasn't a tourist) and don't even bother at point of contact to tell them the cost and ask for payment? not that they give a bill they don't think will be paid
this criticism doesn't even stand on the face of it, it's little more than handwaving
knocks, stitches, broken bones, nose bleeds, etc., the kind of care which is being discussed as the example in the OP
again, you're using specific situations not described in the OP to justify obligations in other different situations
summaries of total delivered services, avg pay, total cost, number of ppl employed in industry, etc.
more money being spent and more people being employed to deliver healthcare to a populace which gets sicker and sicker every year isn't exactly a ringing endorsement of the healthcare being delivered let alone the healthcare system
no, my claim is that the practice described in the op isn't "necessary" and that the word "necessary" has little meaning in your sentence
I cannot find any support that "people" are leaving medicine in drones: more people work in "healthcare" now as doctors, nurses, etc., than ever before
yeah, well no one is saying that
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.
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Fundamentally, it sounds like you perceive that the problem is that people don’t pay enough for health care (whether that is through private insurance or through Medicaid).
This means that the hospital/physician is trying to take advantage of me because I am easier to negotiate with than my insurance company or the government. In the recent past where they could fuck my credit score they had most of the leverage and this would have worked and people like me would have been responsible for propping up a broken payment system. How is this not absurdly predatory?
Now that this is more difficult perhaps the AMA or the hospital lobby or any number of absurdly powerful interest groups which exist to guarantee the welfare of the healthcare industry, can take action on this instead?
I suppose they might also just increase bills so they always meet the 500$ credit reporting threshold but this will probably take them a few years since it will need to at least look somewhat what organic to avoid being sued by some ambitious attorney general somewhere.
The hospital and provider/provider group are definitely not making decisions based off of some credit reporting threshold, they don't have the time or energy for it and charges and costs are too often pegged to other things. The insurance company might be, can't speak to that.
I also make no claims as to if people aren't paying enough, I just want people to actually pay like they said they would (especially in the case of the ED where 9/10 visits are inappropriate and make things more expensive for the people who actually need the ED resources).
Now is the government or insurance paying enough, that's a separate question. No for some aspects of healthcare, in a very demonstrable sense (that is, if your hospital is being paid mostly by medicaid it WILL go out of business without another funding source like being directly propped up by the state government).
Another different discussion is "are providers overpaid" and while that's a much more nuanced question, in a very practical sense the answer is no - if you want to see a specialist outpatient (especially in something like neurology) you are going to wait two months or have private insurance. The healthcare sector of the economy has been trying to slowly boil docs with decreasing salary for decades and it's starting to boil over and you just wont get good care (or care at all in some fields like psychiatry) if you aren't rich. I'd not be shocked if life saving surgery is simply not available within the next 10-15 years because surgeons will just refuse.
But in this case the issue is that you have a problem with the customer service and overall service offered to you by your insurance company, and you are taking it out on the health system. The problem is the health insurance product you purchased not giving you what you want (because of blah blah negotiating with what's probably a private equity owned practice management group with no clinicians in the leadership structure at all). At no point was anyone directly in healthcare involved in what fucked you except for the person who actually helped with the epistaxis.
Generally speaking health systems are very willing to negate with patients paying out of pocket because the charges are made up as part of some bullshit voodoo dance with insurance and the government. The unwillingness to negotiate def increases the likelihood of that professional fee going to a private equity group (the PA probably got paid like 50 bucks for 30-45 minutes of work that was mostly invisible to you).
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I'm going to be a bit fiery here because this comment is top to bottom incorrect. It will never cease to amaze me how strong opinions on healthcare are with no experience, knowledge, or accuracy.
The minimum amount (with room for a lot a lot more) of training for a physician to practice independently in the U.S. is 11 years (4+4+3), there are some exceptions but they are very rare.
The person caring for OP who they are complaining about is a provider (a PA), not a doctor, and has a minimum (and essentially maximum) amount of training of 7 (4+3) years.
Physician lobbying groups have spent the last 15-20 years heavily lobbying for people outside their "club" to able to provide healthcare (providers), because they could charge for it in a supervisory capacity. Now it's biting them in the ass because those providers are lobbying for independent care, providing inferior and infuriating care (often while identifying themselves as doctors) and increasing costs (PA/NP care costs more but it's in stuff that the hospital/ownership group gets to take a bite out of instead of professional fees, for example unnecessary lab testing).
Fixing a nosebleed is harder than you think it is. A lot harder. A school nurse or a person at home can shove a tissue up your nose but that doesn't mean they are thinking about coagulopathy, and considering the risk of TSS, other infection, necrosis, know when to call ENT or to do a further work up and so on. Nasal packing for epistaxis is something requires a surprising amount of considering and critical thought, but you don't know that, the nurse doesn't know that, the PA probably doesn't know it, and an annoyingly large number of EM doctors don't know it. Ask a pediatrician.
Physician professional fees are a small portion of the cost of healthcare.
If I wanted to read 10k (or more) words to learn how to be less wrong about healthcare, where might I start?
(and yes I know you asked for a general primer but the point is to build knowledge of the unexpected complexity).
Here's an example-
https://old.reddit.com/r/Residency/comments/104bwb4/why_was_damar_hamlin_in_the_sicu_after_his/
Why is Damar in a SICU (Surgical Intensive Care Unit) - some people are saying that's best practice, some people are saying that's best quality of care, some people are saying that's because of the resources specifically at UC and some people are saying it is because the case is high profile. And you can find someone saying the opposite for each of those. Everybody knows what they are talking about.
No way to know unless you work there and were involved and some combination of those answers is probably correct.
Stuff is very resource and facility dependent and a lot of things don't have strong consensus.
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I learned how to effectively grade scientific literature by looking for places where you'd see the hordes of "SOMEONE IS SAYING SOMETHING WRONG ON THE INTERNET" types and seeing what they said, and then after years of that picking up the skills myself.
Go to /r/medicine or other similar places, look for the hot button stuff, see what people say and complain about. At first you'll be missing context but you'll pick it up. Bonus points if you also go to the other places with different levels of training like /r/residency.
Be aware of the biases of the various areas though (anything remotely political is DOA on meddit, it's appropriate to hate midlevels but the residency subreddit takes it a little far).
Very common for industry adjacent people to do this, you'll see consultants, tech people, and lawyers pop in with their expertise because they are following or work or because of a partner.
Most of the mistakes people make are pretty basic- assuming it's simple and easy, or because they are falling for one of the agenda pushers (including us).
If you look closely you'll probably see one of those situations where three people with over 20 years of training and who very are on top of it are articulately arguing over if something like if "is a bandaid is actually a good idea or not" and you'll be like Jesus this is a nightmare.
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You're incorrectly imagining that competition to the medical industry would take the form of a smaller less trained private healthcare industry that otherwise operates entirely the same as the current dysfunctional system. In reality it could be something like going into a clinic staffed by a couple of people with bachelors degrees who go through a digital flow chart and either refer you to a full hospital if the flow chart says it's beyond their capabilities, with an estimate of how much the hospital will charge so that you can be an informed consumer, or solve issue using a step by step guide that comes up immediately from the flow chart. This whole process could cost nearly nothing compared to going into a hospital and paying hundreds of dollars to waste an MD's time and be perfectly transparent.
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.
Really? What are the numbers under the status quo?
The unnecessarily is doing work for me but I can't construct any real numbers without a lot more clarification and information, for instance you could do OP's flowchart suggestion if you were cautious and dumped people to a real level of care at a drop of a hat (this is basically how urgent care works, anything that shouldn't actually be managed by a primary care gets sent to the ED and billed by the ED and the urgent care).
The idea that medicine is somehow not complicated is a common one but is indicative of near absent epistemic humility. I'm a doctor and probably in greater than 90th percentile knowledge of other specialties and I can't use the other disciplines algorithms at a standard of care level. The field is big, technical, but also fuzzy (thus the "Art and Science of Healthcare").
We can see this in revealed preferences in innumerable ways (ex: calling consults even when we are 95% sure what is going on because we don't want to make a mistake or get sued).
I sympathize but this struck me as the argument against self-driving cars: it's a difficult problem, there are fuzzy situations, as such it's basically impossible for the cars to drive perfectly, and therefore it's not a viable technology. But this is of course ridiculous: self-driving cars don't need to drive perfectly to be viable, they only need to drive better than the current humans on the road, who are as a group atrocious.
So the real question is, what number of people are dying "unnecessarily" or having "unnecessarily bad outcomes" under the status quo where care may be high quality but expensive and illegible to the end user, as compared to a scenario where care might be less cautious but more accessible. First, you seem to be implying that the base rate of unnecessary bad outcomes or death under current practices is much less than 10%/1%, but we know that medical errors are not uncommon. Is it less than those figures? How much less? Recent figures put the annual number of deaths in the U.S. due to medical error at about 250,000 annually. Is your position that this is substantially less than 1%, or that these are necessary errors?
Second, how many people don't go to the doctor because they are afraid of predatory billing or just because it's too much hassle? How many people experience complications from tests and procedures that had a low probability of being useful? How many people consume ER resources just because it's easier to ignore the bill than with a normal office visit? It's not fair to compare a potentially reformed system as a whole against a subset of outcomes under the status quo.
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I'm married to one, she disagrees. Most of her beefs have been with the embarrassingly dysfunctional nature of the hospitals she's been in that would never stand if there was real competition. EDs that either have no way of checking how many bed the psych department has open or for some reason refuses to believe either those tools or the doctors who tell them they have no beds. Spending countless hours on hold with pharma companies because for some reason totally inconceivable to me you need multiple doctorates to navigate call trees. The pure waste of it all has had me furious more than a few times.
If by "unnecessarily bad outcomes" you mean their nose bleed takes longer to figure out then sure I think people would be more than happy to deal with that and save hundreds of dollars.
No way this is accurate.
Why yes, we're discussing the legal framework your lobbying group has been enmeshed in creating. "We'll crush your upstarts like the pathetic little bugs they are if they dare" is precisely the thing I'm arguing should be abolished.
I refuse to believe she doesn't see a reduction in quality of care provided by mid-levels.
Ask her: "insert pet name here do you see any differences in quality of formulation and medication management (including things like benzo use) between NPs and MD/DOs?"
The rest of her relayed complaints are def real and accurate enough to make me believe you (and won't get any complaints from me, although as always theirs hidden complexity responsible for why those things are the way they are, especially the ED stuff).
Your nosebleed is not meant to be managed by an ED, your PCP should have same day sick slots. It's meant to be managed by a cost effective and cheap entity instead of the TRIGGER THE FULL IS THIS PERSON DYING APPARATUS (which they can't not trigger because liability). If they don't it's because PCPs are underpaid and overworked and most don't want to be one....
The AMA is the villain meme pisses me off so much because it's a "the sky is green" level take. At one point it might have been accurate but at this point the AMA has been lobbying against physician interests for decades and one of those things is deliberately increasing the amount of competition for physicians. Those idiots are on your "side."
And that's not getting into some of the shop talk level stuff here, you can't snap your fingers and make more surgeons for instance. If you gave every hospital a million dollars for every extra surgeon they trained (at the same quality as current) they just couldn't do it. For example currently we are talking about increasing the length of surgery residency (already 4+4+5+(0-3+)) because we can't train them adequately as is (because of the increase in robotic surgery and increasing specialization and IR and blah blah blah).
I don't necessarily have a problem with physicians themselves so much as this attitude that seems to be shared by so many of my partner's colleagues that nothing can possibly be done to fix these systems and instead all the complaints are about individual doctors or features of the system. I've spoken to developers of Epic or one of the Epic competitors briefly and they also noted Doctors are generally hesitant to streamline processes(and working in a heavily regulated industry myself I understand the people aren't the only source of change resistance). But when you have someone who received a decade or more of education personally spending most of their time doing tasks a bright high school student could accomplish it's time to seriously consider burning the whole thing down and restarting.
Maybe you've been burned by incremental changes not panning out in the past but you need to understand that from the outside looking in the whole system is insane and every anecdote I hear only further cements this view. Maybe people in the medical field are just so used to dollar amounts not meaning anything that they truly believe it is reasonable for packing a nose bleed to cost $500 but that's a rate for like, world's greatest expert to fly in and consult in any other field. I'm willing to believe you that there is some important art involved here but if that's how much it's worth to do that service there should be vocational classes for it and someone without an advanced degree should be doing it. The average hourly wage in the united states is something like $30/hour if we call the bandages a hundred bucks that is 13 hours of average wage to pack a nose, someone could make the average American hourly wage and do this procedure 3 times a week to be working full time. Obviously none of this is that simple but do you not see how this doesn't pass the smell test(no pun intended)?
These days physicians aren't in charge of anything, we've been pushed out of administrative and leadership roles (for a combination of reasons including legislation and the fact that nurses are scrambling for admin roles etc. etc.).
I'm not sure that's the correct read from the Epic devs you've spoken to, it's pretty common to use Epic installs as a way to hone broken processes but that's in the limited domains where physicians have control over workflow, which isn't too much. The admin side of things do want to make things more efficient and sometimes that works but other times things are weird for a reason (such as excessive regulatory burden) and people coming in from non healthcare business just can't get the complexity through their heads (Epic is generally good about this, but Apple and Google both dipped into healthcare IT and fled for a reason).
It is true that lots of doctors have limited technical ability and don't elect to use tools like hotkeys and that's probably what the devs are talking about. It's also true that doctors spend a lot of time complaining about documentation and administrative burden but then don't optimize their personal workflow. That's not a new problem though.
Re: the 500 dollar rate. The PA isn't getting paid that, 450+ dollars of that fee is going into whoever owns the PA (likely a private equity backed practice management group these days). Also possible that the charge is that high as part of the insurance negotiation dance and whoever owns the PA is just an asshole (again more likely with the outside investment). Also possible that OP is confused and it's supposed to be overall professional fee charge for the facility the ED is an extremely high level of care and the average patient might be using the services of 30+ employees or something else crazy like that (a lot of which is invisible like the cleaning staff and unit clerks).
People aren't supposed to go to the ED unless they need it.
Also for a lot of visits you don't pay for the service you got, you pay for the rule out (which may or may not involve additional testing).
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