This week’s New Yorker has another article by doctor and health care policy expert Atul Gawande. In the article he attempts to probe why medical costs in this country are spiraling out of control, singling-out one particular outlier in Texas:
It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.
McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami–which has much higher labor and living costs–spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns. [Link]
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p>By systematically eliminating all the likely suspects (e.g., it’s the lawyers and their malpractice suits that cause health care costs to soar), Gawande comes to a conclusion that many doctors probably already grudgingly realize through experience. It is doctors (not all, just the ones who increasingly advocate for tests that the patient probably does not need) who are driving up health care costs for everyone:
“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.
That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?
“Practically to zero,” the cardiologist admitted.
“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures. [Link]
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p>This issue will be of particular importance to the South Asian American community as we approach an attempt at comprehensive immigration reform by the Obama administration. As we well know, medical school students are disproportionately desi. These students will become practicing doctors who will have to choose to either be part of the solution or conform to the problem. I realize this choice isn’t as black and white as I make it sound but I assume there is some discretion. Some of it will boil down to the teaching philosophy employed where they trained and their motivation for becoming a doctor in the first place (e.g. wealth, intellectual curiosity, service, etc.). The greatest factor however, may be the market in which they serve. Gawande finds that there is a”keeping up with the Joneses” profit effect at work.
Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions–Boston, San Francisco, San Diego–became leaders in biotechnology while others with a similar concentration of scientific and corporate talent–Los Angeles, Philadelphia, New York–did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.
Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies–two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream. [Link]
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p>The article points to the Mayo Clinic as a hospital which bucks the trend through a concerted effort which puts the needs of the patient before revenue:
The core tenet of the Mayo Clinic is “The needs of the patient come first”–not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.
“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check. [Link]
I am guessing many South Asian American doctors read SM and I am sure this is a touchy subject. I would appreciate hearing your views after reading the whole piece in the New Yorker in addition to my post. Are there only two distinct choices as Gawande describes at the end? Do you feel you have a choice as to which type of medicine you choose to practice or are your hands tied by circumstance?
Its good that Mr. Mechanics mentioned the well known phrase ‘An apple a day, keeps the doctor away’ in his comment. I have, however, good reasons to suspect that Mr. Mechanics probably means ‘An apple a day, keeps the doctor away, provided you aim well enough.’
I’m only now reading the article. I actually just read Better over the weekend precisely so I could read the article in good conscience. But can I just say—shoutout to Gawande. I love how much his writing exemplifies South Asian American pride–and least of all b/c he’s a doctor. Besides being excellent in his chosen field, he’s pursued writing, has a strong sense of civic duty and a history of political involvement, is completely at home in and committed to America, but still deeply proud of and connected to being from India. Plus he’s got a wry sense of humor. This quote is perfect: ” in the past twenty years, he has done some eight thousand heart operations, which exhausts me just thinking about it. “
I’d like to think that if he was 10 years younger, he’d have been an immediate draftee for this blog. I highly recommend Better.
I totally agree-Better is one of my favorite books on medicine and the US healthcare system, a very good read and also one that makes sense even if you don’t work in healthcare.
Anything to keep away the forever smiling trio (doctor/pharma/insurance)!
From Renu’s post, it sounds like doctors would prefer to underplay nutrition and healthy habits, so that people turn into bundles of interesting and steadily progressing complications that:
1) Ring the cash counter and help doctors catch up for all the lost med school years
2) Allow doctors to play around with cool stuff, of which there is lots
I guess doctors are not people who get up in the morning and pray “loka samastha sukhino bhavanthu”, that wouldn’t be in the spirit of (current) medicine.
Bill Mahr made this comment that pharma companies don’t want you to be healthy, but they also don’t want you to die. They like you to be in that interesting (to them) in-between vegetative state, where you steadily develop new problems, so that they can keep selling you their hope in childproofed bottles. A rather remarkable way of looking at people.
Having had an autoimmune for nearly 20 years now, my optimism has taken a bit of hit (but will bounce back.)
In my particular disease (Crohn’s/ulcerative colitis) , the “standard” treatments have evolved from steroids and milder, relatively inexpensive drugs with bad side effects to immunosuppressive “biologic drugs” that cost a minimum of $15,000/year and have far worse side effects. Nearly all the new drugs are “black box” drugs. (Some are banned for pediatric use in the EU but cheerfully promoted/used here.)
I’ve been keeping up with the research and although underfunded, the most promising avenues for quality of life (there’s no cure here) and remission are with diet and much less toxic treatments (probiotics, “worms”, etc.)
Knock on wood, I’ve been ok with diet for quite a while but can barely make a dent in getting a doctor curious. (In regards to GIs, training has blinded many of them.) A recent visit to an office showed why, everything is pharma branded, pharma paid for–including research (and nutrition).
Anyway, on the side I try to help out people the best I can but the wall to getting money for non-pharma research done is 40 feet high with moats and gun turrets. They own the patient advocate groups and the writing of most of the journal articles. And it’s not obvious, it’s micromoves: a pharma company finds people are choosing fish oil rather than it’s product, they fund a fish oil study, fatally flawed, with a too high doses–somehow it becomes a defining article in NEJM.
I’m not against heavy meds, especially in acute situations but as the only choice in chronic situations, when alternatives exist, the promotion of these meds is nearly criminal–and damn expensive.
(Oh, and go Gawande! His books are great–single sitting nonfiction medical–unheard of:)
The only time I’ve ever needed allopathic medicine and doctor’s care was in India with my bouts of typhoid fever. Otherwise, over here, all I get is digestive problems when I don’t eat right, which are cured by………… eating right. Or colds that are cured by fasting from solid food and drinking ginger tea. Or allergies which are cured by abstaining from dairy and eating alfalfa daily – either in the forms of sprouts or tablets or tinctures.
Let thy food by they medicine.
Consider yourself fortunate that you’re in good general health and free from accidents. I have been similarly blessed myself, but most healthcare costs aren’t borne by people like us. It’s from people with chronic conditions like asthma or diabetes and it encompasses more people as they get older.
I feel relatively healthy on the outside, but who knows? There could be something growing within me. The thing is; I don’t have insurance and without that, I can’t get tested for anything. I never ever ever go for a “general check up”, because I don’t have a general family practicioner doctor nor insurance, therefore I am sort of “forced” to practice “preventative medicine” by eating as healthy as economically affordable.
But who knows? maybe one day my genetics will catch up with me and I’ll get what some of my other family members got. But even then, doesn’t look like I’ll have insurance to do anything about it.
I know people who, once they take a job with a company that offers good coverage, they go in for every test under the sun, even though they look and feel healthy. All the tests come back negative. So they basically wasted thousands of dollars. How spoiled some people are!
Meanwhile, there are people with very real health issues who do not have any insurance at all.
This is a big part of the problem–I assume, therefore, that you don’t eat, b/c you lack “food insurance,” and you’re homeless b/c you don’t have “apartment insurance” to pay for housing.
I eat because I can afford to do so. However, I don’t eat the quality of food that I would prefer all of the time because I cannot afford to go 100% organic and local, therefore I keep it at around 50%, all due to my economic situation.
I have gone to the free clinics spotted in various “hoods” (ghettos) around here, when I have felt something more serious than a tummy ache. That was just a few times. But they just gave me free heavy duty allopathics with side effects that I did not take to the full completion.
When I feel overly stressed, I will pay for a massage. Sometimes I will buy homeopathic remedies in the health food store in cases where I feel flu like symptoms coming on (rarely).
I did have to go to the emergency room once and they were forced to take me, treated me like sh*t, and gave me a few tests and still couldn’t figure out why I had the attack.
Of course, I had no insurance and no money to pay for the few hours I spent there (bill came to $2,000 bucks!. So they handed my name and SS number over to some agency that harrassed me every month for about 2 years, and of course, the bill has now grown to, oh I don’t know – maybe $7,000?
Can’t pay it. Never plan to.
I’ve had better medical care in India.
and thus this is the root of many of our healthcare costs in this country. Have you looked at getting health insurance on your own? You can purchase a policy without your employer and from what you said earlier you are fairly healthy-thus you should be able to get a policy for just about what you pay for that massage each month.
Healthcare is a privilege not a right…..if your water heater breaks you don’t expect the plumber to come out and fix it for free do you? Thus why in the world would you expect to end up in an ER and get treated for free?
No. I never thought about getting health insurance. I have no fixed residence and I travel a lot – internationally. It just doesn’t make sense for me. I do not have the lifestyle that everyone else has.
I was under the impression that hospitals have to treat people in emergency for free and not harrass them. Then later I found that only some hospitals do that. Not the one I went to when I was visiting a town I had never been to before. My hosts called the only place in town they knew. Or they just called an ambulence and the amublence took me there of their own accord.
I had no idea how to work the system. I thought about giving a fake name and SS number, but then I thought, “everyone has access to immediate info via computers today, if I do that and she puts it in the computer system then it might flash “no such name and SS number exists” and I would have been caught in a lie.
I don’t know how it is for nuns and monks of major religiouns like Catholicism, are they provided with insurance from their religious organization? Anyway, we are not.
Um, in the US. In many countries it is a right. You could say even in India ER is a right.
“Healthcare is a privilege not a right”
That is sounding like (gasp) Nazi germany state policies. Healthcare, yes maybe, but emergency healthcare could be looked at differently.
Godwin’s Law. You lose.
If it actually requires an expenditure of resources to obtain then it cannot be a right. Healthcare is a service and you have no right to force society to render it to you unless society has entered into a long-standing agreement to do so.
You can have the government create an arrangement to pay for them to render you that service, but that makes it an entitlement and not, properly speaking, a right. More akin to a contractual obligation than a moral imperative.
Have you been to McAllen TX? Sit in the ER of any of those hospitals in any of those border towns and watch the number of women that come in from Mexico 9 months pregnant and barely making it just so that they can have their child in America. Do they have the right to deliver a baby in the ER with no pre-natal care and a baby that probably will end up in the NICU for months and months costing you and I thousand of dollars because they have no insurance and no way to pay? Sit in the ER of any Houston hospital or any hospital in Miami and watch the same thing unfold-day after day. Hospitals in this country must stabilize a patient in an emergency yes-EMTALA was put into place for a reason, but the emergency departments in this country are being used as primary care clinics…and the issues that surround this are much to complex for this blog.
Health care is a privilege? So people who are sick with incurabale diseases are privileged to take food out of their kid’s mouths so that they can live a painful life? There are people who pay more in a month for health insurance than their mortgage.
Why should people have to live like that?
Someone has to pay for it. If you’re not paying for it yourself someone else is. Hence, you are privileged to enjoy the use of the service.
It’s not fair that people should have to live like that but that’s the way of the world. You can take it up with God.
Alternatively you can create an entitlement program which is still not a right, but mitigates the harm that comes from poor health.
I’m wondering what you all think about the welfare state in this country that basically pays single women to have babies. I’m going to assume that none of the people that frequent this site have had anyone in their family or social circle that has gotten pregnant on purpose – just to get goverment benefits plus child support benefits from their baby daddy. Beleive me, it is going on. People are basically being paid for being dysfunctional and lazy. Myself on the other hand, who cannot even conceive of doing something so deceiptful, seems to be chastised here just for not being able to pay one ridiculously overpriced emergency room bill.
I don’t think people like me, who happen to have a one off emergency room bill that they cannot pay are the root of many of our healthcare costs in this country as stated above here
You might want to get on the case of all those hundreds of thousands of single moms and deadbeat baby daddies who are purposely and shrewdly milking the system for all its worth.
Yo.
We pay for Wars, why cant we pay for the health of society? I thought Altruism was a good thing?
If an increased tax prevents someone from going out to dinner less then I really dont care. If you cant buy your daughter a $80,000 car for her birthday and can only buy her the $40,000 one then my heart goes out to you. “That’s the way the world is” is such a weak argument.
the two paras seem contradictory. i would agree with the first one. if society does agree to healthcare and the expenditure is coming from society itself (taxpayer money) then healthcare does become a right. the government is meant to a be facilitator for what the people want done with their money. i am assuming that in countries where there is universal government provided healthcare people have approved this spending of their own money…i hope i am right abt that!!!
can anyone point to good studies (polls) that indicate what americans prefer in terms of healthcare – universal, government controlled or otherwise
Found this on CNN the other day:
http://politicalticker.blogs.cnn.com/2009/05/29/cnn-poll-americans-ok-with-more-government-influence-in-return-for-lower-health-care-costs/
What would be a right under this definition? Everything requires resources.
The kind of things you find under the bill of rights. Freedom of speech, protection from unreasonable search and seizure, and so on are actual rights because it doesn’t involve you demanding services from anyone.
We don’t have a “right” to drinking water, for example. Clean drinking water is a great thing to have and I’m glad the government provides it for us. As residents of municipalities in developed areas we are entitled to have it provided for us. But it wouldn’t make sense to refer to it as a right.
Here is my point by point rebuttal of the erroneous statements/myths made in the comments here
1) More doctors = cheaper care. WTF…..are you people kidding? Do you really think we doctors control what a patient pays for their healthcare. More doctors simply means less pay for doctors because there will be an increased doctor to patient ratio however, to the patients – the cost would be the same. Why is that you ask? BECAUSE THE INSURANCE COMPANIES AND MEDICARE DECIDE WHAT WE DOCTORS GET PAID AND WHAT YOU THE PATIENT PAYS. Please don’t forget that last statement. I have no control over what I charge someone who comes in for hypertension. I assign the ICD9 code and get paid a set dollar amount for it. Same as you have no control over your co-pay. So no…more doctors only means less pay for doctors and maybe increased options for patients however, it WILL NOT translate to cheaper coverage because the insurance companies will still milk patients/doctors for the full cost.
2) I can’t believe that the patient bears the “weight” of their healtcare rather than the physician: Wait a second here….it’s your health…..you should bear the weight of it. The day you decide to have that extra donut, to smoke that extra cigarette, have an extra french fry, eat the extra burger, not walk that extra mile, not ride that extra 15 mins on the bike; that day you decided to carry the weight rather than let it off. The costliest thing to America’s healthcare system is that 500lb 22 year old kid in the hospital right now who has been left there by his mother because she can’t deal with him and he is too weak to walk. So he is sucking up medicaid to the tune of $1000+ daily because well his mom didn’t want him at home and he needs rehab. And, guess who is paying for his rehab –> medicaid (ie. you)!
3) Doctor’s ordering unnecessary tests: well don’t sue the doctor after your dad dies of brain cancer. Because when he/she told you that your dad’s headache is only 1% likely to be brain cancer so he doesn’t need CT Scan of the head he was actually right. So was the doctors analysis of your dads situation wrong: NO……will he be liable: ABSOLUTELY…..why is this a problem?….because even though the doctor had no control over your dad getting brain cancer and dying; our culture of blame causes you to blame the doctor for “missing something” the would probably have killed your dad eventually anyway. Thus, the doctor orders tests that are not needed.
4) Replace primary care docs with NPs/PAs/DNs: forget that…..across the board that has proven to be wrong. Every practice that uses NPs/PAs/DNs ends up costing more to healthcare because they get specialist consults WAY TOO SOON!
5) Everyone has the right to life: No not true. When you are the 80+ year old patient screaming in pain, with pneumonia, dementia, heart failure and you had absolutely no quality of life before coming to the hospital and will likely be EVEN WORSE after you leave this time; you should probably be allowed to peacefully die. Morphine is a hell of a drug. Use it. And watch you and your family’s health care costs disappear. And please please please don’t sue the physician that actually suggests this course of action and not the one where you end up being intubated, sedated, confused and infected for days on end only to die a horrible death while someone does chest compressions to “save” you. Because, well only ~5-6% of coded patients actually survive the code.
6) Immigrants – it’s the damn immigrants that cost so much: yea ok…maybe the few that know to walk off a plane and walk into a hospital with a diagnosis do cost us some. But most of the others don’t even know the options they have available to them as far as healthcare is concerned.
7) Doctor’s are cliquish thus, they can’t understand “us normal people”: WTF!?!? who do teachers interact with the most: other teachers. Who are engineers closest with: other engineers. Where do the bankers go out to have drinks: the happy hour where the other bankers are. Who do the freaking basketball players play with: other basketball players! What is wrong with you people: OF COURSE you are going to be closest with people of your own profession – it’s the group of people you have the most in common with. Why that is wrong – I just don’t understand. Moreover, dont’ you want your doctor to be a book smart/cliquish chump: she then knows how to treat you and knows who to refer you to if she doesn’t.
8) Ban drugs that don’t meet cost/benefit ratio: good luck getting that accomplished in a democratic society. If that happens you can forget about EVER getting treatment for aggressive cancer. At best most chemotherapeutic agents increase life span by 1-5 years. Most less than 1 year. Good luck getting that approved in a world where benefit is above cost.
Flame away!
Are you suggesting morphine for pain relief or for suicide, or assisted death?
Anyway, I agree that if someone is living out their last days miserably, they should be allowed to die in peace and with dignity. In fact, talking to a lot of elderly people, they would prefer that. Their attitudes are generally along the lines of “I’ve lived a full, long life. Don’t let me get to the point where I’m a vegetable. I’d rather have a peaceful, prepared death”. It’s usually a few of their family members who voice strong objections to letting them go, drowning out the voices of the other family members. The way to avoid this is to get them to put it in writing.
As far as the “extra” donut or hamburger. Many health experts would say even one burger or donut is enough to do some sort of damage. I think we all agree that a “healthy” diet is ideal, but what constitutes “healthy” differs from person to person and expert to expert.
I for one would never deem a meat based diet as “healthy”.
So where do we draw the line?
@ Annoyed MD.
I think someone watches a little too much “House”
I would like to reiterate one point – the government already pays for over half of all healthcare in America, and so rationing is going to be inevitable soon.
Why?
Because the US government doesn’t have the money anymore. We have a 1.75 Trillion dollar deficit this year, and there are no surpluses projected for the foreseeable future. What does this mean? It means that as soon as the government can’t borrow the money to pay for Medicare, it will have to print the money. This won’t be done beyond a point, since it would result in rampant inflation.
So fear not, the problem will solve itself in the next few years. The government will be forced to ration. That rationing could take many forms: limiting end-of-life care, quality-based rationing, or even simply allowing the Medicare Deficit Reduction Act to take effect (across the board payment reductions to all providers).
If I were a doctor (particularly if I were a highly-paid procedure-based specialist), I would fear for my future earnings potential a little bit.
P.S. If you want the hard facts on the state of US healthcare, I encourage you to visit http://facts.kff.org/
Put a high tax on all health risk recreational items like cigarettes, cigars, beer, wine, whiskey, burgers, fries and snickers bars. Channel all that tax money into healthcare. Should take care of the issue.
Thanks, boston_mahesh, for letting us know that your social/sexual life revolves around masturbating to downloaded videos of blonde nurses. Yuck.
Wow. A great initial post by Abhi. But a string full of posts that skirt around the central issues of medical self-referral. I bet a bunch of you didn’t read the original article, didja?
Exotification not welcomed here. Also, whats wrong with desi nurses????
Elitist much? In a modern civilized society things like healthcare, education, enough to eat, clean water to drink etc should be considered human rights, or else we will all look like India. No one should wish that on their fellow citizens.
@Yogafire:
For your right to free speech to be exercised or right to life to be exercised (without threat from others), there are services such as police etc which need to be paid by the society.
So your argument is a little flawed there.
The point that I raised about eugenics (esp wrt disabled people) is not so fundamentally different from costs to prevent someone from dying due to accidents caused by natural disasters, noninsured driver collissions, etc.
Meanwhile we have even more interesting developments happening!
This should have also been posted: “But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.
This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.” [link]
WTF is up w/ the disgusting comments on Mexican mothers and welfare? Is there no moderation here? I’m shocked that fellow desis can say such things about the underprivileged. I thought we had more awareness than that.
Also, healthcare is a right, not a privilege in many countries. The US healthcare system has failed.
I mentioned welfare, but only in relation to people who indiscriminately have kids in order to get it. Most of those who do that are not married and have no plan to ever be married.
I take it you don’t know anyone like that?
They also lie about being on birth control in order to trap dudes into paying child support. And it doesn’t matter if the dude who pays child support is the father or not. Just as long as they get it.
I don’t know any Mexicans doing this though. However, Mexicans are in the demographics that I usually deal with in my particular location.
These things are going on in a greater degree than you could ever imagine.
For honest poor people who really do need some help (like me), then I’m not against some sort of temporary government assitance. But deceiptful and shrwed milkers of the system have ruined it for us. And it is very often a generational thing.
(my emphasis added)
meh. I don’t really agree with this, and a lot of other MDs wouldn’t either. There are many structural and socioeconomic factors that go into people’s lifestyle and food choices that are complicated and intertwined with the management of their chronic diseases. I don’t blame Rupa for dismissing that stuff as the “patient’s fault” because we don’t learn those sorts of things in medical school. But that doesn’t mean that there can’t be another reason why Mr. X keeps ending up in the hospital, other than he’s “irresponsible” and doesn’t take his meds properly. It’s just one way to look at it…and an easy perspective to take when you’ve been chronically overworked.
Not sure about this one either. If someone comes in with a headache or back pain or some other neuro symptom, then if you document a thorough neuro exam that shows no abnormalities…I don’t think you would be held liable, even if you didn’t order the CT scan. However the reality is that sometimes warning signs are dismissed in the rush of getting through patients. My point is, while I understand the rationale behind ordering tests to avoid getting sued, it’s not good medicine and it’s not good for the system either…there does need to be a change in the system that reimburses a doctor for putting in the time for doing a complete exam.
The growing trend for primary care at least is a teamwork model, which includes physicians plus the other people you mentioned. If you ask around, NPs and PAs don’t really have a desire to practice completely autonomously, they will usually want a doctor there.
I agree futile end of life care needs to be addressed. But of course people are going to be defensive when it comes to a touchy subject, like their parents. That’s why it’s important to have a relationship with the patient. Even if there is a separate ICU team caring for the patient, the doc who did most of the caring for the patient outside the hospital should be a part of the team who talks to the family about prognosis.
Annoyed MD – excellent comments. Thank you.
You’d have a right to speech whether the police exist to protect it or not, hence they exist to protect rights, not generate them.
How are you going to have a right to an MRI, however, if the MRI machine hasn’t been invented? It can’t be a natural right if the very existence of the good depends on production and distribution.
What we need is the ability to talk about and advocate for things because they are simply good or useful things to do without having to pretend it’s the end of the world or some grave violation of human rights if it doesn’t happen. Not every political issue has to be the GREAT BATTLE OF OUR TIME UPON WHICH THE FATE OF THE HUMANITY RESTS! Every time someone starts fabricating new “rights” as a justification to do something it strikes me as an argument from emotion rather than a positive case as to why we should do something.
What makes access to healthcare a “right” exactly?
We must kill the Indians and civilize and modernize the country. After we kill the Iraqis. And the Afghans. And Chavez.
76 · Annoyed MD: Here is my point by point rebuttal of the erroneous statements/myths made in the comments here 1) More doctors = cheaper care. WTF…..are you people kidding? Do you really think we doctors control what a patient pays for their healthcare. More doctors simply means less pay for doctors because there will be an increased doctor to patient ratio however, to the patients – the cost would be the same. Why is that you ask? BECAUSE THE INSURANCE COMPANIES AND MEDICARE DECIDE WHAT WE DOCTORS GET PAID AND WHAT YOU THE PATIENT PAYS. Please don’t forget that last statement. I have no control over what I charge someone who comes in for hypertension. I assign the ICD9 code and get paid a set dollar amount for it. Same as you have no control over your co-pay. So no…more doctors only means less pay for doctors and maybe increased options for patients however, it WILL NOT translate to cheaper coverage because the insurance companies will still milk patients/doctors for the full cost.
BOSTON_MAHESH: You’re flat wrong. If there are more doctors, than the insurance companies have more bargaining power against the MD’s salaries. Another words, the doctors would now compete with one another on price. You mention that this would translate to no savings for the patient. You’re flat wrong again. The insurance companies would have to lower price or be more efficient with their capital that they have, and this means passing the savings to the consumer.
WE NEED MORE MDs, LESS BUREAUCRACY, AND ALLOWING CAPITALISTIC/MARKET FORCES TO COMPETE. CURRENTLY, MARKET FORCES ARE BEINGS STIFLED BY THE RACIST AND MONOPOLISTIC AMA.
93: We also need to find that missing caps lock key..
boston_mahesh welcome to 1990. Everything you have just stated has been done. Insurance companies have been squeezing physician incomes for a decade. In real dollars, most general practitioners have seen their incomes decrease over the past decade. You really have to let go of you anti-doctor bias and unresolved insecurities, and pick up a book that deals with this problem so that you can discuss it intelligently. The problem here is not that “doctors make too much money.” Do you really think Aetna and Blue Cross/Blue Shied need MORE bargaining power? Are you kidding me? No individual physician or even small physician group has a prayer at negotiating reimbursement with a national or multinational insurance providers. The problem has everything to do with what we spend our money on. We spend it on end-of-life care, neonatal care and medical procedures. None of these things makes society healthier. The system is incentivized to keep our population dependant on medical care. Everybody has a hand in this, doctors, insurance companies, hospitals, AMA, government and the individual…. please don’t insult our intelligence by simplifying a complex issue like this to Econ 101 supply/demand.
BOSTON_MAHESH: EVEN IF insurance companies bargained with doctor’s on a 1:1 basis do you really think insurance companies would translate those savings to their insurees? This hasn’t happened in the past and it’s not gonna happen in the future. Ultimately they will always try to make money . Enjoy this read: http://www.ncbr.com/article.asp?id=100242 and please understand that becoming a doctor is hard enough we don’t need people blaming us for being “dollar mongers” even though we have no control over it.
95 · Dr T on June 5, 2009 10:25 AM · Direct link boston_mahesh welcome to 1990. Everything you have just stated has been done. Insurance companies have been squeezing physician incomes for a decade. In real dollars, most general practitioners have seen their incomes decrease over the past decade. You really have to let go of you anti-doctor bias and unresolved insecurities, and pick up a book that deals with this problem so that you can discuss it intelligently. The problem here is not that “doctors make too much money.” Do you really think Aetna and Blue Cross/Blue Shied need MORE bargaining power? Are you kidding me? No individual physician or even small physician group has a prayer at negotiating reimbursement with a national or multinational insurance providers. The problem has everything to do with what we spend our money on. We spend it on end-of-life care, neonatal care and medical procedures. None of these things makes society healthier. The system is incentivized to keep our population dependant on medical care. Everybody has a hand in this, doctors, insurance companies, hospitals, AMA, government and the individual…. please don’t insult our intelligence by simplifying a complex issue like this to Econ 101 supply/demand
BOSTON_MAHESH: Hello, and thanks for your informative post. I am familiar with supply & demand. Apparently you are not. If we have more MDs, there would be a decrease in the cost of services. The markets would be more efficient. As an analogy for this: thinly traded stocks have a much higher commission for the trade associated with it, than a Blue-Chip stock, like ExxonMobil (XOM). The biggest fault for our lower number of MDs is the AMA, who artificially limit this value to about 18,000/year even though we can accomodate about 54,000 home-grown MDs a year. We can, however, increase our number of MDs who graduate to 30,000, and the quality of healthcare will not diminish, but increase.
I’m sure that the MD schools wouldn’t mind increasing their revenues by increasing their number of MD students. These types of businesses have a very high fixed cost, and the added MD students would only add very little to the fixed costs, but it would provide a lot of profit. The sunk costs have already been paid, and the marginal cost to educate the next few MDs is very little.
I understand how end-of-life care, multiple and redundant testing, neo-natal care and medical procedures add to these expenses. We spend way too much on these procedures. Who is to blame? Aren’t the MDs getting money for doing these procedures? I also realize that the insurance companies are to blame. The insurance companies are very much culpable here.
Finally, they say that malpractice only adds ~1.5% to the cost of healthcare. Do you sincerely believe that? I don’t believe that for one minute. The malpractice insurance in Florida, from what I understand, is over $100,000. Do you know how much caram boards you can buy with this?
We need to let the Indian MDs stay in India where they are better served to help the people there. The people of India deserve excellent healthcare, and they are more underserved than us.
96 · Annoyed MD on June 5, 2009 09:33 PM · Direct link BOSTON_MAHESH: EVEN IF insurance companies bargained with doctor’s on a 1:1 basis do you really think insurance companies would translate those savings to their insurees?
Great question. I agree with you here. Very good point. Insurance companies are impeding free-market capitalism. Instead, they are promoting predatory capitalism.
This hasn’t happened in the past and it’s not gonna happen in the future. Ultimately they will always try to make money . Enjoy this read: http://www.ncbr.com/article.asp?id=100242 and please understand that becoming a doctor is hard enough we don’t need people blaming us for being “dollar mongers” even though we have no control over it.
Boston_Mahesh… Medicine does not follow a simple supply and demand curve. Am I crazy? No. This is a well-researched phenomenon. There is a disconnect between the people who consume medical services (patients through their doctors) and those who pay for medical services (government/insurers). The payers can not directly limit the number of procedures performed without evoking fears of big, bad insurance companies rationing the care of Joe/Jane SixPack. Doctors have no incentive to limit procedures because as you pointed out, they get paid more, and they can cover there asses from a medicolegal perspective. You are correct that a greater supply of doctors would drive down physician income; however, the bulk of expenditures in our medical system have nothing to do with physican income. The big dollars expenditures are in the form of tests and procedures. These revenues go to hospital systems, which in general are not physician owned. Doctors simply work there.
Thus the numbers of procedures done in a certain geographical area varies directly with the number of physicians in that area. John Wennenberg, MD at Dartmouth has done four decades of research on this phenomenon. Patients in Sioux Falls, SD have an order of magnitude fewer arthroscopies, cardiac caths, etc than patients in Miami or Manhattan. This is because the latter markets have a far greater number of physicians than the former. Is this the doctor’s “fault.” Yes. Would increasing the number of doctors fix this. No. It would obviously make the problem of excessive health care spending worse.
As far as the Indian Health Care issue. The number of Indian physicians emigrating to the US has slowed to a trickle (compared to the 70s and early 80s) and many of them are considering going back because right now the opportunities are better there than they are here.
Increasing the number of american medical school spots is not the panacea to anything, as put forth by others here.
There is a shortage of GENERALISTS and an oversupply of SPECIALISTS. Unfortunately you can’t force medical students or residents (american or international graduates) to go into fields they don’t want to go into. Currently, there are 24,000 first-year residency slots, which are filled by 18,000 allopathic and osteopathic U.S. graduates and by 6,000 International Medical Graduates (IMGs). In the end, it doesn’t really matter where the doctors are coming from because most residency spots get filled. Actually, many primary care residencies in less attractive, underserved areas would go unfilled if not for IMGs, because they are geographically less appealing to American grads.
But here’s the problem. Even after going into a generalist field like internal medicine, the majority still subspecialize. Initially, it was hoped that increasing the total number of physicians in the United States would increase the number of practicing generalists who would provide primary care to the majority of Americans, particularly by serving in underserved areas. Yet, while the total number of physicians has doubled, the proportions of generalist and specialist MD physicians have changed from 50% generalists and 50% specialists in 1961 to the present proportions of 32% primary care to 68% specialists.
The majority of residents (american or IMG) opt for subspecialties, and the reasons for this are many: higher financial compensation for specialists, decreased prestige for generalists, and (for physicians practicing in rural and underserved areas) isolation from technology and peer support. Just like most people in other lines of work don’t want to work in a rural, farm town in Indiana (or Health Profession Shortage Areas (HPSAs), just using an example here; please no hate mail from Indiana), neither do most doctors…and hence the disparity in access to care.
How do we fix this? I don’t know, but some measures that would definitely help take us in the right direction: the healthcare dollars that we pay for physician’s services need to be redistributed. We should pay the generalists who provide preventive care and practice cognitive medicine more. At the same time, we need to cut the salaries of some specialists who focus on the most aggressive care—especially in cases where it appears that they are talking patients into unnecessary procedures. We might consider putting a cap on how many operations they can do in a given year.
Now in terms of physician salaries, they are NOT the biggest factors for costly healthcare. About 22% of healthcare spending goes directly to doctors. The big drivers for Medical costs in the USA are : a. Ever-improving Medical Technology and Research b. Expensive, new Drugs c. Bad health choices that people make (smoking, obesity, consequent cancers, heart diseases) and d. Uninsured People [44 Million in US] ALL of which contribute to increasing Insurance Premiums and Out-of-pocket payments.
Another small detail to remember: physician salaries that are reported are never calibrated to 40-hour weeks – they mostly represent salaries for 60-hour weeks on an average, while salaries in other fields mostly are 40 – 45 hour weeks. So when salaries are compared, the hourly rates should be compared – so a $150,000 annual salary for a 60-hour week family medicine doc would mean $100,000 annually if the same physician worked 40-hours a week instead.
And finally, to clarify some numbers brought up earlier about end of life care, it’s reported that about 27% of Medicare’s annual $327 billion budget goes to care for patients in their final year of life, which is obviously a sad state of affairs.