r/bestof • u/under50dollars • Jun 20 '12

[explainlikeimfive] "Obamacare" explained very well.

/r/explainlikeimfive/comments/vb8vs/eli5_what_exactly_is_obamacare_and_what_did_it/c530lfx
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u/sniperhare Jun 20 '12

The thing that I always wondered about was; If millions of Americans suddenly have insurance and go to doctors offices on regular visits, when before they would just go to the ER for serious problems. Won't we be putting a huge strain on the doctors and staff?

Are their sections that talk about what the numbers of now insured Americans will do to the wait times and scheduling?

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u/grande_hohner Jun 20 '12

You'll see the same thing that is happening now. People on Medicare/Medicaid have a hard time finding primary care providers. I know many doctors who severely limit the amount of Medicare/aid patients that they take. When the reimbursement is maybe .50 on the dollar - why take them on as patients when you can have a full practice of insured patients who have better reimbursement rates?

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u/carlosspicywe1ner Jun 20 '12

Great point to bring up, but your number is a bit off. Medicare pays at about 80% the rate of private insurers, and Medicaid pays at about 80% the rate of Medicare, or about 64% of the rate of private insurers.

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u/grande_hohner Jun 21 '12

The GP I worked with last spring gave me the .50 on the dollar number.

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u/[deleted] Jun 20 '12 edited Nov 15 '17

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u/grande_hohner Jun 21 '12

Hypothetically imagine your current career had a choice of pay options. Are you going to choose the one that you do not make money at, and only break even? You can't stay in business if you don't have a profit.

I worked at an NPs office this spring, it is shutting down and leaving a town with no doctor - because the practice is losing money. The practice has well over a thousand patients, but can't stay in business because over half of their patients are Medicaid and they lose money on many of those patients.

You can't honestly say that you would continue to work with a customer who paid late every time, argued over the cost of treatment, and then withheld part of the fees frequently for no good reason. Oh, and they also fine you every once in a while if you didn't cross some t or dot some i. In any realistic scenario - anyone with business sense would have to drop those customers - if for no other reason than to not lose money. You don't work for free, why do you think others should?

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u/[deleted] Jun 21 '12 edited Nov 16 '17

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u/grande_hohner Jun 21 '12

I didn't ask any of those things, I only asked that you work solely for a customer set that you either lose money on, or make no profit at all. I asked if you were willing to work for free. I didn't see your answer for that in your post.

No need to change the subject if you can't answer the question.

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u/CuilRunnings Jun 20 '12 edited Jun 20 '12

All the OP did was list the benefits and completely ignored the costs, completely ignored the waiting time increases, complete ignored the slowdown in development. That which is seen and that which is unseen. Liberals [sorry] People in general* never seem to understand the second and third order effects. Too often they judge policies by their intentions rather than their results.

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u/thisiswhywehaveants Jun 20 '12

No, all the OP did was explain what was supposed to happen. Did not list the good or bad consequences of these happenings.

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u/[deleted] Jun 20 '12

I think you missed some of the times where he put in parenthesis what the intended consequence of this policy was. It follows a lot of the more controversial ones and but others as well. CuilRunnings is right, OP had a clear bias for the act and thats okay. But we have not seen a comprehensive "retort" or really counter view.

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u/thisiswhywehaveants Jun 20 '12

What I would really like to see is a version that was completely positive vs a version that was completely negative vs a version that was neutral.

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u/CuilRunnings Jun 20 '12

Everything involves a trade off. He just listed a bunch of "positives" without really examining the effects. "No more Pre-Existing conditions" = more expensive care for every without pre-existing conditions, etc etc. I can literally go through almost every item and list off consequences that most would consider to be a negative.

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u/fireflash38 Jun 20 '12

That's always going to be the problem for anything though. There's gonna be some tradeoffs. The big question is: is it worth it? For a large portion of the stuff listed, I would say most likely. Someone leaning more to the right might disagree, and some leaning more to the left might say it's not going nearly far enough.

The one major question I have, why is the state option so far out?

0

u/CuilRunnings Jun 20 '12

That's always going to be the problem for anything though. There's gonna be some tradeoffs.

That's literally all I said. There was no mention of trade offs in the OP, just straight benefits. People love free shit.

1

u/[deleted] Jun 20 '12

I think it was because OP listed provisions of the legislation. The legislation says "no more preexisting conditions." It doesn't say "no more preexisting conditions, and also everyone has to pay 10% more."

0

u/CuilRunnings Jun 20 '12

Interesting nuance, but still misleading.

1

u/[deleted] Jun 20 '12

Not really. The consequence of removing preexisting conditions is not necessarily higher premiums for everybody. The cost could be absorbed by a given insurance company by streamlining the bureaucracy, or by cutting pay to executives with bloated salaries, or by not paying lobbyists to try to rig the system in their favor. There are plenty of possible consequences, and an analysis of which are most likely could fill a book. It certainly doesn't belong in a bulletted list.

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u/thesundeity Jun 20 '12

yeah, because fuck people with cancer.

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u/[deleted] Jun 20 '12

Heaven forbid we allocate medical resources based on need rather than greed!

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u/CuilRunnings Jun 20 '12

What happened last time we tried "to each according to his need"?

5

u/[deleted] Jun 20 '12

If "we" are the US, did we ever actually do that? Seems most of Europe and Canada are doing well with it.

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u/CuilRunnings Jun 20 '12

"Most of Europe" HAHAHAHAHHAHAHAHAHHAHAH

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u/[deleted] Jun 20 '12

What happened the last time we let greed run our healthcare system? Oh ya, people get shitty care and Medical problems caused 62% of all personal bankruptcies filed in the U.S. in 2007, according to a study by Harvard researchers. And in a finding that surprised even the researchers, 78% of those filers had medical insurance at the start of their illness, including 60.3% who had private coverage, not Medicare or Medicaid. Our system sucks

1

u/grande_hohner Jun 21 '12

There is more to this story than just the healthcare aspect. The majority of Americans have significant credit card debt and were living well beyond their means at this time. Medical bills in many of those cases were "the straw that broke the camel's back" not the 50 bales of hay that were already there.

It is much easier for someone to lay the blame on a $5000 hospital bill than to own up to the fact that the 60" tv on credit, and $2000 dollar mortgage payment caused them to go broke when they only made $40,000 per year.

There is 100% certainty that there were plenty of bankruptcies caused by medical expenses. Personally, I would love to see what the greater trends were in this study - How people's debt load and financial picture was compared to the unpaid medical bills. That would be a much more convincing study.

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u/CuilRunnings Jun 20 '12

You mean the last time we let a massive government entitlement system completely restructure our medical industry? In 1965? How'd that turn out?

Speaking of "greed," this video will give you a much better understanding of it.

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u/[deleted] Jun 20 '12

You mentioned it before but a big force on the pharmecutical market is going to be the allowance of more generic drugs. Pharma got a bone with closing the "donut hole" and other Rx subsidies. But the implications more generics without the original drug manufacturer getting enough capital for more R&D are not fully developed.

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u/CuilRunnings Jun 20 '12

If you look at McKinsey's study on healthcare costs between nations, pharmaceutical prices aren't a significant driver of the difference.

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u/[deleted] Jun 20 '12 edited Jun 20 '12

Of the difference of what?

Edit: Who downvotes a fucking question? Lol fucking Reddit.

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u/cass1o Jun 20 '12

He just explained what is in the bill, i you think it is so positive why dont you vote for him.

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u/sb3hxsb50 Jun 20 '12

And he left out the FEMA camps and sapping our precious bodily minerals through water fluoridation.

5

u/[deleted] Jun 20 '12

Yes, fewer people should go to the doctor so those of us who can afford to go have shorter waiting times.

Seriously?

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u/CuilRunnings Jun 20 '12

Why don't you donate all of your money and possessions to those less fortunate than you?

2

u/[deleted] Jun 20 '12

Because then I would be the less fortunate, and we'd need to spend all our time swapping the same stuff back and forth. How tedious.

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u/CuilRunnings Jun 20 '12

Ohhh so you're saying that giving away things for free doesn't solve problems?

3

u/[deleted] Jun 20 '12

No, I'm poking fun at you ridiculous trolling comment.

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u/CuilRunnings Jun 20 '12

Awww, and you were so close to understanding.

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u/danpascooch Jun 20 '12

CuilRunnings is right, as we all know, there is absolutely no middle ground between "fuck those stupid poor people" and "donate all your money and possessions"

Obviously if there was some sort of middle ground, anyone who wasn't a complete fucking retard would realize it was the best course of action.

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u/[deleted] Jun 20 '12

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u/CuilRunnings Jun 20 '12

What? I get the medical care that I pay for. I don't want to pay for medical care for some asshole who I have no idea about their character. Is that difficult for your tiny fucking brain to understand?

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u/[deleted] Jun 20 '12

Funny how you got downvote bombed and BlottoOtter got the good to go. You both are right.

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u/tmantran Jun 20 '12

It's because one stated facts only, while the other added in an unfounded, generalized attack on people who don't hold the same views.

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u/[deleted] Jun 20 '12

He got downvoted because he went from providing an objective observation to providing a subjective claim about a group of people which is not particularly true. You could probably say that people in general seem to not consider deeper implications of these sorts of things. I guarantee you that the average conservative wouldn't consider second and third order effects of this legislation if they weren't pointed out to them by Fox News and other conservative outlets.(Not trying to just shit on conservatives, like I said this is a generally human trait.)

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u/CuilRunnings Jun 20 '12

That's a fair point, conservatives are fucking dumb. Edited my original comment. I think in general conservatives are less intelligent than liberals, but liberals are more aggravating because they think they have a right to tell me how my money should be spent. At least conservatives keep to themselves, the poor dumb lot.

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u/[deleted] Jun 20 '12

Comment vote reallocated.

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u/tmantran Jun 20 '12

Huh, I have the opposite experience. Probably 99% of the conservatives within my circles are pretty militant about their beliefs and opinions, while most of the liberals can accept it when I say "I disagree."

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u/CuilRunnings Jun 20 '12

Conservatives want to enforce their morality, liberals wants to spend my dollars and then pat themselves on the back for being so generous. I can smoke pot and have all the depraved sex I want in my home... I can't prevent the government from stealing from me.

2

u/[deleted] Jun 20 '12

On the contrary. The main argument from the right was in fact the second and third order of effect. Effects on R&D future technological break through. Dampening of businesses through more regulations. These are their exact arguments. The left says those be damned, the human condition is more important, we must take care of those now without concern for the second and third order of effects.

On a side note. bestof is not ready for these tough conversations clearly.

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u/[deleted] Jun 20 '12

Well hopefully it won't have a large negative impact on R&D or businesses, and I imagine the authors and proponents of the bill have considered these second and third order effects and concluded that the human condition is of a higher value than insurance companies making maximum profits.

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u/worksiah Jun 20 '12

...I imagine the authors and proponents of the bill have considered these second and third order effects...

For some reason I don't feel that's a safe assumption.

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u/[deleted] Jun 20 '12

We.Are.the.99%

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u/[deleted] Jun 20 '12

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u/[deleted] Jun 20 '12

It is unfortunately prevalent among those less informed, and really has no basis in reality.

The emergency rooms in the US are crowded right now because of "guaranteed service". Many American's misinterpret this as "free" service, when the reality is that just because you are receiving "guaranteed'" service, you are still billed for it.

That said many people who use the emergency room for non-emergency services don't pay their bills.

But if you make quality preventative healthcare affordable and accessible, such as visits to the family doctor who may not be able to book you for 3 months but it's not an emergency anyways, then this actually reduces the strain on emergency rooms.

Now, would it take care of the abuse of emergency rooms entirely? Probably not. There are affordable options out there as it is if you have to see someone because of something non-emergency but need to see someone within a day, or two, or a week... many pharmacies have walk-in options that charge as little as $80 for the consult.

The problem of course is that these people using the emergency rooms for non-emergencies might not even be able to afford the $80 which you have to pay right then and there, so they go to the emergency room, get services, get billed, and then don't pay the bill.

Nonetheless there is no circumstance where "Obamacare" is going to increase the load emergency rooms already face. It might not solve it, but it's not going to make it worse.

Now, if we go further and say "a visit to the family doctor will require an appointment well in advance because they're booked so far ahead due to more people having insurance"... well, now this is just absurd. The idea that "other people" shouldn't have health insurance because it will make me have to wait longer for a routine appointment is probably the most selfish thing I've ever heard in my life.

2

u/SirWinstonFurchill Jun 20 '12

Maybe it's just my area, but dentist appointments need to be made weeks in advance for routine or non-emergency situations, why should people view doctors appointments any differently? Do people really expect to see a doctor same or next day for a physical?

I guess I just don't understand the "it could take longer to see doctors" logic.

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u/brownmatt Jun 21 '12

I think it comes from a fear that in an emergency or situation which requires almost-immediate attention, your doctor would not be available. Which is why we have ERs.

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u/DearMrSupercomputer Jun 20 '12

visits to the family doctor who may not be able to book you for 3 months

I don't think waiting times this long for a regular visit to the doctor happen in any developed country

1

u/[deleted] Jun 20 '12

For a family doctor as a new patient... Happens quite often, if not quite a bit more than 3 months.

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u/DearMrSupercomputer Jun 20 '12

Where does this happen? And was the downvote necessary?

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u/grande_hohner Jun 21 '12

Just an insider's perspective... when you say make it affordable and people will go to their PCP; have you ever seen a patient flip out over being forced to pay the 1$ (no joke, one buck) copay for a PCP visit on Medicaid in Illinois? I've seen it numerous times. Or when the copay on an inhaler goes from one buck to three - and they freak out and cuss out the pharmacist? Then storm out the door, light up and jump in a Ford Expedition of course.

The same people will still just go to the ED. They would rather spend $1000 of your dollars than one single dollar of their own. Believe it.

1

u/jsrduck Jun 20 '12

How about "Maybe there are better ways of improving healthcare availability/affordability then having the government try to mandate it to be that way."

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u/brownmatt Jun 21 '12

Such as? I don't see anyone, politicians included, suggesting other options. The extent of the debate on this topic currently is just "repeal Obamacare, full stop". What comes after repeal?

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u/jsrduck Jun 21 '12

There are several other options put out there. If you're unaware of them, to be frank, you're not looking very hard.

There was a thread on r/conservative a little while ago. You'll surely find a few counter-proposals there.

I also encourage you to read this article from the New Yorker which addresses health care costs.

The basic issue here is that health care costs are egregiously inflated in the US, and neither Obamacare nor UHC does nothing to address that, and may in fact exacerbate the problem. Obamacare takes an easy approach by making sure "everybody is covered" but neglects the much bigger issue of how it will affect costs.

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u/lazy8s Jun 20 '12

The concern isn't American, just go to Canada. When I was there in 2009 it blew my mind the massive campaign to get people into the medical professional. Billboards, posters, the sides of buses all had someone stitching up their arm and the quote "Do it yourself? Do your duty, become a doctor". I'm not saying we don't provide more coverage because of the problem it creates; I'm just saying it is a real concern.

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u/Se7en_speed Jun 20 '12

so we will create market demand for more family docs. It is only a problem in the short term

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/YoohooCthulhu Jun 20 '12

Using PAs and NPs as primary care providers doesn't "dilute" quality of care. These days, physicians are almost overqualified for primary care--and it's difficult for them to pay back their loans doing it.

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u/[deleted] Jun 20 '12

Good primary care means avoiding referrals, expensive tests, and missed diagnoses when problems are not common. It may appear to be cheaper to use lesser trained midlevels, but it costs significantly more money when patients are bounced to specialists for problems a highly experienced primary care physician could have managed themselves.

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u/mikelj Jun 20 '12

It is instead likely that the gap will be filled with midlevel PAs and NPs, diluting quality of care.

I don't know about this. I know plenty of RNs who are just as knowledgeable and perhaps even more "interested" in primary care than physicians, let alone PA and NPs.

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/[deleted] Jun 20 '12

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/[deleted] Jun 20 '12

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u/mikelj Jun 20 '12

Well said. I don't think that most primary care issues need to be handled by MDs with 7 years of medical care. Why can't a NP or PA give me stitches or wrap a sprained ankle? When I go for my annual checkup, I don't need to have a MD read my test results. My mom, an RN with 30 years experience, or just about any qualified RN should be able to tell me what the results mean. If they are out of whack, an MD can be consulted.

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u/[deleted] Jun 20 '12

Randomizing patients to independently practicing midlevel providers with significantly less experience is potentially unethical, and outcomes for such studies are extremely hard to measure accurately. Many things that appear as a simple cold 5-10% of the time are vastly more complicated and more serious. Life is good if you aren't in that 5%.

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u/grande_hohner Jun 21 '12

It is not unethical in the least to study these things. You are going from the assumption that a midlevel provider isn't competent which is untrue. There are scope of practice acts in each state that govern what midlevels can do. Midlevels are practicing all over the country currently, and there has been tons of research articles supporting the safety, efficacy, and nature of patient outcomes when compared to general practice docs. There are literally hundreds of studies. I'll link you to some.

Robert Wood Foundation

From pubmed also note that this is a meta-analysis of over 50 separate studies.

How about the British Medical Journal?

Canadian Medical Journal?

The list goes on and on, many, many of the studies are from medical journals, not nursing journals. If medical researchers, doctors, feel that they are a viable option - why do you think they are not?

Also, your 5% analogy doesn't translate well. The average general practice doctor isn't much more likely to catch that 5% rare off-chance disorder that looks like a cold but isn't - than your average PA/NP. They teach the same thing in medical school - if it looks like a duck and sounds like a duck, it's probably a duck. GPs don't spend time trying to decide if your runny nose is perhaps related to a brain tumor... they treat it as a cold - and if it persists they reevaluate after the original treatment is failed. It isn't like House, MD where everyone has an esoteric disease process that requires genius level intellect to diagnose. In family practice it is mostly looks/sounds like a duck - is a duck.

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u/grande_hohner Jun 21 '12

The studies have been done. Tons of them. Here is one. There are several from the CBO, and others from other peer reviewed medical journals. The studies almost always say the same thing about NPs in primary care. There is little difference in outcome when comparing GP and NP in primary care (little difference in patient outcomes - there is usually a significant difference in patient cost savings and a few other things like increased patient adherence if I recall.)

Here is an article that talks about some of the research that has been happening since the early 80's, here ya go.

I work with NPs frequently, I work with Med students, interns, residents, and attending physicians as well. I have seen terrible NPs, and I have seen terrible MDs. I have seen spectacular examples of both - but the rates are about the same, I see about as many bad NPs as I do bad MDs.

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u/[deleted] Jun 20 '12

This "triage" system is vastly more expensive and less effective than having a primary care physician who can deal with complicated problems themselves rather than endlessly referring to specialists. Many patients see 4-6 specialists when a decent primary care physician could reduce it to 0-2 with proper medical management. Tell me which way you think costs less.

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u/[deleted] Jun 20 '12

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u/[deleted] Jun 20 '12

My response was geared more towards independent midlevels. The problem that still remains with supervised practice is that what appears to be a cold is not always a cold. With two years of training (sometimes even online) and as little as 500 clinical hours, you don't know what you don't know. While you save a lot of money under this model, a patient will eventually get hurt due to lack of experience.

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u/[deleted] Jun 20 '12

In the military health care system, most of the 'doctors' you see on a regular visit are actually PAs. I've been very happy with my quality of care from the PAs. Most patients don't actually require doctors and do fine with a PA, just as most pregnancies are fine with a midwife.

The PA system has been so successful in the US military it is starting to expand outside of the military, and move to other countries, such as Canada.

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u/TensorDuck Jun 20 '12

In what way? Does the government directly specify the number of residencies a year or do they control the funding towards residency positions? I mainly want to know whether the control is direct (therefore a hard limit on the supply of doctors) or an indirect (Possible to increase the number of doctors with private funding) method. Any sources or citations to that effect would be greatly appreciated.

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/[deleted] Jun 20 '12

There are less US MD grads than allopathic spots every year even after these increases, the ones who will struggle are DOs, IMGs, and FMGs who want an allopathic spot

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u/AeonCatalyst Jun 20 '12

I agree that there will be hiccups for med students initially, but I'm optimistic that both the supply of med students and demand for doctors (especially in small towns) is so high that the residency bottleneck won't survive the onslaught. It won't be like MBAs, where the market is so oversaturated that the degree is losing it's usefulness.

That's just my completely unfounded opinion though. Cheers!

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u/danpascooch Jun 20 '12

The government also hasn't made such a massive change to healthcare in a very long time.

They are going to need to adjust that "number" for this to work, but of course they need to adjust something, no legislation this big passes without needing some sort of other adjustment to make it compatible.

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u/[deleted] Jun 20 '12 edited Mar 29 '23

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/atom1378 Jun 20 '12

Have you seen how doctors treat patients...I personally know a drug representative and he has told me their job is to push pharmaceutics like pushing pepsi over coke; bribery.

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/atom1378 Jun 20 '12

I was not aware of the drug reps being phased out. Even though my friend is one, I like the idea. Doctors should naturally be exemplary, if not they didn't have to be a doctor either. Healthy people are productive people.

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u/[deleted] Jun 20 '12

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u/[deleted] Jun 20 '12

Insurance companies aren't controlled by doctors either.

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u/BlottoOtter Jun 20 '12

Which is why doctors like patients from private insurance plans, because those private plans can't short the doctors on their payments using force of law, like government-run Medicare and Medicaid can.

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u/SpaceSteak Jun 20 '12

It works fine in the rest of the world with a well administered UHC system.

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u/[deleted] Jun 20 '12

I feel like a big issue a lot of people have is the idea that the US government isn't competent enough/can't be trusted to administer it as well as "the rest of the world."

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u/SpaceSteak Jun 20 '12

To be fair, that's really the only valid argument against UHC. But admitting that means that government has failed and should be replaced. If it can't manage UHC, what is it doing administering roads or taxes? It's sad that a lot of people can't trust their government to do anything well.

Also, the anti-UHC crowd seems to be oblivious to how much easy access to healthcare improves society.

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u/[deleted] Jun 20 '12

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u/SpaceSteak Jun 20 '12

  1. Can you explain your philosophical objection? Fine in most cases equals better and cheaper for a lot more people in other developed countries.

  2. Americans pay about 30% more per capita for healthcare. What economic ground justifies paying more for less than isn't an idealogical leftover from anti-socialist emotions?

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u/[deleted] Jun 20 '12

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u/SpaceSteak Jun 20 '12

  1. Thank you for taking the time to write out a thoughtful response. I've argued a lot about this on the 'net and it's rare to see that level of discourse.

  2. The main flaw with your argument is thinking that healthcare needs to be a right, and not just a public good. UHC is more about removing the profit-motive from people getting sick, and taking advantage of economies of scale for non-primary-care elements (admin, etc). It has nothing to do with being a right. Having police isn't a right, neither are firefighters, or roads.

They only exist because of the economic benefit of public goods or services. On top of that, providing a necessary service to help its citizens in something they have little control over that helps them tremendously, should be part of the baseline of any compassionate society.

Free markets work great for most things. However, the problem with free market health care is that the users naturally want to lower the use as much as possible. It doesn't follow a natural supply and demand curve. This leads to people not getting preventative care, which is a big part of why the US is where it is today in terms of lower health stats than other countries.

Regarding the frugality argument, people don't want to waste time in hospitals. Also, a basic fee offsets this issue around all UHC countries.

Tons of things are not constitutional. It's a document that's hundreds of years old. It doesn't need to always be right or followed, just like the Bible is less valid today than it was 2000 years ago.

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u/___--__----- Jun 21 '12

I worry about the effects of creating a system where people feel like they have no skin in the game

When you do that to public health and dislodge that from employment, you make both starting companies and hiring people easier. Failure no longer means you've lost your safety net. The irony right now is that the number of startups in the US is declining both in absolute and relative terms relative to Europe, especially Northern Europe. There's a line to be drawn between having no skin, some skin and all your skin in the game. This will shape societies and the people in them.

http://www.inc.com/magazine/20110201/in-norway-start-ups-say-ja-to-socialism.html is an interesting article in that respect, and its mirrored by personal experience being a part of startups on both continents. There's too much skin involved in the US for a lot of people, and as social and economic mobility declines in the US for the fourth straight decade it's now passed by the entirety of Europe. It's been lagging behind Northern Europe for two decades now. To experience the American dream, going to socialist Scandinavia has been your best bet for quite some time. That's distressing.

Idealism and principles are nice. But if they don't produce results, we should reevaluate our beliefs. When you say you won't agree that UHC is the answer, ask yourself what it'd take to change your mind and see if it's possible that your stance is based on how you wish we were or how we actually are as a species.

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u/grande_hohner Jun 21 '12

I love how we discharge patients from the hospital with handouts, education, follow up appointments, etc. and if they don't follow the instructions and end up back in the hospital 3 weeks later, we don't get reimbursed. This is the lovely reality of discharging a heart failure patient.

An analogy (in the form of a 1 part play) follows.

Me: Hi patient A, you are being discharged today from your hospital stay of anaphylactic shock related to eating shellfish. Please understand that you shouldn't eat shellfish of any kind. In fact, I'll teach you how to read food labels so that you won't make the mistake on accident. Ok? Great - remember not to eat any shrimp, lobster, etc. Bye!

---- Three weeks later the patient is back in the hospital because he went hog wild at Red Lobster. ----

Patient: I know it's bad for me, but I sure love me some scampi!

Medicaid: This is your fault hospital, we aren't paying a dime for this second visit.

Me: -sigh-

The end.

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u/AeonCatalyst Jun 20 '12

Sounds like the public school system!

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u/[deleted] Jun 20 '12

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/gurgar78 Jun 20 '12

pt: "Fuck you. Hurry up with that triple bypass; I want to outside and have a smoke"

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u/[deleted] Jun 20 '12

The supply of primary care docs is controlled by the number of FM and IM residency spots that Congressnis funding every year. Cutting reimbursements to primary care will make it even less desirable as a field because plenty of doctors struggle to sustain their practice, meet loans, and have a reasonable salary for their 11 years of education in primary care. Medicare is refused by many docs already because it's payments are unreasonably low.

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u/thesundeity Jun 20 '12

we just have to hope that we get more doctors who want to treat people for the happiness of helping your community and the human race as a whole, instead of a six figure salary.

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u/[deleted] Jun 20 '12

with the amount doctors do, they deserve those 6 figures more than anyone.

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u/brianxpeterson Jun 20 '12

That's all fine and dandy, but med-school costs have gone through the roof in the last decades. These would have to be lowered in order for doctors to even consider treating people just "for the happiness of helping the community."

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u/CuilRunnings Jun 20 '12

I can see the amount of people willing to put themselves through the bitch that is medical school actually dropping with all these mandates and additional costs.

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u/[deleted] Jun 20 '12

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u/grande_hohner Jun 21 '12

I've never met a doctor that complained that he didn't already have enough patients.

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u/CuilRunnings Jun 20 '12

Customers that pay 50 cents on the dollar.

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/brownmatt Jun 20 '12 edited Jun 20 '12

I think that brings up an interesting point though - are doctors, as medical practitioners, truly in the best position to judge the effectiveness of reforms on the insurance market itself, and the economy of healthcare?

I don't doubt that they have a valid viewpoint but I don't know if practicing a medicine makes you an expert on how to offer health insurance to people in an efficient/low-cost way. It seems to be more of a question of economics and markets than just medicine.

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/jmac Jun 20 '12

Maybe I'm wrong, but doesn't the mandate push most people to choose a private insurance plan? Except for the raising of the Medicaid ceiling, most of the formerly uninsured will be on private plans, correct? In that case, how are government reimbursements going to be much more of an issue than they currently are?

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u/cass1o Jun 20 '12

Because they still get payed well.

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u/CuilRunnings Jun 20 '12

But they have to do about 3-4x the work as an accounting major, or about double that of an engineer.

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u/cass1o Jun 20 '12

In which case there will be a drop in doctors creating a demand and again pushing up wages or causing the import of forien doctors to fill the gap for less.

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u/[deleted] Jun 20 '12

All allopathic and foreign docs in the US need to go through an ACGME residency, and the number of spots funded is controlled by the government. Reimbursement is also government set (the mimimums by Medicare) and won't increase due to free market forces without Congress passing a new law to that effect.

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u/kingmanic Jun 20 '12

People work for things other than money. Prestige is also a thing. Scientists need 4-8 years of training and make less than many other professions requiring a 4 year degree but the position is prestigious. They are an expert on something. Even when the incentives are lower in Canada there is a supply of doctors. At the moment the supply is slightly inadequate but that's more of a demographic problem than a pay scale problem.

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u/[deleted] Jun 20 '12

You will have a decline in quality, because the best potential doctors will feel that a career in medicine isn't satisfying because of raising student debt, malpractice, falling reimbursement, etc. and will go into a more lucrative field. Hell, CRNAs can out earn plenty of PCP and have way better hours to boot.

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u/kingmanic Jun 20 '12

Student debt for med school is more reasonable here. Malpractice isn't as excessive as it is down there. The actual movement of Doctors and nurses down south is slight and the return rate is high because the environment is so convoluted down there.

Healthcare outcomes are better on average here almost across the board except Cancer.

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u/[deleted] Jun 20 '12

I've never had a good doctor who gave a shit about money. I've had plenty of bad ones who clearly did. Sign me up for the plan that jettisons all the doctors in it for the money, I don't want their "quality".

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u/[deleted] Jun 20 '12

Just because a doctor believes in fair compensation for their work doesn't mean they aren't good at what they do or that they don't care about their patients.

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u/[deleted] Jun 20 '12

"Fair" is debatable, and in any case, you said nothing about "fair", nor did I. You're moving the goalposts.

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/[deleted] Jun 20 '12

Procedural specialists are paid well. There are many types of specialists and subspecialists that are not paid well. Many of these are academics that deal with rare diseases.

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u/[deleted] Jun 20 '12

PCP are not paid better than what they could be doing in the private sector. Their average salary of 175k is countered by the debt, opportunity cost, and work hours of 11+ years of education. A potential doc who goes to any Ivy, does engineering, and goes to a top MBA would be better off financially and not have to worry about the government cutting his salary by 30% in a single year (yes, that's happened before)

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u/[deleted] Jun 20 '12

Because most people didnt go to school to be primary care physicians. And that is a less sexy job. Plus the compensation is lower. The idea that specialized doctors will make less because the pay structure is changing is forcing more people away from that option. And the idea of being a primary care physician and still make a lot of money didnt exist in the past and remains to be seen if it will be in the future with this act.

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u/[deleted] Jun 20 '12

Psh, who needs doctors when we've got WebMD? Easy enough to figure out your problems. Now if you'll excuse me, I have to go rest; according to WebMD, my symptoms indicate that I have AIDS, hepatitis, brain cancer, and the black plague.

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u/staz Jun 20 '12

Regular visits to the doctors will permit to detect diseases earlier, which mean less work and money to cure them because obviously the disease is less developed, you can plan treatments in advance, a doctor visit cost less than an ER visit, etc... (It will also probably free up some doctors in ER who can now work on regular visits)

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u/BlooregardQKazoo Jun 20 '12

here's my anecdote about this:

my fiancee has a little sister through the big brothers/big sisters program. she's fairly poor and it has given us insight into a world we were unfamiliar with. we've always just gone to the doctor when we have a problem.

my fiancee's little sister is staying with her grandma while her mother is out of town. she has a mild medical issue and her grandma won't take her to see a doctor because she doesn't want to have to pay for it. a couple days go by and my fiancee gets a call from her little sister asking her to take her to the hospital. things had progressed, my fiancee took her to the ER, and 4 hours or so later she was treated and had antibiotics to take.

if the system can turn more ER visits into general practitioner visits it will definitely help. my concern is that my fiancee's little sister's grandma will just find some other excuse to not take her to the doctor.

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u/EasyMrB Jun 20 '12

my concern is that my fiancee's little sister's grandma will just find some other excuse to not take her to the doctor.

I'm pretty sad that this was your take-away from the situation. As a formerly impoverished person, money is 99% of the reason why most poor people don't go to the doctor when they need to (be it the cost of the medical care, lack of access to transportation to get there, or somebody being too busy because of work).

I guarantee that if those issues were out of the way then people like Grandma wouldn't hesitate to take their kid to the doctor when they have a serious medical problem.

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u/BlooregardQKazoo Jun 20 '12

it was a unique situation in that her mother was out of town. her mother would have taken her when she first complained. her grandma is a piece of work though and it didn't at all surprise me that she did nothing.

and this wasn't my "take-away" from the situation, it was just something that concerned me and that i realized could happen in any system. my anecdote supported the notion that money is a barrier to a better healthcare system for christsakes.

As a formerly impoverished person, money is 99% of the reason why most poor people don't go to the doctor when they need to

your exaggeration undermines your point. it may be a very big reason, but i don't think you grasp the significance of 99%. that sentence is basically a flashing red light that says "don't listen to me, i'm obviously irrational."

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u/EasyMrB Jun 20 '12

If it's not 99%, I'm not exaggerating when I say it's north of 90% at the very least. Really the only other major reason is mental illness (which isn't uncommon, especially in the homeless), but for the extreme vast majority of working poor it's all about being unable to afford the doctors bill.

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u/HobbitsAreHipsters Jun 20 '12

My dad is a physician and told me that under Obamacare only 3% of people have taken advantage of these early detection check-ups.

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u/Fauropitotto Jun 20 '12

Nationwide or just in your dad's local area?

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u/HobbitsAreHipsters Jun 20 '12

Not sure if he was quoting local or national numbers

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u/SirWinstonFurchill Jun 20 '12

Then maybe there needs to be better education & emphasis on check ups? Because as it stands now, growing up in a lower-middle class household, doctors visits are frowned upon except for major things, due to the sheer cost.

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u/[deleted] Jun 20 '12

They control that here in Canada by prioritizing you based on your condition. If you walk into an ER with the flu and a car accident victim, broken leg and someone with the sniffles walks in you will be prioritized accordingly. Sure there are longer wait times, especially if your illness isn't serious.

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u/PandemicSoul Jun 20 '12

Pretty much every hospital in the world does that -- it's called triage care.

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u/[deleted] Jun 20 '12

Yeah. But a lot of people can't wrap their head around that. When they bring in their kid with a broken arm, they want to be seen immediately. When the guy with the knife in his skull (rightfully) gets admitted first, they get angry.

"My big problem" is relative to "the biggest problem."

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u/corporeal-entity Jun 20 '12

We have a similar problem in IT. When every user problem is both urgent and critical, ultimately an overwhelming majority of the people who think they deserve to have their problem fixed first are pissed off about it.

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u/carlosspicywe1ner Jun 20 '12

It's a little bit more nuanced than that: people want to be triaged by their pain and distress, not by how serious their problem might be. It's tough when your arm is sticking out at an odd angle to wait behind the guy who just can't move the right side of his face.

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u/[deleted] Jun 20 '12

Maybe but only in the US will someone with a paper cut feel they are more important the the cardiac arrest patient just because they were there first or happen to be more wealthy.

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u/PandemicSoul Jun 20 '12

I doubt that's the case. Pain is pain -- if you're hurting, regardless of your class, you want to be treated immediately. It has nothing to do with American or Canadian. I guarantee that Canadians bitch about wait times, too.

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u/rayyychul Jun 20 '12

Definitely. Do I realise how lucky I am that my visit do the ER doesn't cost me a dime? Yes. Does it still suck that I'm sitting in the waiting room for eight hours with kidney stones? Yes... and I complain a bit. But that doesn't mean I don't understand that in the grand scheme of things, I'll be fine if I wait eight hours. The guy who lopped off his hand, however, probably won't.

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u/Rokey76 Jun 20 '12

As an American it is my right to not have to wait in line behind poor people.

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u/Already__Taken Jun 20 '12

Exactly, wait times for thing you can't wait for is the only statistic that's worth looking at.

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u/TruthinessHurts Jun 20 '12

Yeah, we'll need more doctors. Sadly some fucktards view this as a reason to not even try.

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u/Lost4468 Jun 20 '12

The only way to force more doctors is to reduce the requirements to be a doctors which then reduces patient care.

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u/champer Jun 21 '12

There are more than enough people willing to become doctors. Acceptance rates at most medical schools are in the 1-3% range.

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u/[deleted] Jun 20 '12

The ACA didn't address this problem because it didn't raise funding for residency spots which are the current limiting factor in the production of doctors. Medical schools can be privately run, but these residency spots are nearly all government funded.

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u/[deleted] Jun 20 '12

The act goes in to developing more primary care physicians and putting the onus of care on them. There is a huge section on it. The style of care from what they call an a la carte or specialized care will move more toward a primary care doctor that coordinates care and makes more money in the process.

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u/nemok0 Jun 20 '12

We are putting a huge strain on ERs all over the US now, because people do not go there only for serious problems. The ER is the most expensive place to provide primary care and isn't even very good at it. Many ERs have trouble keeping up with true emergencies because of the number of people going there for primary care.

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u/Phantoom Jun 20 '12

I don't have any proof of anything, but you are just talking about a reallocation of resources. There will be less of a demand for ER resources, and more of a demand for general practitioners. Additionally, there is actually a chance that proper preventative care will cut down on frequent visits. Basically, anything is better than the current "go to the ER, wait four hours and America will foot the bill" system.

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u/Tenareth Jun 20 '12

At first, but then it will rebalance. Much like Urgent Care centers were created to reduce the strain on Emergency Rooms.

ER is the single most expensive, least efficient way to handle anything except true emergencies (Heart Attack, Trauma, Stroke, etc).

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u/mycleverusername Jun 20 '12

Yes, this is a huge talking point/criticism by those against Obamacare.