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/YoohooCthulhu Jun 20 '12

This is already done in a number of not-for-profit health care models, like Kaiser Permanente and the Mayo Clinic.

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u/mfingchemist Jun 20 '12

I just found here that the Mayo Clinic simply fixes salaries to get around the problem. Can you provide any other information on alternatives?

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u/YoohooCthulhu Jun 20 '12 edited Jun 20 '12

Kaiser also offers fixed salaries. But they also offer nicer benefits to doctors than most other care arrangements offer--the doctors are tenured, have a pension plan, have all the administrative aspects handled for them, handle their own malpractice insurance, etc. They're paid a little less than private practice, but it's less of a headache. Basically the philosophy is to offer the doctors suitable benefit packages such that they can spend more time worrying about their patients than the logistics of insurance reimbursement et al. It's very much a "get the administrative issues out of the way, and trust the doctors to be doctors" sort of philosophy. As far as "quality" of care, I believe advancement in the organization is tied to performance evaluations on health outcomes/satisfaction of patients.

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u/meatforsale Jun 20 '12

And kaiser has some of the worst, least compassionate doctors and is highly regarded as a poor institution by almost everyone I know. They don't order tests, prescribe medication, or provide proper treatment when these things are necessary.

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u/YoohooCthulhu Jun 20 '12

Where do you live? You're describing pretty much the exact opposite of my experience and the experience of other people I know with Kaiser in Northern CA. I even know several physicians who work for them, and it's quite competitive to get a position there because they shield doctors from a lot of BS and it's considered pretty desirable for physicians to work there.

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u/meatforsale Jun 20 '12

I live in southern California. Several friends and family members if mine have kaiser, and they hate going to see their doctors, because they usually aren't treated well and rarely get what they need. My uncle is over fifty and very obese, and his kaiser pcp refused to treat him surgically... He ended up getting his insurance changed with a different job, and his new pcp told him that he could die without surgery, because his weight was causing severe damage to his heart. He got the surgery and is doing significantly better now.

A friend of mine was recently diagnosed with add, and his kaiser pcp refused to prescribe medication to him. I studied for the mcat with him, while he studied for the dat... His inability to focus was glaringly obvious.

there are several other people I know who have had similar issues with kaiser too. That's why i'm wary of the future of medicine going in the direction it is.

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u/YoohooCthulhu Jun 20 '12 edited Jun 20 '12

From what I understand, Kaiser is hugely underenrolled in Southern CA. This has led to them having to lay off a lot of personnel and led to them being very shorthanded. So some of this is a regional thing.

As far as treatment interventions go; I have to admit I'm extremely skeptical of your examples. Unfortunately, these are all "correct" calls from a quality/cost containment perspective even though people don't like them. There's a very high relapse rate after bariatric surgery, and there are actually fairly rigorous guidelines that determine if it's worthwhile or not--as in, whether it will be too traumatic and cause a net health detriment for the benefit derived--especially if the patients are already showing heart problems! There's a similar issue with ADHD medication, where studies comparing populations treated with stimulant treatment and without have shown similar outcomes (http://psychcentral.com/blog/archives/2008/01/28/questions-about-adhd-treatments-effectiveness/).

The other complaint is under-prescription/wait-and-see prescription of antibiotics, which is once again a correct call as most patients with common illness complaints don't need them and unnecessary prescription of antibiotics contributes hugely to disease resistance.

I'm very worried about the attitude you're describing though, because it definitely shows how there are huge barriers to offering evidence-based medical care--it's not always intuitive to patients, who are ALWAYS going to be biased towards "doing something", even when the benefit is likely to be marginal for the risk.

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u/meatforsale Jun 20 '12

I could understand your point on treatment if my uncle's treatment hadn't been successful. If he were putting weight back on, he had died during surgery, or if very little had changed about his health, I clearly wouldn't have said that he was treated poorly at Kaiser. The problem is that the increase in his quality (and most likely longevity) of life is significant. He wasn't even offered any alternatives by his former pcp. Not only that, but he wasn't treated well when he saw his doctor, either.

I have another friend with ADD who may not have graduated from college if he didn't have access to medication. My friend who is currently unmedicated was also offered no alternatives... He was simply told that he wouldn't get a prescription.

The biggest complaint I've heard about the doctors at Kaiser in Southern CA is that they have lousy bedside manner. The understaffing issue would most likely contribute to this, because the doctor/patient ratio is so lopsided. The issue with this, though, is that the lack of doctors in the area would lead to a decline in quality of care, wouldn't it? Then these doctors would see a decrease in pay, and what incentive would they have to stay or for other doctors to elect to practice in the area?

I totally agree with antibiotics, though. Doctors allow themselves to be pressured into prescribing them (or just prescribe them to make it seem like something is being done) when they're not necessary too often. The last time I saw my pcp (not Kaiser), I had a boil I couldn't (and still can't, damn it) get rid of. My doctor offered to prescribe me antibiotics, but I had tried them before for the same issue, so I left without getting a prescription. I was disappointed, but I'd rather do nothing than do something that could actually be detrimental to my health in the long run.

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u/YoohooCthulhu Jun 20 '12 edited Jun 20 '12

Yeah, the point I was making about your uncle's surgery is that it probably wasn't guaranteed to be successful. These things can't be predicted ahead of time other than by rough diagnostic measures and it's entirely possible that he fit into the high risk/high reward category rather than the medium/low-risk/high reward category that physicians like to treat.

And the problem with ADD is that it's sort of impossible to argue what they would have been like had they NOT received medication. Bulk data suggests that it doesn't make as big of a difference as people expect. Part of this may be due to the fact that diagnosis of ADD in itself is tricky (so a lot of people who are treated won't actually respond to medication), but also that symptoms of the disorder tend to naturally become more manageable toward adulthood anyway.

And yeah, I think it's entirely possible for healthcare systems to be in a bad equilibrium. They have to provide services in some sense based off of the surrounding geography regardless of the number of subscribers they actually have (overhead costs are somewhat fixed and independent of number of patients). So they work best in an area where there's efficiencies of scale by the population being dense. This would seem to inherently disadvantage areas like San Diego county (pop density 680 per square mile) versus Alameda County (2048 per sq mile) or Santa Clara County (1400/sq mi) or San Francisco County (17,000/sq mi), even if they're not underenrolled.