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It's easy to say "expect the US expectation of care, turnaround time, and time-to-service to decrease drastically", but many people in the US have terrible turnaround time, terrible time-to-service, terrible expectation of care. They simply can't access decent care in less than six weeks without breaking the bank, or can't access decent care at all. If we're looking at maternal mortality, for instance, the US just sucks by all measures. If we're looking at infant mortality, we're a total failure. And that's before we're getting to the cost part, where you go to the hospital expecting to push out your normal kid in a normal way and get a normal bill, but then it turns out the person who put in your epidural at 3 am was out of network and you didn't ask because you were, like, busy, and you picked your hospital and your OB and everyone else beforehand and made sure they were in-network.

Having been through the US pregnancy and birth wringer, I can compare the US standard of care with the rest of the world's standard of care, and we suck. Cost more, cut more, die more, and spend six hours a week on the phone half the weeks calling a provider, getting a referral, calling the insurance to approve the referral, calling back the original provider. I made four phone calls for every appointment after 32 weeks because of a minor and common complication that had zero effect on the birth except having to get that f*(&ing approval to see the only doctor in two states who would deal with the thing reasonably.

And at the VA max wait for a primary care appointment is 20 days.

> You can't compare the US standard of care with the rest of the world's standard of care.

This is a meme I hear a lot from Americans but having lived in America and elsewhere, I don't believe it at all.

Do you have any data supporting it?

The best I could find is life expectancy (US is #31 worldwide) and maternal mortality rate (US is #46 worldwide). The US doesn't seem to excel here by any means. Can you point to data where the US does excel? Is there evidence that people entering an American hospital exit with better outcomes than people entering say a Swiss hospital or French hospital?

And anecdotally, my experiences with healthcare in the US were strictly negative. Things like $600 for some regular over the counter medication from a hospital (and that's just the co-pay at an in-network hospital). Living in Australia and Switzerland, my experiences were much, much better.

> You are getting WORSE care for the same price when you see an NP or PA.

Whenever I get to choose between NP/PA or MD I will always choose the former. MDs are typically overworked and condescending. Most of the time I already know what the problem is and just need a prescription from them. When I tell that to MD they get offended - I am a dumb patient and MD is a demigod with superior intelligence. Hence I'm supposed to act dumb to make sure I don't offend MD's brittle ego who will otherwise retaliate by billing for some extra "nontrivial" visit.

If I see a nurse or a PA the person will speak with me like an equal, take the time to examine, won't hide their reasoning from me, maintain open notes, etc.

> the hospital gets either equivalent (Oregon) or about 85% of that paid to a physician

People shouldn't be going to hospitals (with rare exceptions). People should be seeing NPs through CVS Minute Clinic, One Medical, Future Amazon Clinic, etc. When you walk in to CVS clinic to see an NP you just pay a flat $45 without insurance. That's how it should be for most care.

The fact that anyone (MD or NP) is being reimbursed over $75 for a short visit (let alone more realistic $300-500) is simply a flaw in the system that needs to be fixed. MDs (or midlevels) don't create enough value to be reimbursed that much.

Note: in France you pay MDs 35 for a visit, 16-ish of that is covered by social security, while a private security costing 50-ish/month covers the rest. I've always got a same day visit if I called before noon.

Edit: I moved out 5 years ago, so the numbers might have inflated a tiny bit. But not much, knowing France.

Australian here.

I’m curious about what you see as wrong with our standard of care?

I can see my GP same day, bulk-billed via Medicare (so no out of pocket cost to me) for whatever I need. Likewise, with a day or two notice I can see a specialist at my local clinic. Also bulk billed.

Out of hours, I can order an in home doctor service over the internet with an average wait time of 4 hrs. Again, bulk billed so no out of pocket cost to me.

I don’t think I’ve ever waited for longer than 24 hrs for a doctors appointment in the 12 years I’ve lived here.

My usual example is the NHS. A lot of medical imaging AI papers are published using NHS data with great claims like

"Normal chest radiographs were detected by our AI system with a sensitivity of 71%, specificity of 95%, PPV of 73%, and NPV of 94%. The average reporting delay was reduced from 11.2 to 2.7 days for critical imaging findings (P < .001) and from 7.6 to 4.1 days for urgent imaging findings (P < .001) in the simulation compared with historical data." https://pubs.rsna.org/doi/10.1148/radiol.2018180921

Except their baseline image interpretation turnaround times (TAT) are completely incompatible with the US. If any radiology group sat on an exam for 11 days, they'd fired by the end of the month. Many hospital medical staff bylaws require final signed reports within 24-48 hours, not even including the professional fee interpretation contracts which can set TATs at 30 minutes.

You can't provide that level of service with NHS-type funding. Oz is probably one of the few systems that's currently functioning well. There's a ton of reasons British consultants leave for there.

> You can't provide that level of service with NHS-type funding.

The crisis with the NHS is not only a mismanagement crisis but also a funding crisis so I think they'd agree. Happily, healthcare funding could be increased to more normal levels (in comparison to other well functioning public healthcare systems as a share of GDP) and still be well short of the high costs of the US. The UK government just prefers austerity over properly functioning healthcare.

So combining your comments with the other comments on the thread.

Radiology has to have a 48 turn-around but it's OK if many patient don't actually see a doctor without multi day waiting times and some portion can't see doctors in any reasonable timeframe. But radiology, we got that covered! It is an important part of health care but it is clear US priorities as reflected in "standards of care" are completely off-kilter (if you're not seeing a doctor at all, radiology turn-around can't help you or is there something I'm missing).

The way standards of care drives up costs seems like a scam but I know not all of it's a scam. In ways it's worse, in the sense it's harder to get a handle-on and stop, being a spectrum that shades from mostly scam to actually good but sometimes too-expensive approaches and so-forth.

>You can't provide that level of service with NHS-type funding

Places like Singapore do well at providing good service on sub NHS funding. Also people actually like the system there unlike the US and to some extent the NHS. (Brit here - NHS is ok but a bit rubbish at times). I think it's worthy of study / emulation.

I think they are something like 1/3 or 1/4 of US spend and #1 life expectancy in 2019 vs like #30 something for the US.

I hate the US' health care system as much as anyone, but I don't think it's reasonable to compare Singapore to the USA that way

Singapore is the size of a US city and has a population of 6 million

It doesn’t come free, you or another demographic is losing. Public schools comes to mind, slow congested public transport ... etc limited beds in public hospitals

Lower quality of life because of High taxes

Waste because old people see a doc as a free social interaction

I don’t know both systems are not right

So you're saying US public schools are great, US public transport is great, and people can easily get treatment in public hospitals for the same price that they would suffer bed shortages for in Country X?

Just trying to understand your points because I think they are quite easily refutable.

I live in Germany and am not a fan of the high taxes but see more from the 42% I pay here than the 33-36% I paid in the US.

Your points are all very handwavy, but to answer. There are good public schools in my district.

The state is currently building a huge new high school a block from me to cover upcoming demand.

I’ve gotten a bed whenever I’ve needed one in hospital. Perhaps that one is not even everywhere and can tend to be an issue in rural areas, but not where I live specifically.

Public transport here is good. It’s congested, sure, but nowhere near as bad as other cities I’ve lived in. The state is currently building several new transit lines.

In terms of tax, I pay roughly the same overall as my US peers. I do earn a bit less, but that’s because it’s AUD.

I don’t even know what to make of your comment about old people. That sounds completely weird. I certainly don’t know any of my older (70+) friends who do that because there are lots of social programs and activities in my local area.

It sounds like most of the US population simply can't afford that level of care, yet is forced to "go with it". In a way this may subsidize those who can afford it.

If patients had an option - a la you can get an appointment now with an external consultant for $X, or wait two weeks - then that would make sense. But instead you pay for health insurance to literally insure against catastrophically expensive health-care costs (that's the point of insurance - "socialize" risk so that the individual doesn't get "wiped out" in case of an extraordinary event), yet you may still go bankrupt even if you do everything right!

Also, most other countries have a two-tiered system. Public health insurance, possibly worse and slower (don't necessarily agree), or you pay extra for private health insurance and get nicer hospital suits, better doctors and short wait times.

I have one of the best health insurances, it costs dearly, and yet I have no way I could get an appointment for anything without weeks wait. Perhaps with exception of emergency room. And it's expensive as hell. And not in a single place I see a price list, and no physician would ever tell me their cost upfront. That's what you call "standards"?

Because "health insurance" is not designed or used as "insurance" anymore. Real insurance takes into account numerous factors which rate your risks of something bad happening to you and comes up with a rate tied to your particular set of circumstances that influence that risk.

Unfortunately, when "health insurance" covers day to day conditions, procedures, etc and costs the same for everyone regardless of circumstances, then it's no longer "insurance" but effectively pre-paying for access to a set of services.. and hopefully, it's services that you want and might actually need.

In the US, it's more of a "healthcare access fee" than "health insurance."

This sounds like armchair musing rather than a determination from actual data. It generally costs a lot more to treat problems as they arise than it does to prevent them. Paying up front for day to day procedures would significantly reduce the burden that guaranteed emergent care places on society already. It also potentially makes federal programs such as SSI/medicare cheaper as previously insured people are much more likely to be healthy.

The numbers are subject to some debate, eg the arguments over the Mercatus Medicare For All paper, but hand waving and claiming insurance that covers day to day procedures isn’t actually insurance is dubious. Not to mention, many modern plans have high-deductibles and function as you suggest, to where a healthy person may receive little covered service but also pay less out of pocket.

https://www.amsa.org/wp-content/uploads/2015/03/CaseForUHC.p...

I think you misunderstood me. I'm not proposing any policy or treatment changes. My point is calling what we have "health insurance" is confusing at best and deceptive at worst, so let's call it by a better name.

That may cause policy changes if people's mindset and behavior shift but at least we're building on better models of the world.

Here in germany if you have a private insurance you will kinda get scammed. Cause hospitals can make more money out of you they will make all kinds of tests on you, cause private insurance will pay it. This wastes your time and doesn't actually benefit you. On the plus side, the waiting times are reduced greatly, you are basicly a high priority patient for them cause, again, you make them more money. In theory everyone could get a private insurance but in practice only very rich people, self employed and people working for the government (the latter two are not eligible for public insurance) do actually get one. I don't know anyone here complaining about healthcare, it generally works great.

You can get gesetzlich versichert (for example with the TK) if you are self-employed. You pay a ton, probably as much as private insurance, but you do get insured.

> You have a habit of posting in healthcare threads and denigrating physicians

Ad hominem arguments are very much out of place here. You have points that don't require an ad hominem yet you chose to use them anyway. I can't understand why, it only weakens your argument.

I agree that ad hominem is of dubious utility; however, here I'd argue this is not an ad hominem in that I made no judgment of the poster, but rather pointed out he has frequently posted on this topic, calling for "investigation of medical cartels by the FTC" and claiming we are "overtrained", and that it is time to "end the Flexner tyranny".

They also heavily advocate for midlevel care as a replacement for physicians because we are "overtrained".

I'm yet to find a physician (especially somebody trained at Harvard/Stanford/etc plus a couple fellowships) who is actively practicing, and who hasn't told me with intellectual honesty that 80% of the patients they see present with trivial cases which could have been handled by a resident or a midlevel. They mostly put up with it because they get reimbursed a couple hundred $ for these trivial cases, which they shouldn't be.

Same for rads fighting over high RVU MRIs and CTs for 30 year olds without prior history. Half of those shouldn't have been ordered in the first place, the other 40% can probably be read by RAs.

That's why I think physicians are overtrained in the US for the type of work they de facto perform.

> There's almost no job where 80% of it couldn't be done by someone significantly junior. Especially when people are going to die if the person in the role can't handle the whole job, and there's no cost-effective way of presorting the work, it's not at all a sign of overtraining that 80%—or even 90%—of the work items could be done by someone far less skilled.

Nobody is going to die if nurses start prescribing acne creams and performing digital rectal exams. I'm talking about trivial routine care which is bulk of entire volume.

Emergency care where people die is a different story. Nobody should be reimbursed anything in emergency care. EM docs and midlevels should be on a salary like in Kaiser, with best outcomes at lowest costs being the only incentive.

> I'm yet to find a physician (especially somebody trained at Harvard/Stanford/etc plus a couple fellowships) who is actively practicing, and who hasn't told me with intellectual honesty that 80% of the patients they see present with trivial cases which could have been handled by a resident or a midlevel.

There's almost no job where 80% of it couldn't be done by someone significantly junior. Especially when people are going to die if the person in the role can't handle the whole job, and there's no cost-effective way of presorting the work, it's not at all a sign of overtraining that 80%—or even 90%—of the work items could be done by someone far less skilled.

> If you want equivalent costs to the rest of the world, expect the US expectation of care, turnaround time, and time-to-service to decrease drastically.

I'm already waiting upwards of 3 months to see a specialist. Every GP I go to wants me out of that room within 10 minutes. If I'm in the hospital, your "rounds" last maybe 2-5 minutes - you guys are constantly interrupting me. Your admins have you on such a tight schedule that you'd rather just send me for another scan, more panels, etc. It's easier to code and bill the heck outta me and my insurance companies that way.

Your industry is 100% anti-consumer... and I have GREAT health insurance as a tech worker. I hurt inside to imagine what those who have worse coverage (OR NO COVERAGE) are going through...

I recently watched the following https://www.youtube.com/watch?v=8LZJz7GtJA0 and literally cried thinking about how I wish someone from your world would respect me/my health like these men vs. cutting me off every other word when I'm telling you about symptoms.

You think it would get worse? Well in my mind it's already trash service because it's a whole bunch of competing industries trying to survive/make money off of each other with the patient as the last priority. The US healthcare system is brutal even if you have the coverage.

> You can't compare the US standard of care with the rest of the world's standard of care.

Also. Uh... yeah I can. We're America.

Please respond. I sincerely want to hear what someone with "MD Harvard Medical School. MGH Radiology Fellow." on their profile would have to say about this.

Funny, I visited a doctor while in Barcelona, it was a much nicer experience than any of my recent experiences with US doctors, I was able to get in same-day with something not particularly urgent, and it was a $50 CC swipe at the door. My friend’s mom broke her hip in Italy, and she was extremely well taken care of. I guess I just don’t see where they’re failing at standard of care.

How many life-years will the US standard of care coming down to the rest of the developed world cost me?

I can enumerate how much the cost of care coming down to that of the rest of the developed world is going to save me. You tell me there's a cost to this. Great. What is it? What exactly are we getting for the ridiculous money that we dump into your industry?

Related question: How many years of life do I buy from your billing guy spending $100 of his time to argue with my insurance company's billing guy (whose time also cost $100), over a $500 procedure? Because as far as I can tell, the net win for me in this transaction is that the procedure you performed costs me $700 net, instead of $500.

The US standard of care is below that of most of the developed world.

> If you want equivalent costs to the rest of the world, expect the US expectation of care, turnaround time, and time-to-service to decrease drastically.

I'm a Canadian that moved to the US. My wife has bilateral hip dysplasia. One side was corrected in Canada, and the other side was corrected after we moved to the US. We have great health insurance here

In both instances, wait time for appointments and surgery was the same, standard of care was actually better in Canada, she had a team of orthopedic surgeons vs in the US she had one surgeon and a handful of nurses and so forth.

But the US hospital had a better food menu, so there's that I guess...

>You are getting WORSE care for the same price when you see an NP or PA.

I am skeptical of this statement on average.

You’d agree that an important part of patient care is listening to the patients, correct?

In my personal experience, NPs tend to do so. Oftentimes I’m coming in for fairly obvious medical reasons and it’s a painless visit.

With doctors, it’s been a crapshoot for me. They adhere to whatever they learned years ago with complete inflexibility.

I still recall my high school dermatologist insisting that diet doesn’t affect acne and even showing me some stupid pamphlet to support her argument despite my insistence that it does from anecdotal evidence. Lo and behold it turns out she’s wrong! I doubt she cares since that’s not what she learned 15 years ago in school.

Simply put, most doctors don’t give a shit if you don’t fit the general case. If a side effect is not on the label, surely you’re imagining it and we can set up some therapy sessions.

It’s bewildering to say the least and very patronizing.

Imagine you had a tech lead try and “fix” any bugs you’re encountering without ever bothering to read the code or see what your approach so far has been. They just spitball some suggestions from what they’ve seen before. That’s how it feels.

It's certainly not better.

Well that is a massive difference from “it’s worse”. If Americans are paying so much more than other countries on their health care for something that isn’t leaps and bounds better, then they are getting fleeced. And given how many health outcomes in the US are fairly middling for a country of its size and wealth, it’s not a stretch to assume the health care isnt actually better. At the very least, you can conclude that whatever benefits their are to our stupendous health care are more than offset by the damage done by the prohibitive cost. Fantastic health care isn’t fantastic if people can’t afford it.

>You can't compare the US standard of care with the rest of the world's standard of care.

That's right you can't. The USA is 31st in life expectancy and falling, behind virtually every other industrialized nation in the world in addition to countries like Chile, Slovenia and Costa Rica.

https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

That's disengenuous at best. Health care only goes so far when half of our population is obese. I would think survival rates for various diseases would be a better metric.

> You can't compare the US standard of care with the rest of the world's standard of care. If you want equivalent costs to the rest of the world, expect the US expectation of care, turnaround time, and time-to-service to decrease drastically.

I think the legal standard of care is mostly just a mistake on the part of the US. Surely it would make more sense to let different people have medical care performed to different standards.

Never personally had a quality interaction with the VA. Neither has any other vet I know.

Your first mistake was having an opinion that the government is ineffective at spending or regulating thing.

The second mistake was thinking this forum would support you.