‘Out here, it’s just me’: one doctor for 11,000 square miles
washingtonpost.com
washingtonpost.com
https://money.cnn.com/2018/06/08/news/economy/immigrant-doct...
https://www.wusa9.com/article/news/local/maryland/communitie...
Why would a well-paid, highly regulated profession allow people to come into their turf and undercut them?
Not saying this is a GOOD thing. Merely pointing out that the system is working as intended.
which factors into the economics of prices negotiated between providers and insurance companies.
We could send blood work overseas cheaper than the piracy prices of labcorp, for that matter.
They could explain it legally as "not medical advice" to skirt any FDA laws, but provide world class health care in reality.
It's a business model that could really work. The "skirt America's dumb self-inflicted crap" business model.
A lot of people who are capable and motivated to be doctors for good reasons are shut out because doctors don't want there to be more doctors who will serve to limit their wage growth.
I also like this 45 minute lecture Milton Friedman gave to physicians telling them how they were making healthcare worse due to this type of lobbying by their representatives. https://www.youtube.com/watch?v=rWlk9HreE7U
https://mediabiasfactcheck.com/washington-examiner/
"In the early 1900s, the AMA lobbied lawmakers to shut down many medical schools."
That's over 100 years ago. No information is provided as to which schools, or what the AMA's reasoning was behind their decision.
Likewise, lobbying to reduce residencies occurred over 20 years ago. The actual reductions were implemented by a Republican Congress and the Clinton administration.
"At the time, they argued there was an impending 'glut' of physicians. It is more likely they were, again, trying to protect their high wages."
Needless to say, that latter assertion is not in any way supported by documentation.
[1] https://www.modernhealthcare.com/article/20140730/NEWS/30730...
We need more midlevels too, I agree, though midlevels are not allowed to do everything doctors can do and are required to have many things approved by a doctor as well. So to increase midlevels would naturally require an increase in physicians.
I come to this from the perspective of someone being harmed by the way it is right now and I don't like being harmed.
Edit: For whatever reason, I was downvoted on this comment. I’m truly curious to know why. Is it too alarmist? Is it betrayal of my colleagues from someone in the trenches of our inefficient healthcare? Am I just restating the well known? Is it believable? Here is an article which should stimulate continuing discussion[1]. As far as I know, this hasn’t changed. I’m not sure how increasing the amount of medical school graduates and residency spots will deal with the issue described.
[1] https://www.propublica.org/article/unnecessary-medical-care-...
I wasn't one of the downvoters (and in fact didn't read this comment until after your edit), but I think part of the issue people might have had with it is that it does across as a bit dismissive of GP's complaints. Yes, you've also correctly identified a problem that's tangentially related to the one under discussion, but you haven't given any insight to why that solving that problem will have any effect in what people were already discussing. It's sort of like jumping into a discussion about people starving due to inadequate food supplies and saying "Yeah, but what about people dying from eating food that should have been recalled due to contamination?" Both issues are about food, but there's no apparent context for the sudden shift in topic.
Depending on the state, multiple nurse practitioners and physician assistants can be supervised remotely by one physician. Add telemedicine and other online tools to this partnership and you’ve got a pretty robust team able to care for a much larger population than one physician could. A zillion other tweaks to the system, and all of a sudden efficiency starts to make an impact. But some artificial barriers must be broken in the process (e.g., coordinated information dissemination between health professionals).
[1] https://www.aamc.org/news-insights/press-releases/new-findin...
[2] https://www.ncbi.nlm.nih.gov/pubmed/26177529
Edit: For now and the near future, there are procedures that only physicians can perform (e.g., surgery mostly). This is not true in most general medical care and even in specialized care.
Instead of acknowledging the impossibility of their desires they jump from villain to villain and magical silver bullet to magical silver bullet. The politicians of course don’t tell them they are being childish, but instead indulge their fantasies.
Why do you think the ability to shop around for a physician something so crucial to preserve in any reform? What does that have to do with outcomes?
Hell, I don't want to pay for anything but I acknowledge that people need to eat so I'm quite happy to have that payment be from my tax dollars.
And it isn't a case of 'well migrants cross the border in the middle of nowhere so it's their fault' - almost all immigrants held in this place are transferred from another ICE detention center (https://trac.syr.edu/immigration/detention/201509/WTXDFTX/tr...)
This is what ~half the country endorses, by virtue of how it votes.
Voters need options to vote for. Money in politics constrains those considerably.
Blaming people just does not speak to the mess well enough to be productive.
To be absolutely clear, this mess we are in is a function of money in politics, voters not seeing a choice they feel good about, and a general trend toward more authoritarian norms.
In any election, voters can and will do one of the following:
Vote Major Party Vote other No Vote
In the last election, a large number of Americans did not have a choice they felt worthy of a vote.
Blaming them does all of us ZERO good. Fear, blame and shame politics do not work to GOTV.
We can have a discussion about how we got here, and I think that makes sense to do.
It's too easy to just "blame the stupid people", as if that's all there is to any of this.
People, who do not see a net positive in either choice may protest, or gamble.
Last election that kind of thing definitely happened.
Now, the subtle bit:
GOP primary picks are of the voters. Dem ones are not. Party won in court asserting it's right to just select regardless of what voters do.
Secondly, money. It is expensive to become a choice.
Summary?
Voters may be left with two poor choices.
Conclusion:
Blaming voters is not productive.
That really is my only point. Blaming and shaming people does not help matters.
The necessary discussion is bigger than that.
Worth a bit of karma to plant that seed.
https://www.al.com/news/2019/09/alabama-sheriffs-release-sic...
Not saying it justifies lack of medical care, I just think you're making an excuse for the wrong "element" of their behavior.
You say that fault is attributed (by the public or whoever) due to [illegal im-] migrants crossing in the middle of nowhere...
Your counter argument is they mostly didn't cross in the middle of nowhere, so it's not their fault they were transferred to the middle of nowhere.
It has nothing to do with where they chose to cross the border illegally, people say it's the migrants own fault because they chose to cross the border illegally, period. You don't get to pick a jail when you're arrested, and you shouldn't be surprised to find out that many US immigration jails are along the southern border in the middle of nowhere.
They might not have chosen to cross in the middle of nowhere, yet their choices are still what caused them to end up there.
Again, this doesn't justify withholding medical care; you just shouldn't be surprised to end up in jail if you break the law, wherever that jail might be.
Not due to demand, but because there are not enough doctors. Doctors do not want to live in a podunk town, no matter how much the hospitals are willing to pay.
This dynamic extends beyond usa. Even in India, doctors command high salaries in rural areas, often 2-3x what they can in metropolitan cities.
A developer is even more relocatable than the doctor. You can still work for a major company and you still have the big city market open to you, even if you live in a small town. Whereas for a doctor it's a major career change.
I have several friends who talk about moving somewhere cheaper, but way more of them are perfectly happy to live in an awesome city with lots of stuff to do.
Though, to be fair, there are a ton of awesome NON-podunk little towns that are a delight to live in.
In any case, one will need to put in the effort to get one's children properly educated. A smaller school district probably gives more opportunities to experience a wider spectrum of activities anyway - I certainly wouldn't have been able to be a three sport athlete, take every shop class available, participate in math and geography competitions, and a whole host of other extra curricular activities in a bigger pool.
And it can easily be a 5x multiplier, sometimes more.
If you choose to live in rural US, you are signing up for this kind of lifestyle; you're on your own. As long as that's advertised I don't see a real problem. If you need health care then you should live near health care. Don't expect the same level of support in rural MN as you would get in NYC.
It's a genuine question; should the US taxpayer pony up so poor people trapped in rural areas can move to population centres and enjoy the benefits thereof?
I'm absolutely opposed to forcing people to move, but if they want to I have no problem spending a bit to help them.
(For reference I tend libertarian-ish)
Labor shortages are a critical problem in many of these communities. Young locals often move to the cities and rarely move back, and while automation has helped support the local industries it has not nearly covered the shortfall. Much of the working age labor that does move into these areas is either illegal immigrants or ex-convicts looking for a fresh start. Due to shortages, minimally skilled physical labor often commands 3-4x minimum wage in my experience.
It is a mistake to think that people want to be rescued from these areas. Maybe some do but most have reasons for living where they live.
The states with the lowest SPM poverty rates are midwestern states with large rural populations, like Iowa and Nebraska: https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ.... (California's poverty rate is almost double those states'.)
The unemployment rate in Iowa peaked at a little more than half the national unemployment rate in 2009-2010.
As noted at your link, many of the extremely poor rural areas skewing the averages are Native American reservations. How do you propose to make them relocate to cities?
If they don’t have the money they should move, possibly with assistance. I don’t see any case for subsidizing services in places where it really expensive to provide those services. Why that’d be like government grants to rebuild houses on a flood plain that got flooded out.
Here's coal mining in the US, over the last 35 years: https://fred.stlouisfed.org/series/CES1021210001
Sure, some people are so disabled they can't travel. For those who are not disabled but are simply poor, here's what they need-- and it doesn't cost much.
- A greyhound bus ticket
- Camping gear: A tent, sleeping bag, inflatable camping mattress
- Clothes
I used to live in a tent. Sure, it's uncomfortable, but it is fully survivable.
While living in a tent in some woods, I pulled myself up by my bootstraps, applied for jobs, visited community centers for showers & food handouts.
Applying for jobs-- How long did it take?
- Blue collar jobs: Took a day to get hired, $13/hr job.
- White collar jobs: Took 3 weeks to get hired $25/hr job.
I've lived in a tent while studying and job hunting 3 times. Now I am quite gainfully employed making over $50/hr.
Should tax payers pony up? Not if you mean people other than the individuals who need to pull themselves up.
Just look at how well you wrote your words. You are functionally literate and comfortable with technology.
When you moved and lived in a tent, did your spouse and children live there too? Who looked after the children while you were job hunting, given that your social support network was back where you used to live? Where did you get your medication during that time? I guess you had a health advantage. You were also lucky nobody came looking for the money you owed them.
Going through challenges makes people grow stronger.
Avoiding challenges makes people grow weaker.
(Which is why SJW advocacy-- such as for safe spaces, censorship of wrong think-- signals weakness in certain sections of [brainwashed] society).
Look: People who lack strategy screw themselves. That's no one's fault but their own. If they get themselves into a mess, they deserve that mess. They should have done their research-- Everyone can access the internet and find life experiences, economic research, etc.
Again-- I lived in a tent in order to put my time into something more useful than waiting tables. I reduced my work hours and bills, so I could learn web development.
My tax dollars deserve to go towards more noble causes than to fund the poor lifestyle decisions of others.
Broke & in debt? Either don't have kids, or don't come yelling for my tax dollars when you decide to make poor decisions. May they be an example for the others.
I lived in some woods in Portland for 3 weeks, applying for jobs daily from cafes, and visiting community centers for food & showers. Landed a corporate office job. Anyone who isn't disabled can do it. Claiming otherwise is a cop out.
The question is: How much do they want to succeed? How much are they willing to sacrifice comfort for success?
People take for granted their mental and physical fortitude. They give up far too easily.
When I hear stories about rural lifestyle and people driving for an hour to get to grocery store, it doesn't seem that out of place.
Some people don't choose, and other people do choose, but more importantly: your food comes from the rural US and you should keep that in mind before being flippant about their fate.
The title seems a little clickbaity to me. 11k sq miles is only 104 by 104 miles. That's about nine counties in west Kansas.
This also means that in areas lacking a certain critical mass of patients, practicing medicine won't make financial sense.
But related to the context of the article: You can't spread that cost out as a stand alone doctor practicing on rural areas. On top of this is added cost of data entry compared to old paper charts, the cost of training staff to be able to do it efficiently, and the extra time it takes doctors to keep notes and sign-off on electronic charts.
Check out some of the recent articles on physician burn-out, especially in emergency medicine, family practice, and general practice. Doctors are deciding it's not worth the hassle, financially or psychologically.
Edit: a couple of recent related articles on the topic:
https://blogs.scientificamerican.com/observations/electronic...
The electronic systems aren't simply recording what the doctor does and making a record of it, as charting is supposed to accomplish. The software is dictating (or at least heavily influencing) the behavior and workflow of the doctor. And anytime something is done out of order results in interrupting that workflow, searching through 10 other screens to find the appropriate checkbox, and then trying to return to your train of thought. The focus ends up being on the data entry instead of the patient.
This is amplified the less specialized the practice is, hence emergency medicine, family practice, and general practice being the most affected. And rural doctors being affected the most since: 1) they generally are expected to handle whatever gets thrown at them since there are no specialists around and 2) they have the smallest practices (can't share costs with other doctors).
Opting out of the system essentially means going cash only, which obviously limits your patients, among other drawbacks. Which leaves burn-out and early retirement or joining a bigger practice in the city. Or concierge medicine, which is one reason why it's becoming more popular.
It's easy to say concierge medicine, but I'm not clear on why that should work, if funneling the same amount of money every month through an insurance company doesn't. What is the difference, other than the marketing terminology?
Easy... They don't take insurance. They're typically cash only, which allows them freedom to do things like charge for house calls.
Or they have contracts directly with employers to do checkups and on-demand visits onsite. Employers that are either big enough -or financially successful enough- to be self insured are essentially paying cash for office visits and most covered services anyway. (Many companies that are ~200+ employees self insure, but still pay an insurance company just to manage it all. An in house or concierge doctor on contract might cut out enough paperwork to get rid of the middleman.)
I've also seen some setup as prepaid membership operations. But the common denominator is they cut out insurance and medicare/medicaid, which cuts out 90% of the regulations... Including electronic medical records.
Anyway, if the loss ratio of an insurance company is more than 85% by law, it seems like you can gain only so much by bypassing them.
And why would you want to eliminate medical records?
>it seems like you can gain only so much by bypassing them.
You do, but self-insuring on it's own saves a big chunk, so what's left is really just the complicated paperwork. The only reason it exists is to complicate insurance dictated rate structures, so get rid of the complicated rate structures for the 80-90% most common visits by contracting a doctor directly and there just isn't the need to pay someone else to manage it anymore.
Then the real gain is paying the doctor based on a simplified negotiated rate, and in return he gets a whole company of regular patients, and can send just one summarized bill to the company for everyone he sees in a week. Not having to file any additional billing paperwork per patient is just a happy side-effect, for both the doctor, the patients, and the sponsoring company.
>And why would you want to eliminate medical records?
It's not to eliminate medical records, it's just a matter not being forced to do them in a certain way. I think most doctors would have loved to start by scanning paper charts at the end of the day, then let some data people convert that into something the computer understands.
But the way it's setup (and mandated), the database is the official record (not the attached notes) so it all has to be done personally by the doctor, or signed-off by the doctor if a nurse or mid-level or medtech enters anything. They basically make the doctors responsible for data entry QAQC, with their malpractice insurance at risk for a screw up.
Doctors are used to mostly freeform notes with a few fill-in-the-blanks and check boxes for orders or standardized info like heart rate, bp, etc. Most software tries to cram 99% of this into a mess of a structured relational database. These also have freeform typing boxes for notes, but getting paid depends on duplicating most of the note information across a huge range of screens and tables so that the billing software understands what was done, and understands it in such a way that is covered by the patient's provider.
They are probably a 6-digit number of ways to code for giving the patient aspirin, but half might not be covered, and the other half might range in price from free to thousands of dollars of copay. And this changes with every different insurance policy, and every different doctors office/hospital system, (depending on negotiated rates with insurance) so that even the most expert billing tech might not know the correct way to bill a particular patient the first time. And oh, if they need to change it later to get insurance to cover it, the doctor usually has to sign-off on it again as if he performed a different exam than was recorded the first time.
It's a lot easier to just scratch down on paper (or in a computer) "gave patient exam and aspirin, bill for a level 2 and rx" or something similar, and then your receptionist knows what to collect or bill. All of a sudden you don't need a staff of billing techs on the phone with insurance companies all day, or a software support contract that your billing depends on.
Now imagine getting all the doctors approaching retirement and working in small practices that switching is worth the expense and hassle.
So it's not being against medical records, but the freedom to do them as you see fit, while avoiding the hassle of compliance.
And one of the few remaining ways to do that is go for the market that can pay cash, which overlaps nicely with both the concierge market and self-insured employers. (and some niche co-op style wellness "clubs", but I'm not familiar)
That doesn't save money because then you don't have insurance! The part of your premium that covers unexpected events can't be saved; only the part that pays for routine care. The word that comes to mind is "optionality" although I'm not sure it is the right jargon.
People always say that insurance is too expensive because it covers routine care, and I've never understood what that is about. It costs essentially zero to transfer money from one account to another, so just because you don't gain anything by having insurance pay, you (on average) shouldn't lose anything either. There can't be any fundamental problem with them providing a payment service.
The employees are still insured, it just means the employer absorbs the risk instead of the insurance company. At a certain point, this becomes cheaper than paying the insurance company. But then the company might take out a separate catastrophic policy that covers anything over $X million in a year.
>The part of your premium that covers unexpected events can't be saved
This is just wrong. A significant portion of that amount can be saved. Some of it is statistics, and some financial structuring.
The insurance company isn't going to absorb a company's risk for free, but there are savings beyond the profit and (overly conservative) risk margins. Segregating your risk pool allows additional control over it, then you can reduce risk in a number of ways, but especially with wellness programs. (My premium contributions at work were cut 75% for participating in the company wellness program.)
I think" a company is also able to hold it's own reserve assets that are backing their risk, and there are additional tax savings with how money changes hands fewer times, but I'm fuzzy on the details.
Anecdotal, but my last two employers were extremely eager to qualify to self-insure, even while still using the insurance company to manage policies. (There's a multi year process to qualify involving financial stability, risk pool evaluation, and sometimes even reorganizing the company structure or re-incorporating.)
>People always say that insurance is too expensive because it covers routine care, and I've never understood what that is about.
They say that because it's no longer medical insurance, it's pre-paid health care plus medical insurance packaged together.
The biggest problem people have with the pre-paid routine care is that it's basically pooled just like the insurance part, and what's routine for me might not be routine for you.
Nonsmoker's, even if they're priced as tobacco-free, have to pay for a policy with smoking cessation coverage. Nuns and 80 year olds must have coverage for birth control. There's mandatory coverage for prenatal visits and labor/delivery, even if you never want to (or can't) have kids.
Insurance is meant to mitigate high cost risks, not be a bureaucratic middle-man for every routine cost. Affordable "risks" shouldn't be insured. Insurance that covers expected* costs isn't insurance. It's just quasi-socialized healthcare with the word "market" attached for political deniability.
In the non-segregatated pools, there's no incentive to keep costs down. You'll be paying for a portion of the weekly doc visits of the bored little old lady who goes and gets every little bruise and goosebump checked out, because why not? It's a no-cost routine visit for her.
Also, you have to pay for coverage for services you might already have free access to. Like if you work for a clinic and they offer employees free visits. You still have to pay for that coverage. Or I want to see a particular doctor that's out of network. I've got to pay out of pocket for a service that I've already paid for. If you forget to get pre-authorization before going to get a mole removed by the dermatologist? Same thing. They might not pay it, because you did it without their permission.
All of these "routine" costs are built into the price of your policy, and for most people it would be cheaper and much less of a hassle to pay-as-you-go for everything thats not catastrophic.
>It costs essentially zero to transfer money from one account to another
Except your money got thrown into slush fund shared with thousands of strangers, and you'll never get as much out as you put in (Unless you're talking about the case of a self-insured employer paying 100%, which is rare.)
>There can't be any fundamental problem with them providing a payment service.
If that was all they did, and you got rid of the pooled routine costs, and got rid of the billing-code/ coverage roulette, and got rid of the copay/ deductable/ out-of-pocket calculation hassles, and if it would just work as constantly as a debit card, then I think people wouldn't have a problem with it.
But that's sort what an HSA does (which is through the bank, not the insurance company.) In practice they're restricted to certain policy types, and don't really eliminate any of those problems, just reduces them.
https://www.healthit.gov/topic/certification-ehrs/certificat...