Family medicine is in decline
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Luckily I have a BlueCross PPO. So I’ll get fast access to a specialist in NYC in Boston then transfer the records back to the local dude if needed. My wife had an issue with a complication, and I found a doctor who was a contributor to a major study on it and we got treated by him. Epic makes managing this trivial.
It’s the best of both worlds, but only if you have the privilege of legacy insurance and PTO.
Where are you? This is unusual.
In America, the "average wait time for a [cardiologist, dermatologist, og/gyn, orthopedic surgery or family medicine] appointment for the 15 large metro markets surveyed in 2022 is 26.0 days" [1]. In Canada, the "median national wait time 1 was 78 days," with wait ime "defined as the period between a patient’s referral by a family physician to a specialist and the visit with said specialist" [2].
Broadly speaking, American medical wait times are quite good, particularly for specialists [3]. But PCPs/capita vary greatly from state to state [4].
[1] https://www.wsha.org/wp-content/uploads/mha2022waittimesurve...
[2] https://pmc.ncbi.nlm.nih.gov/articles/PMC7292524/
[3] https://worldpopulationreview.com/country-rankings/health-ca...
[4] https://www.beckershospitalreview.com/rankings-and-ratings/s...
I don't remember it being this bad in the past. Perhaps things have changed in the several years since those publications were published.
> I don't remember it being this bad in the past. Perhaps things have changed in the several years since those publications were published.
There are several reasons for this, but the gist of it is that pharmas have moved much of the actual work of running large clinical trials to contract research orgs (CROs) and the cost of recruiting patients for trials, training staff, records keeping, and administering the trial becomes out of reach for small independent sites where clinical trials are executed. It's also more efficient on the sponsor side to interface with one large entity rather than several small entities.
I suspect that the increasing demands of technology and burden of records keeping in both clinical trials and health insurance makes it difficult for small independent sites to operate profitably. So what happens is that many small, independent offices end up joining a larger entity that can consolidate some of the "system level complexity" more efficiently. The tradeoff is that it's no longer about the doctor-patient relationship; it's about efficiency and profits.
I also suspect that part of it is that PE realizes that consolidation lets them control prices. If they can control a network of trial sites, then they have more power to negotiate rates with sponsors and CROs for each patient they sign up to the trial. The bigger the network, the greater their leverage. I think this probably also holds true for healthcare and insurance providers in general.
[0] https://www.fiercebiotech.com/cro/private-equity-invests-tri...
Is it? That's pretty normal in my part of the US, and that's assuming you already have a PCP. If you don't, then finding one that's accepting patients can take much, much longer.
Are you in a state with a shortage of PCPs [1]? If so, yes. But most Americans aren't in those states, and in at least a few of them the harm is closer to a political choice than an oversight.
[1] https://www.beckershospitalreview.com/rankings-and-ratings/s...
I'm not asserting that what I've experienced, seen, and heard represents the majority experience. As I mentioned, I don't know. But it's not exactly a rare experience.
I had similar problems with a specialist. Their appointments are typically six months out, and if you need something more urgent, the answer is "sorry that's all we can do." My last actual appointment, after the ~six-month wait, was a simple 15-minute telehealth visit. It's insane.
I have great insurance and I've never had any problem paying. It's amazing to me that doctors seem to really push back against having patients, or their patients having appointments. Isn't this how they make money? What kind of weird market effect incentivizes this behavior?
It's interesting that dentists and oral surgeons seem to be the opposite. I've never had a problem finding one and they usually seem welcoming, happy to help, and glad to have the business.
It is rather messed up but One Medical (now owned by Amazon) and a few other services can be worth the money because they have access to the fast track appointment line.
I only know this because after many many months of searching for a primarily care doctor and waiting for an appointment I was told about this. New patient scheduling for my doc is months out. If I email and ask if I can come in next week they always say how about tomorrow/the next day?
Making friends with folks in the medical field is eye opening to say the least. The system is operating redlined and has been since before Covid. Covid just caused the fractures to finally start showing to the average person.
The real thing coming for us is that every doctor I know other than some specialists are simply counting down the days until they can leave the field of direct patient care entirely. Whether this be early retirement, paying off student debt and bouncing, or making a lateral move to research or a tech firm. The field has gotten to be untenable for many, typically the ones who actually care. The profession as a whole has lost its personal agency to the administrative class. It’s not idle talk either - plenty have actually already executed on these plans.
This has happened all across the American economy, in every business, every industry, every company.
My father was a grocery store manager for decades. He retired and went to be a contractor for a decade. The grocery chain recently tempted him back, by offering him top position (over other candidates, who kinda deserved the position, but that's just how much this company loved my dad, he was literally legendary in the company) in their "show off store" which they had purchased to scoop up the location from a competitor that they want to keep out of the market (yay capitalism) and spent millions to completely re-roof, rebuild, redesign as their premier location, to be used exclusively to lose money in a busy market, to show off for the C-Suite, and to shoot commercials in. My father was clearly super excited to get back to the company, to get back to management which he is very good at, and to get stable health insurance.
He gave up after a few months. Everything is that kind of awful "automated" that any software developer could immediately recognize, with KPIs and useless metrics created by someone inexplicably above you who has zero familiarity with what those KPIs even measure.
No more agency for lower management. Just shut up and follow the whims of the useless nepo-baby who runs your division as it continuously fails to do anything.
I got a small scratch from a squirrel and since it did cause a little blood to appear I figured better safe than sorry and went to Kaiser's site to make an appointment with my PCP.
They had nothing for a few weeks.
So I changed to requesting an appointment with any doctor at the same facility. It then gave me an appointment with my PCP for the next day at 9 am.
I've seen similar problems with vaccine scheduling using their web site. It will sometimes only show appointments at a bigger Kaiser facility in the next town, or an even bigger one 30 minutes away.
But if I actually go in and talk to the people at the front desk at the Kaiser office in my town they can often make me an appointment at that facility.
A friend of mine needed a specialist. She called multiple offices across two different states, and the soonest appointment available was about 4 months out.
Four or five years ago, we didn't typically see wait times like that.
> In America, the "average wait time for a [cardiologist, dermatologist, og/gyn, orthopedic surgery or family medicine] appointment for the 15 large metro markets surveyed in 2022 is 26.0 days" [1].
I want to point out the important missing fact there that the "America average" time tells you nothing about variance across geography, specialty, or patient population, and you really need to at the very least look further down at the charts where they talk about shortest and longest times in the different cities and specialties.
For instance I see Boston's longest 2022 time for family medicine is 136 days, average 40 days. And Massachusetts is one of the top states on your list for PCPs per capita. At least that's better than 2017 where the longest time was "fuck you, get rekt, lmao".
If you need to see an Otolaryngologist (ENT), you might be able to get an appointment within a few weeks. If you need to see an Endocrinologist, it might be 4-6 months.
My surgery took months of specialist appointments and months to get an OR slot. There was a conflict and it was delayed again.
I changed networks and when searching for a new PCP I had to wait over a month for the first appointment.
They seem to rate limit new patients so current patients can get in.
These include Singapore, Thailand, Malaysia, Hong Kong, Taiwan, etc.
The quality of care in these private hospitals is usually high as well.
For some cases, the costs in more affordable locations among the above—even after including economy flights—could be cheaper than treatment in the US.
https://chatgpt.com/share/e/671fb198-2a34-8011-a2e8-e0b4aa45...
International hospitals in Singapore and Malaysia will be more normally priced, but still a small fraction of what you'd spend in USA.
And I pay like... $30,000 a year minimum for this?
I believe 30k is possible for a healthy single American.
But i've been on a "normal" health plan through my wife's job for the last 5 years.
The American health system is experienced totally differently by different classes of people.
That's $23k already before prescriptions and we are in our 30s with no major health issues.
That part doubles what you are paying yearly and is EXTREMELY uncommon. For most Americans, an appointment that costs $800/mo is one you don't schedule because you quite literally cannot afford that and will go through bankruptcy attempting to.
You spend $11500 per person, while the original statement alluded to $30k for a single adult.
Do you honestly not see the difference or are you that well off that $18500 is not a significant amount of money to you?
You are free to argue against whatever strawman you desire... Chasing your own shadow though
The premiums would be $9,600 a year but all in we could spend around $25,000. We had options for higher premiums and lower deductibles as well, but the total max out of pocket was almost identical.
It's a bit complicated to explain the details, but basically you won't pay more than about 8.3% of your AGI for insurance, no matter what your income level is.
Alas, these subsidies may expire next year if Congress does not renew them (they don't actually vanish, they are just income-capped at 400% of the federal poverty level).
Household
Size 400% FPL
1 $60240
2 $81760
3 $103280
4 $124800
5 $146320
6 $167600
From 133% (if you are below 133% you are supposed to use extended Medicaid instead of a subsidized marketplace plan) to 400% the amount of the subsidy goes down bit is still substantial at 400%.
This can result in a situation where if your income is a little over 400% FPL you might come out ahead by taking a pay cat to get under.
Next year, if Congress does not renew the expansion above 400% that was started during COVID, then there will the most abrupt drop possible at 400%: from something to absolutely zero.
My wife and I save at least $6000/year thanks to these subsidies, which put our health insurance into the same general realm as most other industrialized nations (typically 8-12% of AGI on health insurance of some kind).
I appreciate the details you shared here by the way, very helpful for me and anyone else coming by seeing similar premiums and isn't aware of what subsidies do exist.
If medical costs are indeed so high that our insurer needs $X from us each month to make health insurance viable, how does it help anything to make sure they get $X pretty much no matter what?
Do feel free to ask if you have any other questions about this. I do my own taxes, and have had to do a deep dive into the rules/forms for this stuff for several years now.
I don't even understand the concept of a $12,000 deductible when the ACA established maximum out of pocket at:
> "For the 2024 plan year: The out-of-pocket limit for a Marketplace plan can't be more than $9,450 for an individual and $18,900 for a family."
What are you even paying for?
I have no idea! High-deductible plans give you access to HSAs, which are the "don't pay taxes" cheat code (you put in pre-tax money, it gets invested in the market and grows tax-free, and you can spend it tax-free if it's on medical expenses; if you're over 65 you can use it for anything and pay regular income tax). But I'm paying 42,000 per year pre-tax for that privilege + insurance; maybe it's better to just get paid that as salary, take the income tax hit, buy coverage on the open market for far less, and then invest the leftover money.
My plan is Anthem Silver Preferred Blue PPO 4000/10%/7250 w/HSA - in other words $4000/person deductible (or 8k for whole family).
This is through Gusto, company is in New Hampshire.
Have you tried telemedicine? I've done it through One Medical, and it's a charm for little things that require a quick check-up.
If someone wants bloodwork done, to try a drug, or change dosage, it is a faster way to get an appointment.
If they want to get a general inspection and tune-up, it seems less fit for purpose.
Edit: answered my own question. Per questhealth.com "Tests purchased on questhealth.com are only for individuals who intend to pay directly for testing and do not want to submit a claim for reimbursement under their health insurance. "
I was excited for a minute
YMMV I guess.
Everyone has national health insurance, but you also get to choose where to go, and some doctors also offer non-insured services that you can pay for out of pocket.
The result is universal coverage combined with a competitive market that drives prices down and encourages innovation.
I know this is just anecdata, but having held an insurance card there for a while, our family was always able to see our family doctor the same day we called. And the one or two times a specialist or emergency room was needed, there was minimal hassle.
I'm sure there are problems with it, too -- I just don't know what they are. As a customer/patient, it seemed to work far better than the American system I'm used to.
Unfortunately the healthcare systems are in the process of collapsing across the UK and the majority of the continent too.
My pet theory is I don't think it's actually anything to do with the overall funding model. I think it's to do with our inability to adapt to an increasingly elderly population. People's kids here are scattered around the country, often many hours of travel away, living in small apartments, and can't easily look after their elderly relatives in a way that's much more common in East Asia. As a consequence, we are offload that responsibility onto the healthcare system, which treats them as patients with medical issues, when often they are just old people with broadly normal age-related disease. Our systems were never designed to be capable of handling millions of elderly people, and it's not an efficient way of providing the required care, so it's falling apart.
It's not necessarily a correlation, but your comment reminded me of the conversation.
It used to be that doctors were running their own small medical offices a lot. Unfortunately, due to insurance overhead it's no longer profitable for individual doctors to do that, especially without existing patients, so the remaining offices are mostly from doctors near retirement age.
So as doctors retire and new doctors don't want to start their own practices those practices have been getting bought out by large medical networks or private equity. Some offices are also going out of network with insurance companies. It doesn't help that PE is willing to pay a ton more than any new doctor could for the practice.
I'd recommend picking medical plans with out referral requirements and with good out-of-network coverage.
https://www.fiercebiotech.com/cro/private-equity-invests-tri...
> Private equity dollars are flowing toward clinical trial sites as industry conditions demand larger site networks, PitchBook's analysis of first quarter 2024 deal activity shows.
>
> For CROs, scooping up trial sites is one aspect of a greater movement toward vertical and horizontal consolidation, a long-standing trend that is still playing out in the space, the PitchBook report confirmed. CROs continue to combine with contract development and manufacturing organizations to establish end-to-end drug development capabilities under a single roof, making them more competitive in the outsourcing market.> Before the pandemic, she says, she might have done two disability tax credit forms; last year, she did twenty
Did Covid cause massive disability? Did legislation change to make claiming a disability easier or more lucrative? Are people claiming disability in response to inability to get jobs that meet their expectations?
It's not the point of the article, but a 10x increase in requests for "disability tax credit forms" seems like a very significant sign of something deeply concerning.
I wonder how many people seeking disability are more accurately described as disenfranchised. If people are looking at bleak prospects of low-paid jobs with limited possibilities for advancement, alongside soaring housing and other costs, how many people with previously manageable impairments are throwing in the towel and using a disability designation to escape the rat race.
I know a previously-healthy guy who got an early variant that went for his pancreas. He now has Type 1 diabetes, a condition one is normally born with and for which there is no cure, just chronic, expensive and time-consuming treatment.
Type 1 Diabetes isn't something someone is born with. Rather, it's something that you generally get when young (and, in fact, it used to be called Juvenile Diabetes, vs Adult Onset, which is what Type 2 used to be called), but it can happen later in line, all the way into the 20s (or later, I believe).
There is a genetic component, but it's also completely possible to get it with no family history.
It does. Type 1 is fundamentally about an inability to produce insuline. Type 2, an inability to respond to it.
This is simply untrue. You can be born with it, but it's certainly not the common type of type 1.
Being "disenfranchised" can very easily lead to major depressive disorder, anxiety disorders, etc.
A doctor spends a decade working 60 to 80 hour weeks studying medicine whereas an NP is a Master degree, I think which can be obtained online.
There doesn't appear to be clear results yet in studies on the outcomes of NP's vs MD's (see reference).
Another argument is that maybe all that medical school training is overkill in Primary Care and this is perfect setting for NP's or PA's. And also maybe most doctors are not ambitious and forget most of the training they're not using on a daily basis anyway.
I think it would be pretty funny if after more studies NP's showed no different outcomes than MD's.
Interesting write up on NP outcomes.
It’s simply not a great career choice anymore. You start work very late in life, and make only OK money. Some specialists make a lot but they start even later. Some GPs make a lot but they run patient mills. For most GPs, it’s an extreme slog without extreme reward.
The same career issue goes triple for nurses. Young nurses are quitting in droves.
And half of your nurses will agree with them!
North America seems to be alone in requiring a 4 year degree before letting a student anywhere near a medical school.
Additionally since a lot of our healthcare is managed by Private Equity or other forms of investors that are looking for a profit, I suspect with cheaper staff they will just keep prices the same and increase their profits.
Sounds like it has a lot to do with the system.
In the US, because of employer insurance, the cost of insurance is mostly hidden from patients. The cost of medical care is similarly opaque -- consumers expect routine checkups to be essentially free, and sick visits to cost next to nothing. Insurance companies are always trying to drive down their costs, and control access for a huge set of patients.
Previous comment:
If you said "Where applicable, level up folks with the desire and aptitude from IT support->senior engineer. This specific pain point is a talent pipeline health and structure challenge. SWE feelings around this are going to be something to consider, to note when preparing for the opposition" people would go wait, maybe the occasional fresh bootcamp grad or ITsupport technician has the potential to do strong work or manage a team, but in general their education has not prepared them. Of course if you ask a doctor "could the RN or NP run this floor" there's a conflict of interest when they tell you "no", but they're also correct.
Having a nurse is probably better than no medical care at all, so a tiered system where poor people get nurses without realizing they're worse than doctors would have that advantage, but the right overhaul imo would be reducing the years of schooling required to become a real doctor (undergrad, med school, residency, maybe fellowship, finally attending). If doctors skipped undergrad and cut out some med school or fellowship requirements, they'd start working earlier and could afford to choose specialties that pay less. As well as expanding residency slots and moving insurance compensation to family medicine and pediatrics.
edit - here's a good example, https://old.reddit.com/r/medicine/comments/1f6m5i9/its_scary... the good news is they'd agree with you that midlevels do have a role, the problem with scope creep is defining what that role is, and the assumption that the training is 80% or even 50% there
The physician, in turn, rather than having 40% overhead, has no overhead from billing or insurance. They have simple monthly cashflow that they can allocate to cover rent and wages for their practice. This means that the physician can choose how many patients they have relative to their expenses, and decide how much time they have available on average for each patient.
The result is great for the patient, great for the provider, and the sort of thing that will help increase availability of doctors, and their satisfaction with their work.
You can find more on this from https://www.dpcare.org. Here's a map of direct primary care practices: https://mapper.dpcfrontier.com.
And then attaching a user interface to the data that guides the user through a step-by-step self-diagnose process.
There are also a lot of rare things that need expensive procedures that shouldn't be done on a whim. Many medical tests increase your odds of cancer for instance - if you really need that test done to figure out your issue it is worth it, but those tests shouldn't just be done - it is often better to treat the most common causes without verifying that is really the root cause and then only if those treatments fail do the tests to see what you really have.
I have no idea what reduces utilization.
There's major shortage of primary care doctors. Most med students don’t want to go into primary care. Plus, hiring new doctors is not as easy as it sounds… even if there were an excess of doctors looking for jobs, you have to have clinic space and staff in order to run a practice.
Specialists are in the same boat, post-COVID. Having to ref some pts to neurology with a 6+ month wait.
The article is relevant, but it is a case of "you get what you pay for".
The last two doctors I’ve had have gone to “concierge” services to help mitigate this. They stabilize their income with annual membership fees that sidestep the insurance company horseshit. They constrain their roster a bit. They can see people more quickly. But you have to be a member.
It’s sad for me, but I get it from their perspective. “Retail” healthcare in the US is by all accounts a nightmare.
I personally have not had a PCP singular doctor or doctor group in years. I use an urgent care franchise as my PCP.
I have a chronic ailment that requires daily medicine and the medical staff at the urgent care has been more than capable of providing care, writing scripts, and providing referrals to specialists.
For primary care. I believe that's where the name Primary Care Provider comes from.
The difference from urgent care is long term. Having the same PCP for long periods of time provides an opportunity for deep insight and developing a personal relationship.
In my life, as a generally healthy person working in the software industry, I have switched health insurance plans almost as many times as I've needed medical attention. What's the point of going through the trouble to establish a relationship with a PCP when you will see them at most twice, likely only once, before you have to start over after taking your next job?
Urgent care is much easier.
You expect an 80 year old to go to urgent care and spent 30 minutes chatting with a random urgent care doctor to get them up to speed on their medical history? lol.
Due to aging population, this PCP shortage is a big problem. Urgent care is fine for a younger person with a simple medical history, or for simple issues.
We saw a great doctor on our first visit, then our next visit we didn't even get to see a doctor, just a nurse practitioner... Kinda annoying I don't want parenting advice from a nurse... So on our way out when scheduling we asked if we could see the same Dr next time.
"Oh sorry she only works Tuesdays"
"Okay weird but this is 2 months out though so that should be fine"
"Actually Tuesday would put you over a week away from when the appointment was requested I can schedule you with ..."
3 visits later and we still haven't seen a doctor once. Not even a 30 second pop in the room to say hi.
We've gotten like 20 immunizations from nurses and can't ask doctors about any of it..
Like cool cool all for these peopl advancing their careers without med school but like ... Usually you want your doctor's to have gone through medical school
Is your kid sick? If not, you don't need a doctor.
The amount of bad and actually hazardous parenting advice I've gotten from nurses and PA's is staggering.
When we were discharged from the hospital, the pediatric nurse actually told us it was safe to feed him in the car seat on the drive home.
Sure. None of this requires a doctor, though.
> pediatric nurse actually told us it was safe to feed him in the car seat on the drive home
This is bad advice. But I'm failing to find studies that quantify the risk. You're correct that they shouldn't have said this. But I'm not convinced no doctor would advise similarly.
If everyone wants their kid to be seen by a doctor, we either need to lower the standards of doctor or normalise perfectly-well kids being seen by NPs. (That or a higher billing code if a patient demands a doctor for routine care.)
When literally googling your question is more reliable than asking your 'doctor', something is in need of fixing.
Google can't administer vaccines. It also can't fill out a chart that might be important in an emergency.
I'm sure you can get all kinds of dated advice from board-certified physicians too.
What reason would you not give a baby a bottle in the car?
"no pillows no blankets in the crib" was the newest info when we had our last child. I'm trying to remember other things that were different between the kids, but funny thing about having children is there's amnesia about the whole process.
There's roughly 1/366,000 chance of getting into a car accident on any given mile driven (not a great thing to average out, but still, back of the hand calculation). I'm sure that adjusting for weather conditions could get that number down further (if you assume good weather).
Let's say feed a child over the course of 10 miles: 1/36,600 chance of anything happening (hypothetically). Sure, if you do it every day that would be different - or if you live in an accident prone area that somehow skews the estimate. But the absolute risk, while there, is small.
In many cases it's kind of like texting while driving - it surely increases risk, but it can't increase it a crazy amount given how much texting while driving we observe with only a slightly elevated accident rate. But on a nationwide scale, every accident is a tragedy.
We ended up going to another one of their offices 30 minutes away which had availability (i.e. lower population density?).
For the receptionist that said "it would put you a week away"...that's when you should just push back and say that's fine. There are very few appointments that need to be exact. And you know what, if you're not sure and you're there, ask the doctor if it's ok :)
Also because I'm trying to spread awareness and you'll likely encounter this: Be aware of "hospital/facility fees".
https://www.theguardian.com/us-news/article/2024/jun/09/pati...
This happened to us, with a Northside Imaging center in a shopping plaza. A chest x-ray that's normally $50 at a regular center is costing us $500.