canadian anecdote: i havent seen my GP ever. He just oversees resident (student doctors). Ive had chronic health issues for 3 years now without much relief, despite having been to the doctors office 20+ in that time. Most of the time they deflect me from specialist care.
I'm Canadian too, and the only time I didn't see my family doctor (phone appointment) was at the height of the COVID lockdown. Are you located in a remote area?
Honestly, if you have the time, just go abroad to India or Thailand and get a full body check up. Don't leave your medical conditions untreated. Considering the restrictions around getting medications in the US, these hospitals night already have ways for you to prescribe you stuff. Just stick to the reputed ones like Apollo or Narayana Hrudalaya in India or Bumrungrad in Thailand. Or if you can splurge the cash, go for non-resident treatment at an American hospital (which is arguably cheaper than the insurance-covered prices).
there's been an issue with MAID being recommended or encouraged to people who don't want to die, but who have complex chronic illnesses that are expensive to treat. there's been a few really shocking cases of that happening, even sometimes crossing the line into coersion.
> Ive had chronic health issues for 3 years now without much relief, despite having been to the doctors office 20+ in that time.
This is the problem with all of these systems that try to violate the laws of physics (aka: free market economics). They invariably results in substandard care, if you receive care at all. Keeping people alive isn't the same thing as actually solving problems with quality care.
This is my big gripe with the ACA (Obamacare) in the US. It's a shit system that was sold as a quality system. There are so many things wrong with it I am sick of listing them.
My wife is a doctor, so I've been privy to behind the scenes effects. If you think your doctor gives a shit about you when you come to the office with one of the stupid plans, enjoy the fantasy.
Doctors do care. However, they can't see thousands of patients at a loss. They have bills to pay, just like anyone else. More than anyone else, actually. And do, what happens in a lot of practices, is that doctors are forced to become numb to their caring impulse upon realizing that there's a dividing line between quality care and going broke. And so, they churn through patients at a rapid rate because the only way to make it is quantity.
My wife was telling me that the office next to hers has four PA's. They each see 40 to 50 people per day. That's an average of 10 minutes per patient. That's not care. That's medical professionals being forced by a shit system to push on the cash register button as quickly as they are able to just to make it.
It is important to keep context in mind when thinking about some of these things. Imagine an office with a couple of MD's, a few PA's, a few medical assistants and one or two administrators. Collectively, this is a group of people with somewhere around, say, $1.5 million dollars in student loans to repay. They each have homes, cars, kids and other bills to support.
That sets-up a situation where it is impossible for that medical practice to exist below a certain revenue threshold. More accurately, below a certain profit level. If the insurance system they have to work with is shit, they have two options: Close the doors and everyone becomes an Uber driver or keep them open and run as many people as possible through the doors with a $10 to $50 per person gross profit probability per person.
No, do the math. Don't just react to this through emotion. People have to get paid for their work, just like you.
So, let's assume $50 per person average profit (not sure that's a good assumption, it depends on the practice). What I mean by "profit" here is what you get paid (not what you bill, because sometimes you don't get what you bill) vs. what it costs for a medical professional (say, a PA) to provide that service.
Now assume you can churn through 100 people per day. That means $5,000 per day in gross profit. If you are open 20 days per month, the gross profit is $100K per month.
You now have to pay, say $25K per month for rent, utilities, insurance and various other expenses. That means $80K per month. Let's say two MD's own the practice and each gets paid $25K per month salary. You are left with $30K in the bank. You likely have other expenses that will easily consume half of that, cleaning, legal, accounting, software licenses, IT, etc. You are now down to $15K. Which is a formula for going bankrupt.
What do you do? Well, you have to crunch through more people per day and try to maintain the same cost structure per patient. So, you try to see 150 to 200 people per day --if you can, not all practices can do that-- and pump them through as fast as possible. In other words, you cannot prioritize quality care.
Anyone thinking "Just provide better care and bill for it". It doesn't work that way. Say you decide to see only 50 patients per day. Obamacare shit plans are not going to magically pay you double for taking someone's pressure and temperature or going through a basic diagnostic check. The limit function here is that these plans are shit, they don't pay for quality care, they pay for delivering the fantasy of having medical care.
Not to mention the horrible problems of Medicaid/Medicare. That's another half dozen paragraphs.
Yes, everyone should have access to *quality* healthcare at a reasonable cost. No, that isn't possible if imbeciles in government make the decisions. These are the same people who, through incompetence and mismanagement can't seem to give us a world without war and misery. What makes anyone think they can actually deliver solid quality healthcare?
BTW, my wife and her partners finally had enough. They launched a boutique medical care office. They provide high quality care at a reasonable price. Patients are well taken care of, employees make a sustainable salary and nobody has to engage in the soul-crushing practice of treating patients like cattle.
Your per person figures seem low to me, and you're calling it profitability but then taking expenses out of that. Is that an industry term? Where does that number come from?
I would think at least before expenses it would be quite high as medical visits cost hundreds if not thousands of dollars.
This person has an argument but confuses so many basic terms that it gets lost. Revenues are not profits and profits don't include expenses. I'd be happy to read a cleaned up version but right now it's just a confusing mess.
> This person has an argument but confuses so many basic terms that it gets lost. Revenues are not profits and profits don't include expenses.
No. I think you might be confused.
I laid it out clearly. The basic profit has to do with the cost of an MD, PA, medical assistant and front office people interacting with the patient. In other words, the most basic labor cost layer. This is easier to quantify because you can count the minutes each person devotes to that patient.
The other costs are different. These are the business, office, insurance and other general operating costs that apply to the entire practice. In a back of the napkin calculation it is much easier to first subtract basic labor costs from the income per patient and then apply the other stuff in bulk.
I just tried to run through a ridiculously basic calculation to illustrate the point. That was not intended to be a accurate accounting report.
This is a complex multivariate problem. A simple example can't do anything but glace at the problem and, hopefully, inspire people to research and understand. ACA, Medicare, Medicaid and other aspects of our medical system have made things worse over time, not better. Having more people covered isn't equivalent to more people having access to good healthcare.
There are so many issues, for example, the fact that Medicare isn't insurance at all after 55, it's a loan! ACA shoved millions of people into Medicare. In a few years, we might start hearing of states seizing people's estates to pay for the money they owe under Medicare. It's crazy --absolutely insane-- that nobody talks about this and the media did not do their job and educate people as to the realities of this horrid system.
i already understand the economics, these types of systems exist everywhere, usually to the detriment of everyone. However, all they need to do is not deflect me from specialist care, so im not sure it applies 100% here. Check back in a month when i go to the office again and insist on seeing a specialist.
Not sure what you need a specialist for specifically, but for ~$300 you can get an appointment here in South Africa for any specialist you want. If I want to see a specialist, any specialist, I call their office, book, and X amount of time later, they see me. The reason I mention it is that SA has a medical tourist visa you can get, so flying here for your medical needs may well be within the realm of cost-effective for a lot of people in the Western world.
As a general aside. That you have to plead, motivate or beg your government to let you get healthcare from a specialist seems alien to me. I just don't even have the words - your government does not own you!
Mine was more of a general comment on these types of systems rather than an explanation for what you are going through. I have no clue why they are treating you in the way you describe. It might be interesting if you could ask them why they haven't referred you. Even more interesting if they gave you an honest answer.
my best guess is theyre trying not to "over-treat" me, the problem being its a different doctor every single time i go in, so if they all do that i never get anywhere if i have a real issue. also, at my office its tough to get followups with the same doctor. Note that its partly my own fault for backing down when they do deflect me though, but its hard to argue with a doctor when they say "lets just try this for now". Also, Fwiw i didnt downvote you, im not sure why you were downvoted.
> its hard to argue with a doctor when they say "lets just try this for now".
Yeah, I've run into "god complex" with doctors. It's a problem.
When my wife was in medical school she started to get sick and wasn't getting better. She went to probably half a dozen doctors. The outcomes were of the kind you describe "let's try this for now". In the meantime, she was getting sicker and sicker. Ultimately, she did her own research and was able to identify a potential diagnosis. She booked a visit with a specialist. As soon as she entered his office he said: You have a pituitary gland tumor, we have to operate immediately. This affliction presents very specific physical changes. She was in the hospital within a week. Six months later she was back to normal. The doctor said she was pretty much on a path straight to death and, had it not been for her self-diagnosis, that might have been the outcome within a year.
There are many problems in healthcare, cost and insurance are just two of them.
> Also, Fwiw i didnt downvote you, im not sure why you were downvoted.
I appreciate that. Right or wrong, for some reason I have always had this image of a petulant immature child downvoting on HN rather than engaging in conversation. Also right or wrong, I also attribute some of this to the serious failure of our system of education to graduate people who can actually think. They have elevated ignoring reality to a virtue and seem really proud of it. I avoid hiring these kinds of people like the plague, they have shit for brains.
WE NEED TO ELEVATE ACCESS TO HEALTHCARE TO A BASIC HUMAN RIGHT.
That does NOT happen without being critical of what we have.
We need a system where 100% of US citizens are covered and have access to healthcare at a reasonable cost for most of us and at no cost for those who, through whatever circumstance, cannot pay.
What I find interesting about these discussions is that people react badly to comments from someone like me --judging by replies and downvotes-- without ever asking questions to understand perspective. You are one of the few, in my many years on HN, who actually seems interested in actually having a conversation. This doesn't just happen with healthcare, climate change is another topic where people react with uninformed irrational emotion.
Basic concept:
If you want a better world, you have to hold politicians accountable and
you have to push for better results. If you don't, well, here we are,
at the edge of world war three.
Healthcare in the US is a disaster. And this is the case because of a million and one reasons. Nobody can point at a single variable that causes the entire train wreck. Unwinding this on an HN post is impossible. I might be off by a factor of two or more in saying that a full analysis of how we got here might require a 1000 to 2000 page report. So, clearly, for those jumping on my throat for a super-simple example, no HN comment will ever do this mess justice. Chill.
Chill, and understand that we ALL want the same things. The difference is that some of us also want sensible solutions with accountability. In order to improve things, you have to be critical of what you have where that criticism is warranted. You are not going to ever lose weight if you never accept the fact that you are eating too much, eating the wrong things and not exercising enough. The concept is simple, and it applies to lots of things in life, including healthcare.
Obamacare/ACA is a mess on top of our prior mess.
On top of that, we had a President that just lied to the people he was supposed to be working for at almost every level. My family's health insurance cost TRIPLED, from somewhere around $7K per year to over $21K per year. If you include the increases in deductibles and other factors, it's more like $35K per year. When you have a President promising families that they are going to save $2,500 per year and, in reality, they are spending $28K more for less care. Well, this is wrong.
BTW, discussing how much my wife's practice charges their clients is irrelevant. Not going there. My wife and I think it is an absolute travesty that such things have to exist. She would much rather have an open practice. However, she is interested in being able to provide quality care. The effects of Obamacare on medical practices doctors have created a situation where they have to churn through 30, 40, 50 people per day --per doctor-- for things to make financial sense. THAT is the travesty. and that is the consequence of adding Obamacare on top of a system that already was shit to begin with.
How do you get to what I said in the very first sentence in this comment?
We know how. It is conceptually simple. However, it is very hard to execute due to the fact that people don't seem to want to use honest critical thinking:
- You have to abandon ideological cargo-cult mentalities
- You have to be willing to go where the data takes you
- You have to accept that you might reach conclusions that are uncomfortable
- You have to accept that there might be realities that are very difficult to reconcile
- You have to leave politics behind you
- You have to be willing to make honest fact-based assessments
- You have to engage in solid root cause analysis, no matter where it leads
- You have to understand that there's a vast ocean of cost structures that drive this
- You have to understand that there's a vast ocean of regulatory issues that make this difficult
- You have to develop a model that honestly includes thousands of variables driving the problem
- You have to be willing to push reforms out to every problem branch identified
- You have to be interested in the objective, rather than political alignment
- You have to accept lots of things that might not be comfortable
- You have to commit not punishing one group in favor of any other
- You have to understand that the objective will require establishing limits where necessary
- You have to be clinical about the analysis, not emotional or ideological
- Etc.
The list is many times longer than these few points. This is not an easy problem. It is a million times harder when people are not willing to honestly identify what is wrong and go after relevant solutions. It is a million times harder still when people are willing to have politicians lie to us all and fuck things up deeper and wider because they want to protect their ideological alignment.
As examples, I'll give you two problem branches that need to be chased. These are just two of the, likely thousands, we should address with political neutrality and devoid of emotion. Because, frankly, some of these things boil down to just math, accounting.
Every business has a cost structure. Healthcare is not an exception to this simple truth. If you want healthcare cost to come down, you have to attack the cost structure. If you want to sell a burger for $5, the ingredients can't cost you $10.
NO. NO. NO. Insurance companies are NOT THE PROBLEM. They are the effect. The cause is the entire cost structure that drives what they have to do.
Simple example: If you live in a town where everyone is having car accidents at three times the rate of the next town, insurance companies are going to have to charge more. It's simple math. Healthcare is no different.
Where is the cost structure. As I said, two examples. I'll boost that up to three:
1- Cost of education
2- Cost of litigation
3- Regulatory burden
1: The cost of education in this country is ridiculous. At the base of the many branches of the cost structure that drives healthcare costs at every level is the cost of education. Every medical practitioner, scientist and engineer working within the medical industry has, as their baseline, very large student loans to support.
Nobody can work for a salary that does not allow them to cover their own personal cost structure and beyond that, save money and have a life. Everyone needs to retire at some point. You can't work for exactly the money you owe every month. Your "personal enterprise" has to generate a profit.
2: Investigate the amount of money medical practitioners, clinics, hospitals and medical technology companies have to spend on insurance and protecting themselves from the insanity that our litigious society can be. These costs are far from trivial. And, yes, these costs make it into the business equation that drives the cost of healthcare.
3: While regulation and oversight is important, it is obvious that things have gone way too far. As a personal example, a couple of decades ago I became interested in developing a specialized hearing aid for people with a somewhat rare (1 in 100K population) condition called "Acoustic Neuroma". I was ready to invest a significant amount of money to develop this solution. I quickly discovered the FDA approval of this relatively simple in-ear device would cost a minimum of $10MM and as much as $25M (or more). I just dropped it. It made no sense.
Drug and medical product companies have to spend incredible amounts of money to deliver products into the healthcare system. These costs, once again, have to be passed on.
There's so much to unpack. Like I said, thousand of pages and analysis. This is impossible without being brutally honest about root-cause analysis.
By the time an insurance company becomes involved in calculating a premium, all of the above, and much, much, more, have populated the variables they have to use to get to that premium. They are often painted as the culprit. This is so wrong it is probably over three standard deviations away from the mean of the analysis of the healthcare cost structure.
Final example: Our food is shit. Our own food is making people sick. Americans are being poisoned by the very food our FDA (and whoever else) allows onto our shelves. How can healthcare costs possibly be lower when what you start with is a population who's default condition could be labeled as poisoned and unhealthy as fuck due to the food we consume.
No, insurance companies are the least of our problems. That's what Obamacare and every single other proposal from any politician on any side has always missed. They focus on insurance costs and ignore the massive iceberg of root causes underlying the problem.
If we want healthcare to be elevated to the level of a basic human right, we have to be honest about where we are and find real solutions.
