Grinding to a Halt

I’ve been in a foul mood of late at work, and it’s because I see the beginning of the end of the health care system I know and respect.

I am not involved in health care policy, or planning, just the trench-line delivery of modern, ‘high-tech / low touch’ American medicine. I realize it’s terrifically inefficient and at the same time realize I am individually powerless to change it. However, I’ve been thinking more and more about our future, and it’s not at all good.

I’ve recently had several interactions just like this one from Australia:

Sometime during the night they were moved out into a corridor to make room for the incoming. I saw them again the next morning. There was no longer any room to sit beside her, so he stood at the foot of her bed. He was angry. “This is disgraceful” he shouted. “I’ve had top private health cover for as long as I can remember….and now I need it, I can’t even get a bloody bed for my wife!”

He sat, red faced and embarrassed at his outburst. It was all beyond him.

Since November, with few exceptions, we’ve been ‘holding’ admitted patients in the ED. Yesterday we had about 1/3 of our physical rooms occupied with patients ‘admitted to the hospital’ who were going to be cared for in the ED. No windows, no TV, no phone, just a real hospital bed, real hospital food and their medications. It’s the biggest shock to people who haven’t been to an acute care hospital for a while, and just assumed there would be space in the hospital for their loved one. This is, by the way, after we’ve been putting admitted patients in the hallways of the upstairs wards to try to relieve the ED overcrowding.

So, 1/3 of our space is now dedicated to inpatients, therefore the hallways were lined with gurneys of the actual ED patients. Four years ago this was an occasional, ‘surge’ thing and now it’s everyday and around the clock there are patients being cared for in the halls. (Mental exercise: describe how much fun it is to give a history in a busy hallway with people and other patients / families constantly walking by, and I’ll leave the thrill of the physical examination to your imagination).

There’s no incentive for hospitals to add beds, unless you happen to have one of those really-well-billing cardiac diagnoses, and there’s money for that, so hospitals are building cardiac units that are closed, meaning if you don’t have a cardiac diagnosis and a cardiologist on the case you lie in the hall. We have, simultaneously, the best and worst healthcare has to offer.

I’m of the opinion many of the problems of modern healthcare do stem from a complete absence of a market in medicine. I wouldn’t take my car to the shop and just say “fix it” without at least discussing the costs (unless I had the insurance / medicare system for my car, then I’d drive it like a nut and sue if it wasn’t perfect when it came out of the shop). I’m 100% for posting signs in the waiting room, patient rooms (and, regrettably hallways) outlining what these tests they’re getting charge. It’d be eye-opening, and it might just cause a few people to think about need vs. want, and would make my job a little harder. I’m okay with that. I’d like to discuss the pros and cons of ‘do you really need me to CT you from stem-to-stern’ with an alert patient who’s able to make informed decisions.

People ask me what I think the future of medicine is when we’re staring at the overcrowding, and ask what I think will happen. I don’t think it’s going to be anything cataclysmic, we’re just going to grind to a halt at this rate. Money continues to be poured down expensive therapies of marginal benefit, there’s no barrier to asking for more healthcare, “now!”, and have a quick peek at nursing demographics if you’re in doubt about the short and long term problems we face.

The Wall Street Journal (may require subscription, sorry) has an editorial about healthcare today, and here’s the money:

[Shifting to a market system] won’t be easy, especially given the ideological stake that so many politicians have in a government-run system. They like the leverage of determining payment rates to hospitals and doctors, not to mention being able to take credit with voters for providing more benefits. But there is no free lunch in health care, any more than there is in any other part of the U.S. economy.

Health care is either going to be allocated by prices or by government, which in the latter case means price controls and waiting lines. Though it represents one-sixth of the U.S. economy, health care is the one industry in which the purchasers actually have no idea what anything costs. An individual market for health insurance would allow more freedom of choice while making consumers more cost conscious.

If we don’t do something, soon, there not only won’t be a medicare system, there won’t be anyone in the hospitals left to take care of us. If we can get out of the hallway, that is.


Comments

  1. From a pediatrician’s standpoint, the bed crunch problem and the ED problem are the same problem: inappropriate use of medical services by patients and doctors alike.

    Pediatric EDs in my community are packed with kids who are not emergently ill (leave aside for the moment the reasons why this is the case).

    My recollection of medical services at pediatric hospitals as well as peds floors at community hospitals is that most of the inpatients did not require hospital level of care.

    I acknowledge that the situation may be different in the grown-up world.

    best,

    Flea

  2. Steve Lucas says:

    What we are talking about is a shift in the business model of health care in this country. This will require so many changes that they will not be accomplished all at once nor will they be accepted.

    Welefare folks can now call a squad for a free ride to the hospital instead of paying to go to a regular doctor. Many in the politiacal system see this as a plus and a reason for reelection.

    I know one doctor who sends all after hour calls to the ER. The reason is they get paid for the call, if admited they sign the clip board on the door and get paid again, and they eliminate the liability.

    Doctor’s get paid to test, so you test. Working with a patient does not bring in fees.

    Hospitals are the only money making part of the doctor side of the equation so they encourage 24/7 usage. The list goes on with the result of over crowding, over worked staff, and a very frustrated patient base.

    Change is not accepted so the system will only get worse as “experts” tell us how to spend more money on a system that needs a major overhaul, not more money.

  3. Here’s a question that might illuminate the problem a bit – I am asking this earnestly, as I honestly don’t know the answer: if someone were to open a private emergency room, would it be financially viable?

    If it would – presumably by offering high-quality care to those who could afford it – then the next question to ask is why we don’t have them now.

    If it wouldn’t, then I guess we could assume that people are simply not willing to pay for care that is much better than what they currently recieve.

    Personally, I’d love to have the option of private emergency care. I’ve be happy to pay the difference between what my insurance would cover and what I’d be billed, assuming that the quality of the care justifed the additional expense.

  4. “Since November, with few exceptions, we’ve been ‘holding’ admitted patients in the ED. Yesterday we had about 1/3 of our physical rooms occupied with patients ‘admitted to the hospital’ who were going to be cared for in the ED.”

    It sounds like UPR Carolina (University Puerto Rico teaching/gov hospital) where I had the displeasure to see my mother stay, in ICU, for 6 weeks until she passed (she became ill in the PR airport on our way home from a holiday in the Caribbean). Point is, it was dirty (you have no idea). Top paid nurses work in ICU and make $9.50 an hour and have basic training. They work in ICU to get better experience and hope to move to a private hospital (like Auxilio Muto or Pavia) and get another 2 bucks per hour. I certainly hope we are not headed that way with nursing/physician shortage…sigh…

    Cynde

  5. Anonymous says:

    One problem I see with market-driven medicine is that patients have to be willing to take responsibility for their decisions. Let’s say I see a patient that has been put on (cheap) amoxicillin three times in a row for the same persistent sinusitis, by a “quick care” doc, and I(as the Ear Nose and Throat specialist)recommend a stronger (and more expensive) antibiotic, and the patient balks at this. I then get called in the middle of the night from the ER when the patient comes in with proptosis due to an intraorbital complication. Now, am I obligated to treat this horrendous complication in the middle of the night, with a patient that may SUE me for presumably not adequately treating her infection? Am I obligated to take this non-compliant patient to surgery, especially since her high-deductible MSA plan means I won’t be getting paid a dime for my troubles (if she didn’t want to spend money on a good antibiotic, she won’t be spending it paying my bill after the fact)?

    I don’t want to couch this argument in terms of money, but that is exactly what will happen if market-driven medicine occurs. You can’t have the consumer(patient) playing by one set of rules, and the doctor having to play by another–the doctor always has to do what’s right, even if it costs him. In this game, the doctor will always lose. In this scenario, if I refused to come in to treat this non-compliant patient, not only would I be infintely sue-able, but I would potentially be hauled before the medical board to answer charges of patient abandonment.

    The liablity issue has to be addressed adequately before any such conversion to a market-driven health care system takes place. Additionally, if patients choose not to follow the physician’s recommendations solely based on cost issues, then a physician should be able to consider that patient discharged from his or her care at the point of that non-compliance.

  6. We all seem to talk about the market driven fee-for-service no-middle-man medicine as though the problems inherent in this kind of medicine are new and unprecedented. But this was the medicine practiced in this country up until the second half of the twentieth century. Sure, a lot of the pharmacological and technological advances came after but the problem of treating people who are unable or unwilling to pay for their medical care is not new. This theme can be found in William Carlos Williams’ literary work. In fact, I would venture to say that this problem is almost as old as medicine itself. Physicians were able to deal with it then and I do believe they would be able to deal with it now.

  7. Excellent post. Our units have been full to the gills, with our overflow units open more often than not. We’re constantly triaging patients out of the unit to accomodate the ones trying to get in from the ER. Today we hit our limit, and I’m not sure what they did with those ER patients, but they certainly did not come to ICU.
    Not ours, anyway.

  8. Gosh, GD, you sound like a libertarian! (I’m with you on the posting prices thing, but the problem is the prices are artificially high, b/c collection rates are so low. And at my ER, the taxpayers pick up the tab for everyone anyway.)

    Mike: Regarding private ERs, I think what you mean is pay-for-service, as most hospitals are private and for-profit. There are pay-for-service urgent care clinics, at least one I know of in Santa Fe. They can actually charge less because of lower overhead and 100% collection (you have to have cash or credit!). But there are no pay-for-service emergency departments–EMTALA (unfunded mandate) makes us take care of all comers.

  9. My Hospital’s ER has been “full to the gills” for about 2 years now. It creates another problem, in my mind: Every time I walk into work, the ER is in major crisis. I feel like an abused spouse: I drive to the hospital knowing the place will be an out-of-control crisis, I know it will be painful, I just don’t know where the abuse will come from today. The job is starting to affect my health. I walked in one night and there were 75 patients either boarding, being seen, or waiting (In a single coverage ER). Part of it is that any one of these patients may be my next lawsuit, but in reality, it’s more than that. How can I care for 75 patients at once, by myself? I don’t know what the solution is, but the system always seems one patient away from totally collapsing. I just pray I make it to retirement without a lawyer stealing my life savings due to a bad outcome.

  10. bad shift,

    There is such a thing as stand alone ER’s. Emtala aplies to hospitals that accept medicaid/medicare dollars, but does not apply to Urgent Cares, or to a “stand alone ER”, AMA news just had a feature article about them. Florida, I believe is where they started. Myself and others have been tossing around the idea for a while. I have mixed feelings about it. The idea of being able to provide faster, better care they way I want to and not be subject to a hospital administration, and potentially make a lot more mony is intrigueing. But I have mixed feelings as I think most ER doctors wear a badge of honor in taking all comers, regardless of race, economic status, or blood alcohol level. After all if we were to get a patient that needed ICU or surgery they would have to be sent to some poor schmuck working in a hospital that is already overloaded further “breaking” the system that gruntdoc is talking about

  11. This happens every year… respiratory season hits and ERs (and ultimately the patients) are left holding the bag, either due to a lack of beds, or a lack of nurses to support those beds. When we hold patients, we run out of rooms, and sick people are left sitting in the lobby. It’s only a matter of time before somebody codes out there and the relatives drag everybody into court over it.

    This isn’t a surprise… every year we see these disasters coming, and nothing is ever done to address the problem in advance.

    In many ways, medicine is a very poor business, and highly-regulated to boot. People feel entitled to your services simply because they exist, and have no problem stiffing everyone else with the bill. I have patients (some of whom I recognize) who give a different SS# to our registration folks every time they come in, just so they won’t get a bill. These people don’t come to the ER for real emergencies either… they use us as a primary care clinic. They KNOW we have to see them, and all our surrounding walk-in clinics require cash/CC/Insurance just to get in the door. Sending all the non-payers to the ER is the best thing going.

    Once the next round of medicare cuts and pay-for-performance initiatives goes into place, I predict medicare will become the new medicaid. Nobody will accept it, PMDs will fire their non-compliant patients, and they’ll all end up being funneled to the Emergency Room, further exacerbating the problem.

    I enjoy taking care of people; it’s the whole reason why I chose this profession… but between the regulatory burden, overcrowding, payor issues, plaintiff’s attorneys… medicine in general (and EM in particular) gets into deeper and deeper trouble every year.

    My opinion? It’ll take a true collapse of this house of cards before anyone takes it seriously.

  12. Those of you thinking about a market solution are just dreamers. When a Republican President can pass a boondoggle of an entitlment program like the Prescription Drug Benefit, and the only complaint made by the other side is that it’s not enough, then getting the government back out is an impossibility.

    We have the perfect storm of policital opportunity about to hit. Democrats are already on board for universal health care, and big business, the Republican constituency, is screaming for relief from its pension (primarily healthcare) obligations.

    The VA is the model, and pretty soon we’ll all be using it.

  13. I work in a hospital that has about 900 beds and sees about 50,000 ED visits per year. On a daily basis we keep about 6-8 of our 25 beds full of admitted patients. Almost always there are three to four psych paitents holding for a room. We have several psych hospitals in town, they are always full. Most of the time we are holding one or two ICU patients in the ED. There is undue strain on the ED in terms of staffing, patient safety and patient satisfaction. The hospital grades us on patient satisfaction, the plantiff laywers grade us on patient safety and the turnover of nurses and lack of new recruits speaks volumes for the working environment. I think a great deal of education is in order. First we need to educate the PCP’s not to refer every patient that calls their office to go immediately to the ED. On an average day about one in 5 or 6 of my patients will have been referred to the ED by another MD, or will have seen another MD for the same compaint and just want “another opinion”. The patients need education on the cost of healthcare. I frequently see patients that won’t go their MD because they owe them money. I am quite sure that they are not going to pay us either. Also the hospital needs to understand that overcrowding in the ED is not and ED problem, it is a reflection on the failure of the entire hospital system to perform. I am not sure what the answer is, except to try and educate everyone along the way and hope someone pays attention. It is always easy for everyone to blame the ED for being overcrowded, slow, having no privacy, being inefficient…….

  14. I work in a 40 bed ED with about 200 inpt beds and almost 70,000 annual census. The top administrator on call closed the hospital a month ago one Sunday afternoon for several hours because the inpt beds were full. There were very few anticipated discharges. There were 35 or so admitted pts taking up the ED beds and hall beds, and a waiting room full of ED patients yet to be seen, in a ED that on an average winter day admits probably a quarter of the daily census. It was ugly.

  15. Yikes.

    Am I headed into the wrong profession?

    -J

  16. Paul Starr. The Social Transfomation of American Medicine. Basic Books, 1982.

    Read this book. Everyone who reads this, read this book. Starr predicted this crisis of access twenty four years ago and offered solutions. No one has surpassed his work in 24 (24!) years because his analysis is still absolutely thorough and correct.

  17. I concur with a lot of the arguments made here, and I agree that a dose of market discipline would probably help — but only up to a point.

    I don’t know what the answer is, but one thing seems reasonably clear: if health care were left entirely to the private market, there’d be a lot of sick patients out there who wouldn’t get any medical care because they couldn’t afford to pay for it. And we wouldn’t tolerate that. We’d do what we had to do to get the government back in the business of subsidizing health care for the poor, the sick, and the elderly. Eliminating government subsidies will not happen — we’re not that barbaric. The question, then is how to manage the subsidies intelligently and humanely.

    And that’s a tough, tough thing to do. “The market” isn’t a silver bullet, any more than “universal coverage” is a silver bullet. I think one of the biggest obstacles to changing anything in health care is fear — fear that we’ll be worse off under a new system than we are now. So most of us hate the status quo, but we fear what would happen if we tried to change anything.

    I agree with TheNewGuy: this house of cards will have to collapse before anything will change. The good news? It will collapse sooner or later. I’m betting on sooner.

  18. Jeremy

    If you havn’t entered medical school yet. DON’T DON’T DON’T, A THOUSAND TIMES DON’T.

  19. Jerry thanks for the info of pay-for-service ER’s, I didn’t know that. Seems like decompression at any level would be a good idea over all (though like you said, if those patients are ill and require admission then they overload an already taxed system).

    Oh, come on Kevin, I know at least 2 doctors who enjoy their work–maybe Jeremy’ll be one of those. (And if not, maybe he can be one of the many others like myself who spend a lot of time hiking and backpacking!)

  20. Wow, thanks for the comments, please keep them coming.

    For the record, I don’t think ‘the market’ is a synonym for soup lines and lack of medical access for the poor (Charity hospitals used to exist, and will continue to). And, while I think it’s a terrific ideal for a society to ban together to make sure there’s a safety net, those in the net have an OBLIGATION to realize they’re spending the hard-earned money of others (the Government doesn’t make money, it spends yours) and therefore it’s for emergencies and true needs, not wants.

    I’m extremely pessimistic about rationing that’s not monetary. HMO’s (and yes, I realize they aren’t perfect, nor is any system) tried to impose external constraints on expenditures, to the utter vilification of the entire industry. And I worked in the military system, which is as close to socialized medicine as I ever want to get. The care was fine, but the access was limited, and there was a ‘one size fits all’ to it, not to mention the entitlement mentality that came with it.

    The UK is having fits with their socialized system, as are the Canadians: big chunks of the budget with big management and poor accountability. The devils we know are high costs and relatively rapid access (if you have money / insurance), and huge annual increases in expenditures without commensurate increases in effectiveness.

    In the US given BOTH political parties’ track records with fiscal restraint it’ll be a race to complete bankruptcy of the nation. “We’ll pay for that!” will be the cry of both the pander-parties. Another devil we know.

    Does that mean there’s no place for a government safety net? No, that’ll always have a place. And, money will always talk, so there’s a place for private insurance. The trick is to have enough people pay DIRECTLY for their insurance so it’s not abused, and for the insurance companies to stop poaching on big companies and have to market to individual consumers. (Insurance also shouldn’t, IMHO, pay for stuff like routine physicals, etc, it should be for acutal illness (and I expect an argument about that)). And we should demand that the government money spent on healthcare isn’t siphoned off either by crooks or paper-pushers. (Our family doesn’t give to charities that have more than 10% overhead, why should Medicare?)

    And, I ordered the book, free-standing ED’s exist (they aren’t called that but they’re there) and they just treat the symptoms of the problem. Jeremy: Yes, and good luck. You’re in good company.

  21. heh…um…Kevin…

    I match in March of 2007. Too late to turn back now.

  22. Jeremy,

    OK, don’t put a bullet to your head. We need energetic young docs to tackle the challenges we face. I enjoy EM. It is more interesting than being being a plumber, patholgist, or physical therapist. I just wonder if it can be maintained for a lengthy career. All the things discussed above have made a noticeable difference in the last 10 years in how hard daily practice is. Factor in the swimming sharks waiting for you to misstep in an impossible work environment that is booby trapped starts to wear down the most energetic, idealistic among us. EM, as the “safety net,” is the canary in the coal mine for the whole system.

  23. To Jeremy: I’m an ER doc. I went out to dinner last night with several of my med school buddies. I’m the only ER Doc, I’m the only one in a specialty being raped by lawyers. While they were gloating about their future, their next job, the advances in Neurology, GI, etc. I kept talking about how I just want to retire. I’ve been physically and verbally assaulted by patients, had my nose broken, been spit on, and about once a year I’m threatened with a lawsuit. I’ve had to take HIV meds several times after bad needlesticks. Don’t be a martyr. It wears on you after a while.

  24. Anonymous says:

    As a patient there are some things you guys say that seem very troubling. I worked for over 30 years and always had good ins. through my place of employment. It was part of my benefit package just like many other folks health plans. My contribution to this plan was very cheap (about 30.00 per month). Being employed full time I could have certainly afforded to pay more for the plan we received.

    Flip ahead until now! I’am disabled and no longer work. I receive social security disability benefits based on the number of work credits I had earned during my lengthy employment. When you qualify for SS disability ins. payments, you have to wait for 2 years before you can begin to receive medicare. I applied for medicaid during this period, waiting for medicare to go into effect. I was approved, but I have what is called a spend down that must be paid each month, before I can receive my card for coverage for that month. That spend down is more than $300.00 each month. Now for $300.00 per month verses $30.00 per month, I have lost my PCP, who I had for 15 years, because his office does not accept medicaid. I have been looked at and spoken to by health care professionals who must believe that since I’am using medicaid I must be some lazy lowlife who hasn’t worked a day in my life. I have to go to a medicaid clinic to receive my check-ups and prescriptions.

    I think many of you have misconceptions and preconceived ideas of what you believe about certain people, based solely on the type of coverage they have. You could try and convince me that this is probably a figment of my imagination, or, that I might be sensitive over the circumstances, and therefore read things into peoples behavior that may or may not be there. That is absolutely not true. Remember, I had good coverage for more than 30 years. I have experienced this difference in the medical professionals behavior first hand. The worst is going from being treated like an intelligent human being when I would go to the Dr., to all of a sudden it being assumed that I’m an illiterate person, who couldn’t possibly understand my own medical conditions.

    So yes, the healthcare certainly needs fixing but so does many of your attitudes.

  25. To the last poster Anonymous.

    My sympathy for your condition. And no, you should not be spoken down to based on your insurance coverage or for any other reason; that isn’t right. I suggest you find doctors who you think treat you properly.

    That being said, I think you will not necessarily find it very easy to have a broad choice of doctors in many places when your only coverage is Medicaid. Your former doctor’s practice probably found the way they were treated by Medicaid agencies, and now more commonly their low-dollar managed care contractors, was unacceptable. Medicaid rates rarely cover overhead, never mind paying for the doctor’s time, and that is when they pay at all. Going to a practice with your Medicaid card is basically telling them you expect care without properly paying your way.
    On those terms, it is remarkable that any doctors at all will accept Medicaid. If you think you are entitled to service on those terms, then I am not surprised your visit is not met with enthusiasm. That kind of entitlement attitude is very common among Medicaid beneficiaries, unfortunately, and for a provider who sees himself as giving away services without pay, it can be grating after awhile. Many doctors would rather not deal with that kind of negative repetetive experience, and so avoid all Medicaid patients. As a doctor who has and continues to see Medicaid patients, I can see their point. If it became onerous to me, I would do the same.

  26. anon 7:50

    I browsed through the posts. I really don’t see anything about judgements made about the character of people on medicaid. I think you are reading something into it. Doctors who accept medicaid do it precisely because they DO CARE about the patient. In many situations it actually COSTS the doctor to take medicaid insurance. If medicaid reimburses me 30 dollars for a visit, but the cost of supplies needed, billing, insurance, staff costs, electricity, etc costs 50$ then I took a 20$ out of my business to see the patient. Other businesses can’t operate like that, neither can medicine. That is why the system is broke.

  27. Anonymous says:

    Well, I certainly see both of your points about medicaid. My point is, when I was paying 30.00 per month, out of pocket, I received wonderful medical care. Now that I’m paying hundreds of dollars per month (for a plan that you say doesn’t cover much) I receive second rate care at best. I haven’t changed, as a person, since the days prior to becoming ill, and I’m paying more out of pocket, on a limited income, than before and the difference in treatment is quite noticeable. I have never in my life treated any physician with anything other than respect, I expect to be treated the same way.

    I worked all my life and paid into these programs (the same as you do) so why the attitude when a situation arises that forces us to use these programs for the very reasons they were developed in the first place?

    Medicaid could save millions of dollars if they stopped rewarding single parenthood with more money and increased benefits with every birth.

  28. “My point is, when I was paying 30.00 per month, out of pocket, I received wonderful medical care. Now that I’m paying hundreds of dollars per month (for a plan that you say doesn’t cover much) I receive second rate care at best”

    You are forgetting something, here. Your employer paid most of your insurance premiums. Consider yourself lucky to have only had to contribute $30 a month for so long. It sounds as if you had great employment benefits. And on your behalf, I am sure your insurer then treated the charges of your doctors much more fairly than does your Medicaid managed care plan now. From your post, the spenddown requirement of Medicaid requires a monthly deductible before you are covered by them. Annually, that seems to be a total of $3600, by your figures, after which you become eligible for Medicaid coverage. Compared to what you paid out of pocket, that must seem like a lot. I am sorry you seem to confuse what you are paying out of pocket with what was actually paid on your behalf when you had better insurance and lower contributions. Now you think you are paying more–and you are as far as out-of-pocket expenses go–but you almost certainly aren’t as far as what you and your insurer together are paying for your services. As I and others have posted above, Medicaid patients typically don’t pull their weight as far as fairly covering their costs go. You may attribute reluctance to provide you service you are used to as unfair, but when you aren’t offering adequate payment, you are fortunate to have anyone to see you at all. A doctor doesn’t owe you his time today at a discount below cost just because years ago you had better insurance that paid some other doctor better. Medical practice isn’t a collective, and you don’t accrue an entitlement to someone else’s service just because you paid taxes, or insurance premiums years ago when you were working.

    It is probably moot, but did you ever consider the value of private disability insurance during that time when your contributions to your medical insurance premiums were so low?

  29. I see it from your perspective, but when you had “good insurance” and were paying 30$ per month your employer was probably paying a bundle and you benefited from all the other people in your plan that were not utilizing health care. The health care dollars don’t just magically appear.

  30. Your both right and I’m not disputing that, nor do I think my 300.00 per month “spend down” is too much for me to be expected to pay. We just aren’t talking about some of the same issues.

    As for the question pertaining to if I had thought about disability insurance while I was paying all those low premiums, the answer is “of course I did”. I not only had provided to me by my employer short term disability that would have lasted 6 months, I also made sure I had a safety net by extending my short term disability for 3 years. A plan that I paid the full monthly premiums for.

    What you don’t know, is that within weeks of trying to return to work after major cancer surgery, and getting ready for radiation treatments, I came home one day (we all did) and found a letter in the mail telling us that our boss was cancelling our entire group policy for our health ins., it was effective exactly 3 days after we received the notice. Since he cancelled the entire policy, none of us were eligible for COBRA. Try having cancer and purchase private health ins. IT WON’T HAPPEN. But, there was HIPAA, that states that since I was in a group policy and that policy was cancelled through no fault of mine, I had to be offered a plan. Trust me, you don’t want to know what that plan would have cost. It was not doable.

    I was still trying to continue working at that time so my long term disability didn’t help at all. By the time I left the work force, I had cancelled my long term disability, because I couldn’t keep up the payments with all the medical bills that were way out of control.

    I’am thankful for what I’m receiving. I just think before anyone passes judgement on someone else and treats them in a manner in which they believe they should be treated, they should ask some questions and become knowledgeable about individual situations.

    Of course, we will never see eye to eye on this, our perspective is completely opposit. You are both looking at it “objectively” while I’am completely “subjective” to this issue. That makes a world of difference.

  31. Jeremy,

    Think of it this way. You’ll never have to worry about having enough money to put food on the table, about paying your utilities, your mortgage, about your kids not being able to afford to go to college. And, with even a little bit of financial planning, you’ll not have to worry about being broke in retirement and living off charity.

    Keep some perspective if you can. No matter how bad you think you may have it, there are many others who are much, much worse off.

  32. “Jeremy,

    Think of it this way. You’ll never have to worry about having enough money to put food on the table, about paying your utilities, your mortgage, about your kids not being able to afford to go to college. And, with even a little bit of financial planning, you’ll not have to worry about being broke in retirement and living off charity.

    Keep some perspective if you can. No matter how bad you think you may have it, there are many others who are much, much worse off.”

    Perhaps from your vantage point it may seem that way, but that isn’t true.

    There are no guaranteed incomes, no guarantee that your patients or their insurers will pay you for work done, no participation in retirement (unless you go to work for the government or a big corporation), no disability insurance beyond what you are able to buy yourself, no employer-paid 401k, health insurance only if you buy it yourself or run a group large enough to get reasonable group rates.

    The ignorant and envious presume your income is always high and is guaranteed, but it isn’t. You will only get paid as long as you work, and will be paid well only if you work very hard and even then, there is no guarantee of that. In short, it is like other small business based on skilled services. Except unlike building contractors and tradesmen, and even lawyers, you generally don’t get paid up front.

    Unlike other fields, educational costs are much higher, delay to career start is longer and incomes have been more static than in other professions. You will be doing more things at one time than others in different careers who may be intelligent and well-educated but who get earlier career starts at lower educational cost outlay.

    The fact that there are others worse off is irrelevant. Take no comfort in that. And don’t believe those who think that past high incomes are some assurance that the future will always be the same.

  33. Jeremy,

    Agree with CHenry. Matt doesn’t know Jack. I made less in 2005 than I did in 2004, which was less than 2003, despite working more hours each year and advancing through my 5 year partnership track. I owe 100K from medical school. As an ER doc your earning potential is greatest right near the start and declines as the night, weekend, and holiday hours can’t be sustained with age and family committments. You build essentially no equity in your practice as other specialties might. CHenry is right. There is no employer sponsored retirement, health, or disability plan. You have to see all patients, but they dont have to pay you. The work is hard and booby trapped. I have been at it 5 1/2 years and collected three frivolous lawsuits. One has been dropped, a second will be dropped shortly, and a third has no merit in hell but is still working its way through the court system. The emotional toll is tremendous. A large percentage of people including patients, consultants, and hospital administration are angry and have an overwheliming sense of entitlement. You will be required to do more multitasking and make minute to minute critical decisions than arguably any other career on earth while having incomplete information, shortage of hospital beds, and shortage of nurses.

    Matt does not know Jack. I don’t know what fence he is looking over. For the level of service you provide, with the risks assumed, in the austere work environment I predict you will be unequivically WAY WAY UNDERPAID. But hey, I will go to work tomorrow with a smile on my face while the rest of the country gets to watch the Superbowl

  34. “Matt does not know Jack. I don’t know what fence he is looking over.”

    I know what fence he is looking over. He is the enemy amongst us. He is one of the sodomites, a plaintiff’s attorney.

  35. “There are no guaranteed incomes, no guarantee that your patients or their insurers will pay you for work done, no participation in retirement (unless you go to work for the government or a big corporation), no disability insurance beyond what you are able to buy yourself, no employer-paid 401k, health insurance only if you buy it yourself or run a group large enough to get reasonable group rates.”

    Sure there are. You may not like the reimbursement rates, but you are the best paid profession in the WORLD on average. What’s more, even though it’s not as much as you want, you can sign up to have the government pay your bills. Unlike a building contractor or lawyer, you don’t have to worry about the owner going under.

    If the emotional toll is too much, get out. You enter into a profession, any profession, knowing that the stakes will be high because your patients and clients are putting an incredible amount of trust in you and you control their lives to an incredibly large extent. And whine all you want, but you are compensated on average 5x better than the average American worker, more if you’re a surgeon (according to the US Dept. of Labor). If you’re not emotionally prepared to deal with it, then get out. Too much is riding on a professional’s skills.

    You don’t like Medicaid/Medicare or insurance, don’t accept it. There are plenty of blogs of physicians who are doing just that who can help you. You don’t like being responsible for all the overhead, don’t take it on. Again, there are physicians who are blogging about that as well who would probably help you.

    If the risk is too much, buy some additional insurance or get out. You’ve got a better chance being bankrupted by a lawsuit as a truck driver than you do a physician. And if you can’t accurately assess your risk in that arena, you’re probably not much good at doing it in any other. And since professionals are paid in part to understand and educate their clients/patients on the nature of risk, you’re only doing them a disservice if you can’t determine it.

    If you feel underpaid, go work the third shift in a meat packing plant for a few months. Wait some tables. Get a job cleaning rooms at a hotel. That way you won’t have all that pressure and responsibility you’re whining about. See how underpaid you feel on $20,000 a year.

  36. Poor Matt,

    So jealous. So uninformed about medical practice. Has to make a living trying to take from others. Jeremy, there are professions worse than EM such as being a ranting lunatic atttorney who makes straw man comparisons in his effort to feed off and destroy the success of others.

  37. At 3:28, Matt wrote:

    >”Sure there are.”

    Really? Exactly where and how? If you are referring to my patients, well, no one guarantees they will come to my office, ever. I have to work to build my reputation and their trust. Every day.

    >”but you are the best paid profession in the WORLD on average”

    Maybe in your “WORLD”. Otherwise, that is utterly meaningless and unverifiable. Sorry to say, we don’t get paid by some magical paymaster based on statistical income averages. What are you referring to, pay to family practitioners or orthopedic surgeons? Weighted averages or not? Recent data, or not? All occupations, or a select group of professions (perhaps excluding dentists, whose last average income stats exceeded that of physicians, at least in the USA)?

    >”Unlike a building contractor or lawyer, you don’t have to worry about the owner going under”

    I am no more guaranteed payment when the patient is uninsured than the examples you give here. I don’t get to pre-qualify or demand letters of credit most of the time, either. What is more, I can’t seek a mechanics lein against an unpaid debt. Even when the patient is insured, I am not guaranteed to be paid. The insurers even say that.

    >”If the emotional toll is too much, get out.”

    Please show me where I ever suggested anyone get out. I am not planning on quitting.

    >”You don’t like Medicaid/Medicare or insurance, don’t accept it”

    Thanks for the sage advice, I would never have figured that out without you. Plenty of other doctors have already voted with their feet on Medicaid, for reasons I have stated above, and some are doing the same on Medicare. I have dumped some private insurance companies whose pay policies I didn’t like. If Medicaid and Medicare became unacceptable, I would do the same with them, too.

    >”You’ve got a better chance being bankrupted by a lawsuit as a truck driver than you do a physician.”

    Show me. I don’t believe you otherwise.

    >”If you feel underpaid, go work the third shift in a meat packing plant for a few months.”

    Why should I? And whatever made you think I would respond any less rationally to economic incentive than anyone else? Matt, you seem to burn with indignation and resentment at doctors, as if you think that because there are others whose work–perhaps because it is less skilled or less risky–is not as well paid as mine or yours that it is unreasonable to even discuss reimbursement issues. Sorry you feel that way, but the rest of the world generally doesn’t.

    >”Get a job cleaning rooms at a hotel.”

    I have done those sorts of jobs, Matt. I like mine better. If that is your way of trying to shut me and others up, well, forget it.

    >” That way you won’t have all that pressure and responsibility you’re whining about.”

    Where have I complained about pressure and responsibility?

    Matt, if you want to be an angry self-righteous crank, that is your privilege. Have fun with all that. When you blow off meaningless, unverifiable and unbelievable “statistics” to fortify what you say, you aren’t convincing me. You have implied that physicians are guaranteed their incomes, which is laughably untrue. Then you say that they earn more than any other profession in the world, which is contrary to other recent income statistical reports I have read. And you conveniently omit the opportunity and educational costs to qualifying to earn a professional, which further gives the lie to your words.

  38. Matt (Or are you CJD in disguise?),

    Thanks for all the counseling tips. What is your fee? You have quite a command of EM practice inaccuracies that I won’t take the time to try to educate you about.

    I have not worked in a meat packing plant, but I have worked the third shift in a Crown Pacific sawmill, scraped paint, cleaned and painted campground latrines for the USFS, been a timber faller, bucked hay, shoveled horseshit, worked as a short order cook, cleaned microbiology test tubes, laid cinder block, and taught school as I worked my way through it. I don’t have just a singular perspective. Been there, done that.

    The Dept of Labor statistics don’t tell the whole story. An annual salary of 150 or 250k from a plaintiff attorney perspective must look like “WOW a greedy doctor that I need to take something out of”. But the annual salary does not take into account the high startup and investment time costs, as well as high annual practice costs (licenses, CME, etc) that are a personal expense.

    Tell me this. If I hired you as an attorney would my “emotional distress” from a frivolous lawsuit be any less real and important as the emotional distress caused by an 10 hour delay in diagnosing appendicitis that resulted in no damages? Would you fight with such vigor for whoever is paying you, or is it just a matter of principle that you dislike physicians and that their distress and concerns is somehow not really real?

  39. “You’ve got a better chance being bankrupted by a lawsuit as a truck driver than you do a physician.”

    Even if that is true, just because you guys are sodomizing other professions for your own greed doesn’t make what you’ve done to medicine right.
    “You enter into a profession, any profession, knowing that the stakes will be high”

    When I got in, it wasn’t this litigous. As ER’s got busier, patient care got thrown right out the window. Now practicing “Defense” is all we have time to do. It effects patient care. Matt, your profession is killing people.

  40. “Maybe in your “WORLD”. Otherwise, that is utterly meaningless and unverifiable. Sorry to say, we don’t get paid by some magical paymaster based on statistical income averages. What are you referring to, pay to family practitioners or orthopedic surgeons? Weighted averages or not? Recent data, or not? All occupations, or a select group of professions (perhaps excluding dentists, whose last average income stats exceeded that of physicians, at least in the USA)?”

    My world is the USA, which includes the Dept. of Labor. Parse the statistics however you want, but it doesn’t change the facts. On average, physician is the highest paid profession in the world. As for guaranteed income, you clearly don’t appreciate what it means to have a paymaster that never goes broke and can print its own money. Go read the blogs of those who do.

    “Show me. I don’t believe you otherwise.”

    If you’re a truck driver and you’re in a wreck of almost any kind, your chances of the resulting injury being significant enough to kill or seriously injured, and thus leading to the kind of damage award that could bankrupt you are incredibly high. Plus, since you likely don’t make as much as a physician, if you’re self employed you probably don’t carry as much insurance as a physician. Whether you drive local or OTR. Now, tell me how often the average podiatrist has that chance.

    In fact, out of the million+ physicians in this country, how many have ever been bankrupted by a lawsuit? I realize this is a fear of you guys, but how often does it really happen?

    “Matt, you seem to burn with indignation and resentment at doctors, as if you think that because there are others whose work–perhaps because it is less skilled or less risky–is not as well paid as mine or yours that it is unreasonable to even discuss reimbursement issues. Sorry you feel that way, but the rest of the world generally doesn’t.”

    I have no indignation or resentment. I think you should be paid well because you do a difficult and demanding job. I just don’t like whiners.

    “If I hired you as an attorney would my “emotional distress” from a frivolous lawsuit be any less real and important as the emotional distress caused by an 10 hour delay in diagnosing appendicitis that resulted in no damages?”

    How many med mal cases do you think there are with no actual damages? You’re illustrating physicians’ ignorance of the law. Considering the cost of bringing a med mal case, why would anyone file the case?

    “Then you say that they earn more than any other profession in the world, which is contrary to other recent income statistical reports I have read.”

    Cite the source, then. As for professional fees and opportunity costs, etc., again – quit whining. Or better yet, go tell your sob story to those who are working those jobs you guys left long ago. See what kind of response you get from real people. Your lives have clearly become too insulated.

    “Has to make a living trying to take from others.”

    Actually, I work at giving back what you took from them. The injury people like you caused with your negligence and the damage that results. Maybe that’s why you never talk about the victims – they never meant anything to you in the first place.

  41. But back to the point, it’s all going to be moot in 5-10 years anyway, because while you’re pissing and moaning about lawyers and how miserable you have it, we’re marching inexorably on toward universal health care.

    You might want to get over your lawyer fear/obsession (and for ds, his ass obsession) which leads you to do the insurers’ bidding and start focusing on the real train coming down the tracks. You haven’t got much time left to stop it. Or go to one of those countries’ whose legal systems you love so much and practice there so you’ll be used to it.

    You’ll get your limited liability workers’ comp style system and your reduced if not eliminated malpractice premiums, but it will have a price. You sure you want to pay it?

  42. Bingo! That last comment settled it for me! I think Matt is actually Doc Elliot! I don’t think he’s CJD because even though he’s stuck in a gutter profession, he doesn’t seem to resent/hate doctors and makes some redeeming comments. Elliot seems to think we won’t accept lower wages if it means saving our healthcare system from parasites like him. Many physicians (including me) have responded on Kevin’s website that we’d be happy to take pay cuts in exchange for tort reform. You can cut my salary 40% if it means I could take care of patients instead of sodomite lawyers.

  43. For the record, Matt, or MattBish, is CJD. Our favorite unemployed plaintiffs’ attorney.

  44. Hooray for lawyers.

    Matt’s comments are revolting. How can you look at yourself in the mirror, man?

    Flea

  45. Flea,

    Don’t shoot the messenger. I haven’t made one statement that was false.

    The truth is sometimes ugly for those who haven’t faced up to it, I understand. But it’s never a problem looking yourself in the mirror when you’re telling the truth.

  46. “You can cut my salary 40% if it means I could take care of patients instead of sodomite lawyers.”

    This comment illustrates just how well paid you are. If you would trade away 40% of your salary, that’s a hell of a salary. Your insurance premiums certainly don’t constitute 40% of your salary.

    You should DEFINITELY quit whining. Although I doubt you will, because your ass obsession appears to be how you define yourself.

  47. Grunt, if I’m unemployed because I have time to make comments and educate physicians, since you post in this blog daily, does that mean you have literally nothing else to do whatsoever?

  48. TheNewGuy says:

    I thought I smelled CJD.

    I would also gladly take a pay cut if it meant some meaningful tort reform. I paid approx 40K this year for my modest malpractice coverage, but I’d pay more to be totally indemnified. What does your legal malpractice insurance cost you a year, CJD?

    Playing the public-resentment-of-rich-doctors game seems to be your favorite rhetorical gambit. As for telling our “sob story” to “real people” (implying, of course, that we’re not real people, just faceless, bottomless deep pockets, waiting to be fleeced), plenty of my patients appreciate how long I went to school, and how well I treat them.

    But that’s OK. We’ll see what kind of “whiner” you are when you have your next kidney stone. Pain is pain, buddy… but I’ll gladly hold back on that morphine so you can show off to your colleagues how you don’t whine. You say the word, and I’ll let you scream/writhe/puke so you can tell them you “took it like a man.”

    Just out of curiousity… do you say the same thing about the clients who attempt to retain your services? All that “whining” about pain and suffering after all… how do you stand it?

  49. New Guy, you didn’t really read my posts, did you? I’m glad you make a lot of money – I think you deserve it. Not once have I said that you didn’t work hard for it or earn it. Read what I wrote, not what you want me to say.

    Do you object to someone arguing that you’re just a rich souless person after another dollar? That you don’t care about those you work for or on? Welcome to the club. Do you object to it when physicians say the same about others? Do you object when one of your colleagues uses terms like “sodomite”? I’m sure you do, because you wouldn’t want to be considered a hypocrite, would you?

    As for the whining, what’s sad about it is that you all feel so totally ineffectual, so whining appears to be all you do. Most of you don’t appear to have the slightest clue what to do about your declining reimbursement rates. Don’t you wonder where your AMA “crisis map” is on this issue? Do you not have talking points unless an insurer supplies them to you?

    We just had a Republican administration pass, almost without objection, the largest entitlement program since the Johnson era. And we’ve got big business screaming for health care relief. Universal health care is about to be a foregone conclusion, and all you guys appear to have the ability to do is curse lawyers. Your malpractice premiums will be a drop in the bucket compared to the income lost, not to mention the wholesale changes in your practice, when that happens.

    But what are you doing about it? What is one of the potentially most well funded groups of people in the United States, who have more at stake if universal health care becomes a reality than anyone else, doing to stop this? Or do you want it? What’s the AMA doing on this front? Where are the vitriolic letters to the editor? Where are the crisis maps, the empty claims of physicians leaving and people going untreated as a result, the marches on the state capitol? What do you think is going to have more of an impact on your bottom line – keeping a few people who have been hurt really bad from getting fully compensated or Washington completely running your billing?

    Is it too complex an issue? Is there no easy party to demonize? What’s the deal? This is the real issue. The baby boomers are going to hit and the strain on US health care is going to be enormous. Do you really think any politician is going to let GM go under because of healthcare costs? They have 1 million workers whose health care they are providing for. And that’s just GM.

    Incidentally, I paid about 4% of my income in malpractice premiums last year – about what the average physician pays. If I handled complex and costly cases like med mal on a regular basis, it would have been significantly higher. If you want to be “totally indemnified”, buy more insurance and do just a little bit of asset protection planning. While no one is totally and completely indemnified, you can come damn close. I warn you, though, you will have to speak with an attorney to do so. If you’re smart, you’ll talk to a plaintiff’s malpractice attorney to get a better idea of exactly what your exposure is.

    Like I said, I believe you’ll get your wish of complete indemnification. But I bet you won’t like the price you pay for it.

  50. will quit soon says:

    Regarding physicians being the best paid profession in the world, has anyone looked at the hours dedicated by physicians? Would any other profession get out of bed at 3 in the morning to go to the ED in a winter’s storm to evaluate a patient with belly pain who has no insurance and will probably not pay the physician and then probably sue the physician if the outcome is less than perfect? Granted the average plastic surgeon is living a very comfortable lifestyle, but not the average physician. This will become more evident as the numbers of physicians decrease in the future. I am only in my 50’s and had planned to practice medicine well into my 70’s like my father before me. However, I will close my practice next year and join a corporation selling medical devices. No, it won’t be satisfying, but at least I won’t have the fear of losing my house and my wife’s and children’s financial security. I’ll probably join a few medical missionaries abroad to keep a hand in clinical medicine. And will my patients lose out? You bet, but that’s the world we have all created.

Trackbacks

  1. Galen's Log says:

    Earning Cranky Points

    Warning: for health professionals only. Certain things tends to make doctors cranky. Such as being alledgedly allergic to all opiates except intravenous Demerol. Sure, it could be true. But not nearly as often as claimed. Wondering how to earn Cranky

  2. SciGuy says:

    And the winner is…

    Erica, who submitted GruntDoc in the first iteration of Battle of the Books. This is thoughtful, well-written blog by a Texas emergency physician that I will return to. The most recent entry is a pretty depressing view of emergency rooms…

  3. symtym says:

    Well Said!

    I see the same issues:

    GruntDoc
    Kevin, M.D.

    Yesterday we were "housing" 12 inpatients (most ICU/telemetry) in our 16 bed ER with an annual census now peaking at 40K (up from 25K, fifteen years ago).