Claude Cloquin, hepatitis C.

There IS some limit on what the US can afford to spend on medical care, and I suspect we have already passed it, as medical provision sucks more and more of our gov. budgets crowding out all other needs, to now include education.

For most Hep C patients, should we start with the cheaper medication which will cure, I’ve heard 70%, then go the nuclear route? A friend’s child had it last year, and the $92k drug was used in concert with another ~$45k drug to cure him. In my poor part of the country, where meth is king, oxy prevalent and heroin growing in popularity, it’s bankrupting us. An irony in my part of the world is, the shared needle use of drug addicts causing the Hep C spread is driven by the abuse of oxy addicts,… who received those drugs from doctors. At least in this kids case.

Lee,

As an outsider looking in, the corporate takeover of healthcare looks a lot like the corporate takeover of agriculture.

Lee, I will just take on one of your points, since I could write about this stuff all week long. Being a physicians is not like a lot of positions. Healthcare over large geographic areas are usually controlled by 1 or 2 major players. Taking a new job for a hospital based physician (read anybody that takes care of really sick people) requires getting staff privileges at the hospital. That process involves a mound of paperwork, background checking and usually takes 3-6 months. Once you have privileges, then you have to get credentialed for every insurance company that you may encounter treating patients. Can’t credential insurance at the same time as privileges, since most insurers won’t accept applications until you are credentialed at a hospital. So another few months trying to get insurance contracts for the major players. So if you were to just quit your job, you are going to be out of work for a while, probably close to a year. Now look at the non-compete clauses in your contract, you may have to leave the area, since you can’t set up shop within 50 miles of your health care entity. But that entity has hospitals or clinics in all populated counties. So time to sell the house that you are upside down in, relocate the kids. Not easy for many to do.

So you decide to move to a different state. Same process as above, except no hospital will start applications for privilege, until you have a license in that state. That may be another 2-4 months, thousands of dollars, and another few days of paperwork.

Imagine that you are an established physician in the hospital and the community. Maybe 55, your practice was just bought by the hospital. You continue to treat your patients, except that the contract you signed say they are no longer your patients. They now belong to the hospital. If you were ever to leave, you can’t advertise to those patients your location, or even call them.

A friend of mine just “relocated”. His hospital that bought the practice sent out a letter stating that He had left the area, but they had other excellent physicians that would assume their care. When patients ask where he went, the answer is “we don’t know” . Yet he relocated 3 miles away.

Back to our 55 year old physician. As in many industries, that more experienced person is not as desirable to a health system as a new grad. Too set in their ways, too knowledgeable, and less controllable. All around a liability for the goals of big medicine. So She is stuck. But she is a good physician, always does right for her patients. Now the big medicine bean counters start profiling her along with all the other Doctors. At first, they tout efficiency; read ordering fewer tests, prescribing fewer expensive medications, and fewer referrals to specialist. They count the number of CT scans, stress tests, blood tests, referrals and pharmacy costs that each physician orders per patient. The efficient physicians that spend less, are extolled and profiled as an example to all. The high cost physicians, are put on notice. When they fail to bring their costs down, their contracts are not renewed. So they tow the line, or leave. So she is conflicted. She either practices medicine that she don’t believe in, or she could get a new job. See what that entails above. In all of this, at no point are true outcome measures, such as mortality, missed diagnoses or correct diagnoses tracked.

This is not coming from a disgruntled physician. I am a very successful Pulmonary Critical Care Doc, and I have been able to do extremely well in this current environment. It does not mean that I am blind to what is happening, or blind to where this is going. My older colleagues right now are getting screwed because in spite of their incredible experience and track record they are not mobile for many reasons, so are very vulnerable to the pressure of big medicine. The new grads coming out, they don’t have any experience in contracts, have never seen medicine that is not controlled, coming from a supervised training environment, so they don’t know any difference. Best I can tell though, they do not seem to be any happier in the managed care environment. They left residency under the impression that they could see and examine a patient. Come up with the appropriate diagnosis and effect an appropriate treatment plan, and make it happen. The reality is eye opening for them.

I would have almost word for word written a similar response to chuck.

I will throw in one more scenario. A large primary care practice is bought out. They are used to sending their patients to the best specialist in town and the patients still expect them to do that. However, they are now directed (at gun point literally) to use farther away less skilled less experienced specialist who are employed by their systems and do cases at the owned hospital (ie big$$$ faculty fees which is where all the money is).

I find it crazy when local docs send me their parents to operate on and when I ask how come I don’t see anyone else anymore … They tell me it’s forbidden by the new owner. No disclosure no control and patients still trust their docs to act in there best interest. Most don’t ask who’s the best etc or who treats your family. Want to see the 5th best cardiac or spine surgeon in the area ?

I could write for weeks on how the demise of independent docs will be the demise of our health care system as we know it. We are headed in a direction where we will all have the equivalent of VA health care. Much better than nothing I think, but so different than what we expect and have.

Agreed our health care costs too much but the current direction is going to do little to save cost, but that is another weeks writing. We could close all the amazing private universities in the country, sell their assets, and distribute to state schools and we’ll send more people to free or low cost colleges. After all education is the same regardless of where u go right??!!

For me, too. Thanks for making the post. Very informative.

Most hospitals produce a low net margin and even that is under pressure. This is driving the consolidation we are seeing, and it will continue. In NC, one side of our legislature has passed a bill to eliminate sales tax refunds for nonprofits, cancel the CON law and put medicaid in an HMO. Vice president of Novant Health and president and chief operating officer of Presbyterian Medical Center in Charlotte: The proposed budget “will cripple the health-care industry and monumentally impact access to emergency and preventive healthcare,” Vincent said. “Together, these changes will systematically dismantle North Carolina’s healthcare infrastructure,” That’s a bit over wrought, but you get the picture.

So hospitals are consolidating for: negotiating leverage with insurance companies (though with ACO’s they will become insurance companies); operating efficiencies; availability of capital; scale to cover a population (ACO). It’s going to interesting to watch an industry so important to us transition from performing all the services they can bill for- the fee for service model, to one getting paid a set amount per person to meet all the needs of a population.

Read more here: http://www.charlotteobserver.com/news/politics-government/article24812710.html#storylink=cpy

The ACA only made sense if we switched all of it to a single payer model, and that was a nonstarter.

The ACOs that are cobbling together have a heavier administrative arm than the hospitals they replace. The administrators need to control the panel of physicians, at the cost of quality if necessary, and the financial incentives will be turned on their heads. Everything that is a profit center now (do more, pay more) will become a cost center soon (do less, keep more).

Physician assistants and nurse practitioners will carry the bulk of outpatient care, and hospitalists will manage the inpatients, relying heavily on protocols and checklists, with a lot of internal review- we’ll be spanked by committee rather than spurred by conscience. The one to one connection, doctor to patient, will be more clogged up, responsibility and blame will be diffused. Care may become more systematic- more similar across geographic areas.

Maybe that’s a good thing.

The insurance cut and the excessive drug costs- I don’t see where these are seriously controlled. That’s a lot of overhead.

Over the years I developed a way of doing things, but that way will have to change- has already changed quite a bit.

I will miss idiosyncrasy. And I will hate having a boss.

Spare a thought for how your bosses will suffer.

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That is some consolation, admittedly.

Hey!

You were invited to consult Thesaurus for JimK’s word along the lines of a positive bias- something akin to “giving the benefit of the doubt” but not so pedestrian.

Get busy.

Ha, ha how true that is…

I used to hate my bosses. Changed jobs several times. Damn another bad boss.

Later on, I started a company and hired people (like myself). Man they were irritating - just like I was. Karma…

It appears that Sanjay has run out of words. He must have used all of his.

That being the case, I will take charge. Since the bias that instantly conjures negative thoughts about certain classes of humans is bigotry, I hereby declare that the bias that instantly conjures admiration for an individual human because of his/her membership in a favored class to be gigotry. Gigotry is often unjustified. However, you will be highly unpopular when you point out examples.

I’ve got my reasons.

My brother, a conductor- his line:

How do you make a first violinist, with a PhD in performing arts, and with the lifelong goal of playing in an orchestra, completely and bitterly unhappy?

Hire him.

An unusual afternoon- 3 in a row, all cleared the virus with the one pill per day treatment.

So far, no serious side effects, nobody had to stop the drug. Near 300 by now.

The drugs are crazy expensive, but we are getting good at the wrangling- so far, nobody failed to get the treatment for lack of money.

A difficult disease, leaving the scene, not with a bang, but a whimper.

It’s a good day to be in the business.