An ambulance driver chimes in on his blog...

Post #306,602 by dmcarls 4/2/09 2:15:45 PM Reply	An ambulance driver chimes in on his blog... http://ambulancedriv...-to-my-world.html [...] "Hospitals in every corner of this country can quote comparable figures. It's not even a purely urban phenomenon; it happens on a daily basis at PGHNSTRACH, and thousands of other small hospitals in every little hamlet in the United States. And the vast majority of all those ER visits are paid for by you and me with our tax dollars. Now, the authors of the report would rather be horsewhipped than draw conclusions about the socioeconomic status of the most egregious abusers, but I am under no such constraints. Let's just say that Aetna and Blue Cross ain't footing that three million dollar bill, shall we? No privately insured patient visits an ER that often. If they did, one of two things would happen: They'd either lose their coverage or it would capitate, or they'd die shortly from their catastrophic illness. No, that three million dollar bill, in Austin alone, is footed by the taxpayers. Proponents of a national health care plan would have you believe that the problem is one of access, that the 15% of uninsured in this country have nowhere to turn but the ER for their care. Horse. Shit." [...] (more in his write-up)
Post #306,604 by boxley 4/2/09 2:38:29 PM Reply	locally here in atlanta a certain segment of the population wants to go shopping downtown but doesnt want to pay cab fare so they call 911
Post #306,605 by Another Scott 4/2/09 2:45:40 PM Reply	Interesting. Thanks. I'm not sure it's as simple as he implies, though. The times I've been to emergency rooms (from a child to recently), there were an awful lot of people there for serious things, not free pregnancy tests and the like. No doubt that some people do go to them because they won't be turned away, though. Perhaps if there were as many walk-in clinics as Starbucks then ERs wouldn't be as popular (and expensive). Cheers, Scott.
Post #306,607 by jay 4/2/09 3:11:21 PM Reply	He has some good ideas No, that three million dollar bill, in Austin alone, is footed by the taxpayers. Proponents of a national health care plan would have you believe that the problem is one of access, that the 15% of uninsured in this country have nowhere to turn but the ER for their care. He has some good ideas but the above is at least partially wrong. Heck, a friend of mine who had health insurance was once told by their doctor "I can't do anything for you because it's not covered but wait a day or two and you'll be sick enough for the ER." 1. Strengthen primary care by shifting reimbursement away from the current procedure-based model, and forgive medical school loans to any medical student entering a primary care field. In twenty years, maybe less, the problem of primary care access will be solved. The forgive loans part is probably a bad idea, but moving away from reimbursement payment models is a very good one. 2. Repeal or drastically overhaul EMTALA. Put an end to the indentured servitude of ER doctors who are forced to provide a substantial portion of their services to people who don't need to be in an ER in the first place. EMTALA is abused but it also serves a critical function. Before this was mandated, emergency rooms often turned away people who appeared to have expensive problems or where not carrying proof of insurance. 3. Institute a copay system for ER visits for Medicaid recipients. As long as the care is free, there will be no incentive to use it intelligently. And by taking the steps in #1, there will be far more primary care clinics willing to see Medicaid patients. That is a good idea. 4. Institute a review system for ER visits by Medicaid recipients who also receive food stamps or other forms of public assistance. Anything determined not to be an emergency, take the copay out of their other benefits. If a citizen who pays for their insurance is forced to decide between other bills and their ER copay, why shouldn't we expect the same of people on Medicaid, who aren't required to pay premiums of any sort? That would be a huge mess, hard to implement, hard to police and likely to punish the worst off. I would much rather see a system that gives ERs a good way to channel patients back to regular care if their problems do not require immediate treatment. 5. Come to some sort of compassionate, but reasonable, standard of how much futile care we are willing to subsidize. 27% of Medicare expenditures are spent on people in their last year of life. I'm not advocating feeding Grandma to the coyotes after she breaks her hip, but any nurse, doctor or EMT who has ever cared for a nursing home patient knows that, for a great many of them, we only prolong their suffering, not their life by any reasonable measure. Huge can of worms, but probably a necessary one. Jay
Post #306,614 by Another Scott 4/2/09 3:47:39 PM Reply	On #5 and related issues. I've seen statistics about "most medical expenses are in the last x months of life" many times, but I think it's probably less revealing than most people think. I suspect that it's not that the 85 year old folks are costing so much before they die, but rather that most people in the US end up in the hospital before they die. IOW, it's not mainly an age thing, it's a hospitalization thing. Many things are better treated almost anywhere other than hospitals (especially with MRSA being such a problem). No, I don't have any statistics handy to back that up - it's a WAG. Most people who die do so because something is wrong (few actually die of "natural causes"), and our medical system tries to fix things that are wrong. Some of those things that are life threatening are very expensive to try to fix. I don't think the solution to rising costs is necessarily to say that people who have < 5 years left based on life expectancy actuarial tables shouldn't be treated when they, say, get pneumonia. http://www.ssa.gov/O...ATS/table4c6.html IME, those who are fortunate enough to reach 85 don't generally want heroic things done to preserve their life, but others make those decisions for them (often based on the medical system not fully discussing the person's condition and the real options). And I've seen physicians jump to conclusions and recommend not treating an old person within seconds of seeing them, when the person was treatable and had a good prognosis - so it works the other way, too. I do think that "defensive medicine" is a problem, but I'm not sure how much of that is fear of lawsuits and how much is hospitals trying to scrape up every dollar they can to cover those who can't pay. Until someone presents a nice table of the US medical system with a breakdown of income and expenses, I'll be skeptical of solutions. There's too much anecdotal stuff out there. How much of our medical system is salaries? How much is drugs, (including drugs that are never used because they weren't from the hospital's or nursing home's own pharmacy)? How much is building overhead? How much is fancy equipment? How much is bandages, disposable sterile things? How much is billing expenses? How much is advertising? How much is training (including medical schools)? How much is profit? How much is liability insurance? And what are the rates of change on those things? Why should some physicians get $50k a year and some $x00k a year? Until we understand the real numbers, it's nearly impossible to control them. As with any big problem, there isn't a single simple solution. Cheers, Scott.
Post #306,616 by drook 4/2/09 3:57:08 PM Reply	On fancy machines There was an episode of ER where a doctor returned from some time in Africa with Doctors Without Borders. He was convinced we over-tested and over-diagnosed people, and started canceling orders for MRIs where he didn't think it was necessary. Then someone explained to him why the U.S. system wasn't like Africa. Here, we do have the big fancy equipment. It's usually not needed, but when it is there's nothing better. Thing is, it's a massive fixed cost. If you only used it the 20 times a year you really need it, you'd have to charge each of those patients $50k. So instead you use it once or twice a day and charge each patient's insurance company a few thousand. Thats how you can afford to have the machine. No, I have no idea how to fix this. Or at least no idea that would ever make it through congress. -- Drew
Post #306,618 by Another Scott 4/2/09 4:20:01 PM Reply	I don't know how common it is... but around here there are MRI machines in office parks. I assume they get enough business from the various hospitals that it helps reduce the argument that each place needs their own. That's good. But many hospitals are not-for-profit while I'm sure each of these MRI companies are for-profit. So, there are plusses and minuses, and MRIs might not be the best example any more (though I'm sure they're over-prescribed because they're available). Hey! I could get in the business for $45k! - http://www.dotmed.co...utm_campaign=Base ;-) Cheers, Scott.
Post #306,624 by drook 4/2/09 5:05:36 PM Reply	They're making money on full-body scans You can go in and get a checkup and they'll point out every shadow and dot you might want to get checked out. A study of the practice a few years ago showed that the rate of complications from exploratory surgery to check out all these symptomless shadows dwarfed the rate of true positives. -- Drew
Post #306,697 by dmcarls 4/3/09 11:23:53 AM Reply	Re: On #5 and related issues. >>> "Until someone presents a nice table of the US medical system with a breakdown of income and expenses, I'll be skeptical of solutions." I have not seen any sites that give that data, but here's an example of one CEO struggling with the budget: http://runningahospi...eliberations.html [...] "The personnel budget, including benefits, is about $545 million per year. A $20 million savings is thus approximately 4% of this amount. If we were to accomplish this in layoffs alone, we would have to eliminate over 300 jobs. (This is based on an average cost of $80,000 per employee. This number may surprise you, but it is a Âfully-loadedÂ figure, including all benefits, taxes, and the like. Also, this has to be offset by the amount of severance pay for those people laid off.) With 6,200 full-time equivalent employees currently on staff, this would be nearly 5% of the current staff. But that is on an annual basis: To achieve the same savings in the remaining six months of the fiscal year, we would have to double the number of people laid off, or over 600." [...] A long blog article, but it gives some insight into the costs of this type of thing.
Post #306,708 by Another Scott 4/3/09 12:35:31 PM Reply	Interesting. Thanks.
Post #306,754 by Ashton 4/4/09 3:48:29 AM Reply	Can't think of an issue more fraught with problems of Scale than 'Health. Care.' Concepts of 'disease' (is this even a useful construct? Many, now, think not.) of ancient traditions, now perplexed by new techno possibilities (if not probabilities.) of massively intertwined disciplines: about all of them, from physics through chem, math/statistics, engineering (of a micro-kind) ... now (nascent) moving to gene-level + that hoped-for intuition -- which cannot be taught. of 'science' presumptions, often not supported by authentic scientific practice (or knowledge of same.) of psych, in all its forms.. But, almost-last: intricate divisions of labor, Class-distinctions, a tradition of massively-rote training -- all this also involving Qs like, ~ just What is my Specialty-training 'worth' on the market ? (and.. is it Enough?) Lastly: an army of opportunists, admins of an 19th century style of record keeping, on through 10%ers of every stripe -- all seeking a cut of the insurance meme (rephrased: how skillfully can I contrive wording so as to insure only the hale/hearty -- while possessing boilerplate capable of disqualifying -- most anyone who actually Needs repair.) It's foremost now: a Bizness like no other. And suffers from the same Suit-like tunnel vision in so many places. This-all does Not justify much idealism in the raw recruits, especially after they are processed. Good Luck re-Forming this roiling bowl of $dreams, Murican mythos, egos and almost-science -- all undefinable. If bad money drives out the good, then -- Babbitt shall win. And we seem still to be a crass nation of Babbitts. Obama: YPB, but maybe a Brave-enough Bastard (??) Wouldn't touch that bet with a 11' hypodermic.
Post #307,264 by Another Scott 4/13/09 12:35:11 PM Reply	Another story on US health care costs, with links. http://business.thea..._cost_so_much.php Multiple readers want to know why US health care costs so much. A complicated and fascinating question on which agreement across ideological lines is extremely limited. [...] (Via Sullivan). I'm not sure her conclusions follow, but it's a starting point. More is at the NY Times: http://economix.blog...t-so-much-part-i/ (Parts 2 - 7 by Reinhardt can be found here - http://economix.blog...reinhardt/page/3/ ) Cheers, Scott.

Welcome to IWETHEY!