Healthcare in the USA today.

[whitewave]

I find your objection to physicians investing money somewhat puzzling. A physician who is financially independent is one who is not beholden to private equity or a health system and can practice as he/she chooses. Yes, My husband and I have investments including real estate - that doesn't play into my practice of medicine at all (except for my retirement date). I suspect we are in the 1% but I really don't know (and anyone who was a casual observer of our life would never be able to tell). That doesn't make me any less of a physician or devalue my experience at all.

I don’t understand her posts either. DH made $27,000 a year in residency. They didn’t up the salary with outcry. They limited the work week to something like 75 hours and maybe threw in retirement (we didnt have an institutional retirement plan so we didn’t start saving until we were 30).

We have high net worth because of DH’s hard work and we live below our means. My house is less than 3,000 sqft, I drove a Honda minivan for 7 years and our kids went to private school and then public school and have part scholarships and all go to public university). We did inherit another house since both DH and his mother are only children.

I also don’t have a problem with doctors making money, especially those like my husband who are working 80-100 hours a week.

The reason DH’s company started as a multi speciality surgical clinic was because they could have an APMC, which offered more protections at the time than individual LLCs etc. and it was easier.

 

[whitewave]

I hope my comment on nurse practitioners was not taken as being anti-doc I have some awesome doctors on my care team, one while working the ER saved my life by getting into a major argument with another doctor over treatment.
I just meant that I am happy with the care provided by the nurse practitioners and they do have more time the way they schedule them where I go.

Karl, I see a nurse practitioner too for something and I also find her well qualified and I’m very satisfied.

 

[MaisOuiMadame]

Hugs to you @whitewave , your DH is a hero, but you're the great woman behind the hero who keeps him going!!!!
Your community is so fortunate to have you!


@MakingTheGrade , I'm sorry you're feeling this way. It's unfair. But I was so relieved & happy to hear from you!

 

[whitewave]

Hugs to you @whitewave , your DH is a hero, nut you're the great woman behind the hero who keeps him going!!!!
Your community is so fortunate to have have you!


@MakingTheGrade , I'm sorry you're feeling this way. It's unfair. But I was so relieved & happy to hear from you!

Thank you.

I just checked resident pay grade. So back in 2000 it was like 36-38K a year and now it’s about 55k-58k a year.

 

[missy]

‘The Invisible Kingdom’ Review: Malady Unknown

Our medical system does not deal well with uncertainty. If a diagnostic test can’t determine what’s wrong, then the patient must be wrong.

www.wsj.com

"

‘The Invisible Kingdom’ Review: Malady Unknown​

Our medical system does not deal well with uncertainty. If a diagnostic test can’t determine what’s wrong, then the patient must be wrong.​

She lay in the dark in the small hours of the morning, awake, wrapped in a fog, encumbered by never-ending fatigue as the world slept—a gray traveler in a gray world. In this cocoon, she would stare at her computer screen, browsing for imaginary outfits to be worn on imaginary outings. It was an act of longing, of sorts: an attempt to be the person she wanted to be, someone who could enjoy life free from pain. But the greatest ordeal—greater than the unexplained electric shocks that rattled through her body or the unbearable abdominal pains that kept sending her back to the ER—was her doctors’ denial that she was sick at all.

As Meghan O’Rourke recounts in “The Invisible Kingdom: Reimagining Chronic Illness,” there is often loneliness in being sick. But for those with rare and undiagnosed conditions, the very acknowledgment of suffering is denied. The chronically ill self is negated, not by disease but by a medical system that frequently rejects patients’ experiences and dismisses their testimony.
For Ms. O’Rourke, there was no beginning to her illness, no sharp moment when she went from healthy to unwell. “The Invisible Kingdom” is thus not a straightforward accountcharting the usual stages fromdisease onset to medical intervention to ultimate recovery—the hallmarks of many illness narratives. The author’s symptoms ranged from unexplained hives to migraines to brain fog, from fatigue and muscle spasms to pinpricks of electric shock and aching lymph nodes—all coming over her in waves. She could perhaps trace the illness to her college days, or to the stress of losing her mother, or to a childhood summer in Connecticut. For Ms. O’Rourke and many sufferers like her, the progress of illness is disorderly, cyclical and endless. As a result, this is a story “about living with, rather than eradicating or defeating, a disease.” It’s also about “letting go of the American ethos of overcoming” that has haunted discourse about everything from cancer to Covid-19.
Autoimmune diseases, chronic fatigue syndrome, fibromyalgia, Lyme disease and now long-Covid: These are some of the disorders that don’t have easily identifiable markers. Their symptoms come and go, varying between patients and even within a single patient over time. Yet our medical system doesn’t deal well with uncertainty. If a diagnostic test can’t determine what is wrong, then nothing is wrong; the patient becomes a problem patient, the disease a figment of the imagination.

​

Gaslighted by the people she went to for help, Ms. O’Rourke slowly began to doubt herself: “It was my fault, a sign of some internal weakness, a lack of moral fiber.” Her body had turned against her, and then, alone in ways she had never anticipated, she started turning against herself. “I could taste the solitude of the human body like brine in my mouth,” she writes. This is the darkness through which the chronically ill must travel.

Where once the focus of medicine rested on an individual’s experience, our antiseptic era has become generalized and systemic. Ms. O’Rourke describes the shift away from the “body in balance” metaphors of antiquity and recounts the sacrifices we’ve had to make along the way. We may not have faith in the four humors anymore, but as modern medicine expunged the bilious fluids, it also turned away from the individual and toward the greater homogeneity of specific germs, diseases and conditions. By the 19th century, Western categories of sickness were divided, principally, between the kinds that afflicted our bodies and the sort that, like “hysteria,” were believed to originate in the mind. “The less we understand about a disease,” Ms. O’Rourke explains, the more the medical profession tends to “psychologize, and often stigmatize, it.” The burdens of proof lie with the patients, yet their testimonies are often considered suspect. Ms. O’Rourke’s account of endometrial pain, and its dismissal by her doctor, offers a sadly common example.
“The Invisible Kingdom,” like chronic illness itself, doesn’t end in a cure and doesn’t offer magic bullets for those who are suffering. What it does provide, powerfully, is a reminder to “those of us at the edge of medical knowledge” that “we live in the gap together.”
“To become chronically ill is not only to have a disease,” Ms. O’Rourke tells us, but also “to have a new story about yourself,” one that is difficult for others to hear. Patients must become their own best advocates, finding well-organized societies and chat groups with which they can compare notes. It is a process that doesn’t end but is “full of fits and starts, anger, resentment, chasms of unruly need.” Living with chronic illness, like living with disability, is an act of defiance against a world that would rather not see or hear you. To refuse this invisibility takes a great act of courage—a demand for better treatment from our medical system.
Ms. O’Rourke, a former Guggenheim fellow and the author of “The Long Goodbye” (2011), a memoir on mourning, gives shape and color to the invisible life of patients whom society has failed. She offers hope for patient-driven change. Most important, she provides an account that many will be able to relate to—a ray of light into those isolated cocoons of darkness that, at one time or another, may afflict us all.
Ms. Schillace, the editor in chief of the journal Medical Humanities, is the host of the online “Peculiar Book Club” and the author of “Mr. Humble and Dr. Butcher: A Monkey’s Head, the Pope’s Neuroscientist, and the Quest to Transplant the Soul.”

"

 

[missy]

"

Many patients in US continue to face pandemic-related delays in primary care​

Many older adults and individuals of historically underrepresented groups who experienced a delay in care due to the COVID-19 pandemic still have not received care, according to recent research.

In particular, survey results from the National Poll on Health Aging revealed that nearly one in three adults aged older than 50 years had a COVID-19-related delay in care in 2021, many of whom said they have not rescheduled their visit nor plan to.

Ahmed A, et al. J Gen Intern Med. 2022;doi:10.1007/s11606-022-07406-7.
“While we were not surprised that many older adults have experienced delayed care due to the COVID-19 pandemic, we were surprised that so many of these individuals either had not yet rescheduled disrupted care or were not planning to,” Jeffrey Kullgren, MD, MPH, MS, the associate director of the poll and an associate professor of internal medicine at Michigan Medicine, told Healio. “This group, older adults who had disrupted care but have not yet received or rescheduled it, may be at particular risk for more health problems down the line unless health systems proactively reach out to them.”

Delayed care among older adults​

Kullgren and colleagues polled a nationally representative sample of 1,011 adults aged older than 50 years, who responded to a wide range of questions online or by phone in late January 2022. Among the cohort, 83% of participants were vaccinated against COVID-19 and 70% were boosted.

Overall, 29% of respondents who had a primary care visit scheduled in 2021 reported a disruption to care related to COVID-19. Among them, 15% of respondents said they postponed, rescheduled or canceled a primary care visit, while 11% said their provider postponed, reschedule or canceled their primary care visit.

Most respondents already had a makeup visit (56%) or scheduled one (20%) by January. However, 14% of respondents said they did not reschedule their appointments yet, and 8% do not intent to reschedule, according to the researchers. Unvaccinated adults were least likely to reschedule their missed appointments (53%) compared with vaccinated adults (74%) and vaccinated and boosted adults (85%).

In addition to primary care, 31% of respondents reported a canceled or delayed dental appointment and 28% reported a canceled or delayed procedure, test or operation. Accounting for all avenues of care, 64% to 85% of vaccinated or vaccinated and boosted respondents had rescheduled care as of January compared with 30% to 53% of unvaccinated respondents.

“There are many ways in which delaying needed health care can lead to more health problems down the road,” Kullgren said. “Delayed care for chronic conditions such as diabetes, hypertension or heart disease can lead to new complications that could have been prevented through monitoring and medications. Delayed elective surgeries for conditions that limit physical activity, such as knee replacements for severe osteoarthritis, can hinder mobility and increase the risk of falls. In these and many other situations, delayed care can result in missed opportunities to intervene on health issues before they lead to more serious problems.”

He advised physicians to communicate the health problems associated with delayed care to patients, particularly those at high risk.

Delayed care among historically underrepresented groups​

In addition to older adults, individuals of historically underrepresented groups were also more likely to delay or not receive medical care due to the pandemic, according to separate findings published in the Journal of General Internal Medicine.

“The pandemic has been devastating, leading to unprecedented public health and economic crises,” Rishi K. Wadhera, MD, MPP, MPhil, an assistant professor of medicine at Beth Israel Deaconess Medical Center, told Healio. “Racial and ethnic minority and low-income communities have been disproportionately affected by both the direct and indirect effects of the pandemic. Moving forward, our public health and policy strategies must prioritize health equity to ensure that the long-term effects of the pandemic do not continue to disproportionately affect communities of color.”

Rishi K. Wadhera
Wadhera and colleagues conducted a serial, cross-sectional survey study of 2,470,717 adults using data from the U.S. Census Bureau Household Pulse Survey. Online survey results were collected weekly from April 2020 to July 2020 and biweekly from August 19, 2020, onward during the pandemic from the National Center for Health Statistics.

The researchers calculated the proportion of adults who experienced a delay in health care by race and ethnicity across four consecutive time periods: wave one (April 23, 2020, to June 16, 2020), post-wave one (June 18, 2020, to Sept. 14, 2020), wave two (Sept. 16, 2020, to Feb. 15, 2021) and post-wave two (Feb. 17, 2021 to May 10, 2021). They then estimated the likelihood of delaying or not getting needed medical care by race and ethnicity compared with non-Hispanic white adults.

Among the cohort, the mean age was 48.9 years and 48.4% of the adults were men. Also, 62.7% of adults were white, 16.9% were Hispanic, 11.5% were Black and 5.1% were Asian.

During the study period, the proportion of participants who delayed or did not receive care decreased from 38.7% to 19.1% (P < .001). Asian (OR = 0.74; 95% CI, 0.69-0., Hispanic (OR = 0.89; 95%, CI 0.84-0.93) and non-Hispanic Black (OR = 0.94; 95% CI, 0.9-0.99) adults were less likely to delay or not get medical care during wave one compared with non-Hispanic white adults. However, Wadhera and colleagues reported that during wave two, Hispanic (OR = 1.25; 95%, CI 1.2-1.29) and non-Hispanic Black (OR = 1.05; 95% CI, 1-1.1) adults were more likely to delay or not get medical care than non-Hispanic white adults. By the end of the post-wave two period, Asian (OR = 1.22; 95% CI, 1.16-1.2, Hispanic (OR = 1.39; 95% CI 1.34-1.45) and non-Hispanic Black (OR = 1.17; 95% CI, 1.12-1.22) adults were more likely to delay or not get medical care.

Overall, nearly one in five adults in the U.S. continue to delay or not receive medical care due to the pandemic, according to study author Ahmed Ahmed, MPP, MSc, a doctoral candidate at Harvard Medical School.

Ahmed Ahmed
“These findings are alarming and suggest that many individuals may not be receiving important screening tests (eg, mammograms), care for chronic conditions like diabetes and high blood pressure and/or are avoiding the hospital when they have life-threatening symptoms (eg, chest pain),” Ahmed told Healio. “The impact of these delays or deferrals in care on health could be vast over the long term.”

References:​

Ahmed A, et al. J Gen Intern Med. 2022;doi:10.1007/s11606-022-07406-7.

Pandemic disruptions mean many older adults still haven’t gotten needed care. https://www.healthyagingpoll.org/re...-many-older-adults-still-havent-gotten-needed.
"

 

[Karl_K]

I dont know anyone who has an illness who hasn't had a covid19 delay in appointments.

 

[missy]

"
WASHINGTON -- President Biden didn't skimp on discussing healthcare in Tuesday night's State of the Union speech -- although he took a little while to get there.

His first mention of healthcare didn't come until about 25 minutes into his speech of a little more than an hour, after he talked about the Russian incursion into Ukraine and the American economy. His first healthcare-related topic was the high cost of prescription drugs, especially the high price of insulin.



Pushing for Capping Drug Costs, Medicare Negotiation

"We pay more for the same drug produced by the same company in America than any other country in the world," he said. "Just look at insulin." He introduced 13-year-old Joshua Davis, a boy with type 1 diabetes who was in the audience. "He and his dad both have type 1 diabetes, which means they need insulin every single day. Insulin costs about $10 a vial to make. That's what it costs the pharmaceutical companies, but drug companies charge families like Joshua and his dad up to 30 times that amount ... For Joshua, and for the 200,000 other young people with type 1 diabetes, let's cap the cost of insulin at $35 a month so everyone can afford it ... And while we're at it, let's let Medicare negotiate the price for prescription drugs, like the VA already does."

And, he added, "the American Rescue Plan is helping millions of families on Affordable Care Act plans save $2,400 a year on their health care premiums. Let's close the coverage gap and make those savings permanent."



Healthcare came up again 10 minutes later, when Biden expressed concern about Wall Street firms that were taking over many nursing homes. "Quality in those homes has gone down and costs have gone up. That ends on my watch," he said. "Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and expect and [they'll be] looked at closely." The White House on Monday announced more detailed plans for improving conditions in nursing homes.

Pandemic Progress

And, of course, the president discussed the COVID-19 pandemic, starting out on an optimistic note. "Because of the progress we've made, because of your resilience and the tools we have been provided by this Congress, tonight I can say we are moving forward safely, back to more normal routines." He noted that severe COVID cases have dropped to a level not seen since last July, and that the CDC recently issued new mask guidelines, under which "most Americans in most of the country can now be mask free."



Biden listed four steps to move forward on the pandemic. "First, stay protected with vaccines and treatments," he said. "We know how incredibly effective vaccines are. If you're vaccinated and boosted you have the highest degree of protection." He touted the Pfizer anti-viral pill, noting that it "reduces your chances of ending up in the hospital by 90%." And he noted that the administration is "launching the 'Test to Treat' initiative so people can get tested at a pharmacy, and if they're positive, receive antiviral pills on the spot at no cost." He also said that beginning next week, those who have already ordered and received four free COVID-19 tests from the federal government will be able to order another four tests from the covidtests.gov website.

"Second, we must prepare for new variants," said Biden. "Over the past year, we've gotten much better at detecting new variants. If necessary, we'll be able to deploy new vaccines within 100 days instead of many more months or years ... I can't promise a new variant won't come. But I can promise you we'll do everything within our power to be ready if it does."



"Third, we can end the shutdown of schools and businesses," he said. "We have the tools we need. It's time for Americans to get back to work and fill our great downtowns again ... Our schools are open. Let's keep it that way. Our kids need to be in school."

"Fourth, we will continue vaccinating the world," said Biden. "We've sent 475 million vaccine doses to 112 countries, more than any nation on Earth. And we won't stop."

He urged Americans to put aside their divisions over the coronavirus. "Let's use this moment to reset," he said. "Let's stop looking at COVID-19 as a partisan dividing line and see it for what it is: a God-awful disease. Let's stop seeing each other as enemies, and start seeing each other for who we really are: fellow Americans."

Abortion Rights Defended

Abortion also came up during the speech, although Biden didn't mention it by name. "The constitutional right affirmed in Roe v. Wade -- standing precedent for half a century -- is under attack as never before," he said, referring to the 1973 landmark Supreme Court decision that legalized abortion nationwide. "If we want to go forward -- not backward -- we must protect access to healthcare. Preserve a woman's right to choose. And let's continue to advance maternal healthcare for all America."



Biden closed his speech with an exhortation for Congress to pass what he called his "Unity Agenda" -- a four-point plan in which every point touched on healthcare. The four points included:

• Beat the opioid epidemic. "There is so much we can do -- increase funding for prevention, treatment, harm reduction, and recovery," said the president. "Get rid of outdated rules that stop doctors from prescribing treatments. And stop the flow of illicit drugs by working with state and local law enforcement to go after traffickers."
• Take on mental health -- especially among children. "Children were also struggling before the pandemic -- bullying, violence, trauma, and the harms of social media," he said. "It's time to strengthen privacy protections, ban targeted advertising to children, demand tech companies stop collecting personal data on our children. And let's get all Americans the mental health services they need. More people they can turn to for help, and full parity between physical and mental healthcare" in terms of insurance coverage, something the administration previewed in a call with reporters Tuesday morning.
• Support veterans. "Our troops in Iraq and Afghanistan faced many dangers -- one was [being] stationed at bases and breathing in toxic smoke from 'burn pits' that incinerated wastes of war -- medical and hazard material, jet fuel, and more," Biden said. "When they came home, many of the world's fittest and best-trained warriors were never the same. Headaches. Numbness. Dizziness. A cancer that would put them in a flag-draped coffin. I know. One of those soldiers was my son Major Beau Biden. We don't know for sure if a burn pit that he lived near ... was the cause of his brain cancer, or the diseases of so many of our troops. But I'm committed to finding out everything we can."
• End cancer as we know it. Biden said that the goal of his newly relaunched "cancer moonshot" initiative "is to cut the cancer death rate by at least 50% over the next 25 years, and I think we can do better than that, turn more cancers from death sentences into treatable diseases ... To get there, I call on Congress to fund ARPA-H, the Advanced Research Projects Agency for Health."

"We can do these things," he said. "It's within our power, and I don't see a partisan edge to any of those four things." Biden ended on a familiar optimistic note: "The State of the Union is strong -- because you, the American people, are strong," he said. "And we will be stronger a year from now than we are today. This is our moment to meet and overcome the challenges of our time."
"

 

[missy]

"

We're Depriving Underserved Patients of the Best Drugs​

— Pharmacoequity has evaded the U.S. for far too long​

by Utibe Essien, MD, MPH, and Harlan Krumholz, MD, SM May 2, 2022

During a busy clinic day for patients without health insurance, one of us received a jarring announcement. Certain lifesaving medications that we had previously been able to freely provide to patients were no longer available. The costs of these drugs were far beyond the reach of our patients, and so healthcare teams were forced to switch patients to less effective regimens. We doctors were escalating their risk by switching to cheaper regimens or not being able to start newer, more effective therapies in patients not yet on them.

We did not go to medical school to deprive patients of effective treatments, and yet, there we were, creating harm rather than providing benefit.
As expensive, new medications show their game-changing effects on health, we're becoming increasingly concerned that innovative breakthroughs, however welcome, may actually worsen disparities.
As policymakers and advocates seek ways to revive the congressional social safety net bill, a measure to curb the cost of prescription drugs continues to receive broad partisan support. However, we have yet to see how this bill, or others like it, can ensure that all Americans, regardless of race, ethnicity, or socioeconomic status, have access to the highest quality medications needed to manage their health needs. This goal, referred to as pharmacoequity, is one that has evaded the U.S. for decades.
Several research studies have shown wide disparities in treatment because of medications costs. A study one of us published in 2019 found that 1 in 8 Americans with cardiovascular disease did not adhere to medications because of cost. These individuals shared that they either skipped doses, took less medication, or delayed filling a prescription to be able to save money. The world of oncology has described the financial toxicity that comes with expensive chemotherapy and immunotherapy treatments and the physical and psychological burden these costs place on patients with cancer. Furthermore, a recent analysis from the CDC found that cost-related medication non-adherence was associated with an over 20% higher rate of death for patients with chronic diseases.

Our research has also made clear that cost is simply one barrier leading to treatment disparities. We have shown that even when adjusting for insurance status, education level, and household income, Black, Hispanic, and Asian patients are less likely to be prescribed novel, evidence-based diabetes medications as well as stroke-preventing medications. A well described body of research shows that Black patients, including children, are less likely to receive appropriate pain medications for anything from a leg fracture in the emergency room to chronic back pain at their primary care physician. What's more, the COVID-19 pandemic has further highlighted these disparities, as communities of color experienced poorer access to vaccines and new antiviral therapies to prevent and treat this devastating disease.
Decades of research experimentation and medical racism have wreaked havoc on the trust communities of color have in the medical system. Yet, beyond distrust, limited opportunities to those who are willing and able to begin new therapies abound, including poorer insurance coverage, burdensome copayments, and limited access to the appropriate medical prescribers. Even physical access to pharmacies limits drug access for communities of color who are more likely to reside in so-called pharmacy deserts. This unequal access to medication is made worse by implicit or unconscious bias that results in some medical providers prescribing certain therapies less frequently to lower income individuals and patients of color.

So, how do we achieve pharmacoequity and bring our nation towards a just health system? First, the appropriate prescription drugs must be available for all patients, regardless of the type of clinic or hospital where they receive care or from whom that care is provided. We can achieve this by implementing health system solutions, such as prescriber nudges, to help reduce treatment bias by race, ethnicity, or social class. Second, accessibility to prescription drugs must be improved. To achieve this goal, we must target the initial prescription a patient receives by ensuring all Americans have access to health insurance including through Medicaid expansion or a universal insurance system. We know that such programs work: both the U.K.'s National Health Service and Australia's Pharmaceutical Benefits Scheme are able to provide evidence-based therapies at affordable costs to the majority of their populations. We must also bridge the geographic gap that some patients have in receiving medications. We can invest in strengthening medication delivery systems including through collaborations with rideshare companies and direct-to-consumer delivery services such as Amazon's PillPack.

Finally, affordability of prescription drugs must be addressed. Americans pay more for prescription drugs than any other nation in the world. The high rate of medical debt associated with these costs results in deferred spending on basic needs such as housing, food, and education and will continue to widen the wealth gaps between low-income and individuals of color and their more advantaged counterparts. We need national innovations to reduce the cost burden on individuals, particularly for novel life-saving treatment. These may include some of the strategies within the previous Build Black Better bill such as improved drug price negotiations by the federal government and caps on spending limits for Medicare enrollees. However, we also should consider broader strategies such as an essential medications list, international reference pricing for drugs, and increased cost regulation across the prescription drug cascade, from drug approval by the FDA to the determination of consumer pricing through intermediaries such as pharmacy benefit managers.

We are on the cusp of a life sciences revolution, but we are stepping into an era that could create ever greater disparities if we do not act immediately. The prescription drug measures within the Build Back Better bill offered insight into what policymakers can do to support affordable healthcare for the most vulnerable, but bolder action is needed. Effectively and equitably distributing novel, evidence-based, and high-quality treatments to underserved patients should be our nation's priority. In doing so we can achieve pharmacoequity.
Utibe Essien, MD, MPH, is an assistant professor at the University of Pittsburgh School of Medicine. Harlan Krumholz, MD, SM, is professor of medicine at Yale and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation. He is also a member of the MedPage Today Editorial Board.
"

 

[missy]

NYT Essay

Lessons From a ‘Difficult Patient’ (Published 2022)

Sal was the kind of patient that doctors strive to avoid. But for one medical student, he provided an education in compassion.

www.nytimes.com

Lessons From a ‘Difficult Patient’​

Sal was the kind of patient that doctors strive to avoid. But for one medical student, he provided an education in compassion.

• 
  
• 
  
• 
  
• 
  

Credit...Lucy Jones


By Gina Siddiqui
Published Oct. 18, 2022Updated Oct. 21, 2022
Sal was 58 when I was assigned his case. Sal had been diagnosed with cystic fibrosis in the 1960s and was considered an old survivor; all his friends who had been diagnosed at the same time, including his younger brother, were dead.
I was 21, a few weeks out of college and one of the youngest students in my medical school class. Our assignment, to follow patients with chronic diseases to their clinic appointments, felt like a formality to my classmates whose parents were doctors and who already knew what went on in hospitals. But for me it was eye-opening.
On the day of our first appointment, I stood waiting for Sal on the freshly buffed floor of our hospital’s clinic lobby, fidgeting with my white coat and trying to hold my clipboard in a way that looked natural. The morning wave of physicians and researchers speed-walked past me to the elevators, coffee or cellphone in hand, eyebrows furrowed.
After 30 minutes passed with no sign of Sal, I called his cellphone. He wouldn’t be coming for his appointment today, he said, and would have to call back; he was on a call with the clinic receptionist, giving her a piece of his mind. Before I could respond, he hung up.



I looked up and saw, three cubicles away, a receptionist on the phone. She was red in the face; she kept starting to speak and then stopping, as if being interrupted. Eventually she hung up, sighed and walked over to a neighboring receptionist, gesturing back at her phone.
My phone buzzed in my pocket: Sal. This week was terrible, he said, because he had caught a cold. It was no use blowing a whole afternoon by going to a routine checkup. It was a waste of time, he said — time he didn’t have.

In the body shop​

As we talked, I learned that colds are a major concern for people with cystic fibrosis; for many it is the cause of death. “I’m stressed out,” Sal said, adding an expletive. I asked if instead of trying to ride this out himself, he might let a doctor help him. He was reluctant but eventually agreed to come to the clinic. But when I asked to squeeze Sal into the afternoon schedule, the receptionist looked incredulous: Was I sure the doctor really wanted to see Sal?
Sal, I was learning, was what medical people call a “difficult patient,” one who doctors avoid. I watched him quiz his new doctors to see if they had read his chart carefully. How many of the bacteria species that colonize the lungs of cystic fibrosis patients could they name? He rewarded correct answers with even harder questions about local antibiotic resistance patterns. If the doctor said he or she didn’t know, Sal glared quietly; if they made up an answer, he was merciless.
After Sal’s appointments, I stayed behind with the doctors who were discussing his case. They set aside their medical differences of opinion and found solidarity in complaining about him: Did he have any idea that everyone else waited graciously for whoever was available, while he demanded a new doctor every other visit?

​

​

Sal’s pulmonologist of 30 years had retired, and the clinic had been struggling for months to figure out who would take on Sal’s case. Since not many cystic fibrosis patients had made it to Sal’s age, Sal suspected that many adult pulmonologists, especially the older ones, saw his ailment as a pediatric problem that they wouldn’t have to deal with, and ignored its nuances. In the case of several doctors I met, he was right.

Credit...Lucy Jones


The next year of medical school I went from being an observer to having patients of my own in the hospital. My job was to write medical to-do lists for each patient, covering every organ system. I learned a 21-point inspection of sorts to troubleshoot each malfunctioning part, as if my patients were machines in a body shop.
My supervising doctors showed me how to set the rates at which my patients’ kidneys produced urine and their lungs expelled carbon dioxide. They made these decisions quickly, with little self-doubt. Hormones, fluids, wires, tubes, sedatives, paralytics; the bone’s ability to remodel, the heart’s strength to contract — I was responsible for all of these things and had limited time to make all these plans. Don’t worry, I was told, we’ll start you with easy patients.
One such patient was a man who needed emergency surgery to remove an oxygen-starved section of his intestines. The remaining segment was brought through his skin and stitched beside his belly button, a plastic bag taped around the opening where stool now left his body.
When I woke him up before dawn to examine his wound, he did not resist or chide me for my cold hands, as Sal would have. He didn’t challenge the plan or ask follow-up questions. Rounds on him never took more time than I had allotted. My colleagues were right: He was an easy assignment for a medical student, because he was a shell of a person.
The nurses in the I.C.U. told me they had seen many patients like him — that critically ill patients often detach themselves from what they must endure. They asked me to imagine waking up defecating out of my abdominal wall and if it would change who I thought I was. Patients on the brink of death are not demanding and inquisitive like Sal. They are formless putty in the hospital’s hands.



A year and a half on the wards and a few hundred patients later, I had become better at breaking people down into their medical machine parts. My evaluators judged this skill during medical rounds, when we distilled patients’ histories into a single sentence, a feat made easier with patients like the man with bowel surgery. These patients succinctly told me what would fill in the blanks of my medical one-liner and didn’t cloud the picture with any personal thoughts of their own.
Passive patients were “easy” because we doctors could efficiently take total control. But once patients left the clinic we could promptly absolve ourselves of that responsibility. I had no idea what happened, for instance, when my patient with bowel surgery had to figure out how to do groceries and clean his bag of stool himself.

A three-ring history​

That summer, I visited Sal’s house in South Philly, and he took me for a drive in his yellow Viper. “The great thing about not having kids is all the disposable income my wife and I have for fast cars,” Sal said. (Male cystic fibrosis patients lack the ducts that enable sperm to be ejaculated, rendering them infertile.) We sped along back roads to his favorite Italian restaurant.
On the mantel of Sal’s home were photos of him and his younger brother. Next to these was a pile of medical binders. Sal kept daily records of his lung function, his muscle strength and his respiratory symptoms, compiling statistics monthly and yearly. He did this manually, before the advent of FitBits and Apple Watches. He also collected clinical trials and review articles on cystic fibrosis. Sal was on his third five-inch binder.

Credit...Lucy Jones


The doctors made fun of Sal’s tomes and took bets on who would catch the hot potato next month and be expected to wade through his thousands of pages in 30 minutes. I thought of the meticulous attention to his disease that these binders embodied. How absurd that this asset was perceived as an albatross.
It was my first lesson in recognizing patient qualities that benefited their health but not the doctor’s workflow. Doctors did not commend patients who expected to understand all their test results, or who pushed back against treatments that were only weakly supported by evidence, or who wanted to talk to a doctor on the phone instead of waiting a week and missing a half-day of work for an in-person appointment.



The only patients deemed more difficult than insistent patients like Sal were his opposites: patients so overwhelmed that they stopped wanting to pay any attention to their illnesses at all. They are well known to every doctor: a dialysis patient, gray from uremia, eyes glazed over when asked why she missed her last session; a double amputee now bed-bound, refusing home visits; a boy with severe food allergies who won’t carry his EpiPen with him.
Sal did not bring his binders to his next appointment. They were becoming too cumbersome, he said, so he had started to simply jot down any crucial notes. These all had the same upshot: Sal was growing sicker and weaker. During one appointment I sat in on, Sal complained that he could not lift as much as he could the previous year: Why was that? And what could he do about it?
The doctor pointed to his own gray hairs — advancing age, nothing to be done about it. I expected Sal to press the doctor to back up this proclamation with numbers and parameters for lung function, or to demand a new doctor. Instead, he was quiet for the rest of the appointment and seemed to shrink into himself on the examining table.
Later that week Sal wrote me an email: Prepare a speech for those moments, like the one that week, when patients come to you at the end of their rope, and you have no more solutions to offer, he said. I think I was studying for an exam, and brushed off the message.

Cultivating distance​

By now I was almost done with medical school. As we neared the end of our rotations, actors were hired to play patients and give us feedback on our bedside manner. They said things like, “It made me feel better when you looked me in the eye to break bad news.” We laughed, half-insulted, half-guilty.
I practiced “therapeutic distancing” to make decisions about patients coolly and unemotionally. I didn’t share much about myself or display vulnerability or uncertainty. I practiced not thinking about my patients once I got home.
With Sal I maintained none of these conventions. He and I continued to email back and forth. I sent updates about medical school, vacation travels, relationships and my plans for the future; Sal updated me on his declining health. Then one day my email to Sal bounced back, because he had died.



Years later in my training, on a late night home from the hospital, I reread Sal’s emails. Bathed in the blue light of my laptop screen, his advice about preparing a speech spoke to me as if from a ghost. I now had a command of anatomy, pathophysiology and pharmacology. I had impressed my supervisors and diligently maintained therapeutic distance. I was finally starting to become confident as a doctor. Why, then, did I feel so empty?
At first, the speech I wrote was for him. I told Sal that he should not blame himself any longer for growing weaker. He had fought his ailment valiantly, and his brother’s photo could occupy that space on the mantel alone now, without the binders. For a while I wished I had given him this speech, but I knew why I didn’t: I wasn’t his doctor.
Sal did not seem to want speeches of that sort from his actual doctors. He had become unpleasant toward members of the clinic staff, distrustful of everyone before his appointment even started. If Sal was told there were no prescriptions or procedures to fix the problem he was describing, he would condemn his team’s command of medicine and declare the appointment a waste of time.
It was not just we who had mechanized Sal; he had mechanized us, too. He expected near-infinite knowledge from his doctors on technical matters but dismissed their opinions as individuals. Sal had come to expect only a machinist’s answers from doctors, and at some point that became all he would accept.

Image

Credit...Lucy Jones

The weight of knowledge​

Now I am the speed-walking supervisor asking my medical students to provide a one-line simplification of a person’s suffering. My focus is on which diagnoses would be most dangerous to miss and how behind I am with my other patients. I often tune out the personal stuff.
Modern medicine has trained me and my fellow doctors to pin patients down, like beetles to be examined on a bulletin board. Their free motion impairs our efficient taxonomy of them. Unsurprisingly, patients do not feel well understood while pinned on the paper roll of an exam table. But how else can we cover everything we must in an appointment lasting 30 minutes or less?



To its credit, medicine has tried to shift further toward seeing patients on their terms, with telehealth visits, open notes and hospital services at home. But even with these, the titanic burden of medical knowledge to which doctors must do justice can crush opportunities for intimate conversation.
I know none of my patients today as I knew Sal, and none of them know me as Sal knew me. Even if I had infinite time for them, patients treat me differently as a full-blown doctor. I carry responsibilities — to be knowledgeable, skilled, punctual — that Sal did not hold me to when he took me under his wing.
Now the speech that Sal inspired is directed inward. I tell myself that patients reach the end of their ropes for medical reasons, personal reasons and often a mix of the two. Sometimes just managing the medical reasons is challenge enough for me, and that’s OK. But when I’m the “patient” at a bank or courtroom or post office, I’m reminded of what competency feels like without humanity. That helps me summon that timid young woman on the buffed lobby floor, who knew nothing about medicine but earned her first patient’s trust by being kind and sincere. She has started seeing patients again.
The Medical Life
Oct. 21, 2022
An earlier version of this article misstated the cause of infertility among male cystic fibrosis patients. These patients lack sperm ducts congenitally, they do not lose them later in life.

 

[GliderPoss]

Once again, I feel endlessly blessed by Medicare & the public healthcare system in Australia. Yes, I still pay a lot in private insurance as not everything is covered BUT I've never feared the cost of going to a doctor or hospital when required. I was recently rushed ER for emergency surgery and didn't pay a single dollar. Stories of people in the US paying $100K for a hospital visit is an absolute outrage....

 

[LilAlex]

‘The Invisible Kingdom’ Review: Malady Unknown​

Our medical system does not deal well with uncertainty. If a diagnostic test can’t determine what’s wrong, then the patient must be wrong.​

Late to this thread but just wanted to say that most docs are fine dealing with uncertainty -- even with their own health. They exclude the "bad" things and often patients are left with symptoms for which there is no specific treatment. It is usually the patient who pushes the doctor for "an answer."

For people in the field, if it's not cancer, infection, autoimmune inflammation, or a reversible lack of blood flow, there is not much any drug or doctor can do. (There are a few exceptions, of course.) There are a lot of symptoms and frailties that we accumulate as we age and for which there are no cures. You may have a friend or family member who is on ten different meds for symptoms: pain, anxiety, nausea, constipation, muscle aches, etc. Symptoms matter but it's not the same as a diagnosis.

 

[Karl_K]

So frustrating, the other day I saw a heart doc instead of the usual PN it took almost 18 months to get in for a 9 month checkup.
He comes in and says hi, we met on a remote visit a couple years ago its nice to see you in person. Looked at the computer for 2-3 min, listened to my lungs and heart, said schedule for a year, 5 min out the door.
No follow up testing like had been talked about 18 months ago or anything.
cachung! billed the insurance company $500 not that they will pay that much.

 

[LilAlex]

Looked at the computer for 2-3 min, listened to my lungs and heart, said schedule for a year, 5 min out the door.

Sounds like bad care. Or else you are a rock-stable non-smoking regular exerciser with great blood pressure and lipids and with zero concerns to bring to his/her attention. Those people are rumored to exist.

Not saying this person did this but it can be 30 min behind the scenes before a visit to get up to speed on a complex patient.

 

[missy]

Late to this thread but just wanted to say that most docs are fine dealing with uncertainty -- even with their own health. They exclude the "bad" things and often patients are left with symptoms for which there is no specific treatment. It is usually the patient who pushes the doctor for "an answer."

For people in the field, if it's not cancer, infection, autoimmune inflammation, or a reversible lack of blood flow, there is not much any drug or doctor can do. (There are a few exceptions, of course.) There are a lot of symptoms and frailties that we accumulate as we age and for which there are no cures. You may have a friend or family member who is on ten different meds for symptoms: pain, anxiety, nausea, constipation, muscle aches, etc. Symptoms matter but it's not the same as a diagnosis.

I understand what you are saying @LilAlex but speaking from my personal experience this is not what I am dealing with and let's just say I find many docs shy away from a complicated patient. They don't give their time, energy and attention if one doesn't fit into the proverbial box. I have had doctors say to me, your case is so complex. I don't know where to begin. I give them credit for their honesty. It's the doctors who act like they do care and want to help but within time give up and aren't honest about it. My career was in healthcare and I have seen changes over the decades. In fact, it was the impetus behind my leaving the field. I refuse to give less than stellar care. Healthcare is even more of a big business (corporations taking over and the doctor has much less control) than it has ever been. IMO it is now profits above ALL else. Whereas before it was patients then profit. Now it is profit and then maybe, if you are lucky, patients.

So frustrating, the other day I saw a heart doc instead of the usual PN it took almost 18 months to get in for a 9 month checkup.
He comes in and says hi, we met on a remote visit a couple years ago its nice to see you in person. Looked at the computer for 2-3 min, listened to my lungs and heart, said schedule for a year, 5 min out the door.
No follow up testing like had been talked about 18 months ago or anything.
cachung! billed the insurance company $500 not that they will pay that much.

So sorry @Karl_K I share your frustration. Many doctors have a quota they must meet and cannot spend sufficient time with patients. It's not OK. It's not acceptable. IMO this started happening way before the pandemic but the pandemic highlighted the problems even more clearly. I hate doctor shopping but in this day and age we are forced to search to find a competent and decent physician. Even more so now we must advocate for ourselves and cannot rely on our physicians. We must always do our due diligence. I hope you can find a doctor who can help you and support you in the way you deserve.

 

[Karl_K]

I checked the visit notes in my chart he did reference the blood work I have been doing with my diabetes doc.
I have an abnormal ekg and they did not check it, I also have a enlarged RV and was told they were going to recheck it(echo) after next visit.
Then they kept changing my appointment and 9 months turned into 18.

 

[wildcat03]

Sigh. It's all really frustrating. It's hard to be a physician and feel like you can't care for your patients properly. It's much much harder to be a patient and feel like you aren't being cared for properly. In all reality, the limits and requirements placed by insurance companies and Medicare create a lot of this. For every patient who comes to the ER, nurses are expected to ask: 1) COVID screening questions, 2) domestic violence screening, 3) pregnancy related screening (are you or have you been pregnant in the last 18 months, and then follow up questions). Plus smoking, alcohol, drug use (although we have a very active substance use intervention group, so this screening can be useful). All of these questions sometimes for a hangnail! None of this leaves the patient feeling like their concerns have been heard.

Meanwhile we're short SO many nurses and we're burning out the current ones by asking them to work extra all the time.

Most of the physicians I know who are happiest with their practice are either DPC or concierge. It's hard to stomach paying for that kind of service when we already pay through the nose for health insurance (and in truth, my family probably rarely "wins the game" on our health insurance expenditure - we would likely save money if we just paid out of pocket but obviously would have no catastrophic protection - but I recognize that we are fortunate in that and it could always change). Most primary care patient panels are 2500 patients. Most concierge doctors have a panel size of 400-600 patients, allowing them to spend an hour for a single visit with a patient. However, they have no third party payor requirements for regulatory stuff or paperwork, so that allows them to 1) minimize overhead and 2) maximize time spent with patient, not time doing paperwork. DPC is a slightly different model but still with a smaller patient panel and less overhead. Of course, this also creates a 2 class system, but some DPC practices are actually not much more than insurance-covered visits with high deductible plans (although those prices might still be out of reach for those with medical assistance).

So, in summary, I have no answers.

 

[missy]

Sigh. It's all really frustrating. It's hard to be a physician and feel like you can't care for your patients properly. It's much much harder to be a patient and feel like you aren't being cared for properly. In all reality, the limits and requirements placed by insurance companies and Medicare create a lot of this. For every patient who comes to the ER, nurses are expected to ask: 1) COVID screening questions, 2) domestic violence screening, 3) pregnancy related screening (are you or have you been pregnant in the last 18 months, and then follow up questions). Plus smoking, alcohol, drug use (although we have a very active substance use intervention group, so this screening can be useful). All of these questions sometimes for a hangnail! None of this leaves the patient feeling like their concerns have been heard.

Meanwhile we're short SO many nurses and we're burning out the current ones by asking them to work extra all the time.

Most of the physicians I know who are happiest with their practice are either DPC or concierge. It's hard to stomach paying for that kind of service when we already pay through the nose for health insurance (and in truth, my family probably rarely "wins the game" on our health insurance expenditure - we would likely save money if we just paid out of pocket but obviously would have no catastrophic protection - but I recognize that we are fortunate in that and it could always change). Most primary care patient panels are 2500 patients. Most concierge doctors have a panel size of 400-600 patients, allowing them to spend an hour for a single visit with a patient. However, they have no third party payor requirements for regulatory stuff or paperwork, so that allows them to 1) minimize overhead and 2) maximize time spent with patient, not time doing paperwork. DPC is a slightly different model but still with a smaller patient panel and less overhead. Of course, this also creates a 2 class system, but some DPC practices are actually not much more than insurance-covered visits with high deductible plans (although those prices might still be out of reach for those with medical assistance).

So, in summary, I have no answers.

@wildcat03 and I greatly value and appreciate physicians like you. I know you’re doing an impossible job under challenging circumstances. I just want to cry for everyone involved.

 

[LilAlex]

I understand what you are saying @LilAlex but speaking from my personal experience this is not what I am dealing with and let's just say I find many docs shy away from a complicated patient. They don't give their time, energy and attention if one doesn't fit into the proverbial box. I have had doctors say to me, your case is so complex. I don't know where to begin. I give them credit for their honesty. It's the doctors who act like they do care and want to help but within time give up and aren't honest about it. My career was in healthcare and I have seen changes over the decades. In fact, it was the impetus behind my leaving the field. I refuse to give less than stellar care. Healthcare is even more of a big business (corporations taking over and the doctor has much less control) than it has ever been. IMO it is now profits above ALL else. Whereas before it was patients then profit. Now it is profit and then maybe, if you are lucky, patients.

I get it. Not sure why I chimed in without knowing the context.

Sorry you are not having a better experience.

Specialists at a local medical school (faculty, not the resident/fellow clinic) may dig in deeper as a point of pride... From past exchanges, I know you know this already; you are a savvy consumer.

 

[missy]

I get it. Not sure why I chimed in without knowing the context.

Sorry you are not having a better experience.

Specialists at a local medical school (faculty, not the resident/fellow clinic) may dig in deeper as a point of pride... From past exchanges, I know you know this already; you are a savvy consumer.

No worries @LilAlex and thank you.

 

[Karl_K]

@wildcat03 and I greatly value and appreciate physicians like you. I know you’re doing an impossible job under challenging circumstances. I just want to cry for everyone involved.

@wildcat03 me too!

 

[missy]

"

A Remedy for the Federally Funded Physician Shortage​

— Raising or eliminating the cap on residency spots can make all the difference​

by Christian Hardoy November 13, 2022

Much has changed in healthcare since the 1990s: HIV infection is no longer a presumptive death sentence, minimally invasive and robotic techniques have redefined a variety of surgeries, and telemedicine has greatly expanded access to care. Why then, in the face of such remarkable advancement and change, has the number of doctors the U.S. produces each year not changed enough to meet the evolving needs of our population? The answer is Congress.

To become fully licensed physicians, there is but one path forward for medical students: residency. With the vast majority of residency programs subsisting on federal funds, an estimated 82% in 2018, the federal budget has a direct and frighteningly limiting effect on the number of physicians the U.S. produces. This federal bottleneck largely results from the Balanced Budget Act of 1997, which capped the number of federally funded residency spots at 100,000. Since then, the only increase has been the 2021 plan to add a mere 1,000 residency spots (phased in over 5 years). In context, that is a 1% increase in 24 years. In the same time, the U.S. population grew by 22% and, according to the Association of American Medical Colleges (AAMC), the number of medical school matriculants has increased by 37.5% since 2002. Based on the numbers, the shortage isn't stemming from a lack of need or medical school students, but rather a shortage of federally funded residency spots.

For the average American patient, this represents yet another barrier to receiving much-needed healthcare services. The simple fact is: there is no healthcare without doctors. Fewer physicians per person means fewer patients can receive care, or less time per patient.
While the need for physicians of certain specialties or in specific regions may vary, the U.S. as a whole is in the midst of a physician shortage that is just beginning. A report by the AAMC predicted a terrifying shortage of between 37,800 and 124,000 doctors by 2034. With more than two of every five U.S. physicians turning 65 or older within the next decade, a growing aging Medicare population in need of ever-more specialized care, a young population increasingly in need of mental health services, and a general increase in the total population, we can't ignore the growing demand for physicians.
The COVID-19 pandemic in particular has highlighted the importance of doctors and other healthcare workers like never before, as well as the increasing burden placed upon them. Hospitals across the country have been overrun and understaffed in varying waves throughout the last few years. According to a Mayo Clinic publication, 62.8% of physicians demonstrated one or more manifestations of burnout in 2021 compared to 38.2% in 2020, and over the same time period physicians reported increased depression and decreased satisfaction with work-life balance. The specific challenges of the pandemic may be unique, but this test of our fortitude is just a taste of the true crisis yet to come.

This predicament also begs the question: Why has so little changed in over two decades? The answer is complex. The prevailing Congressional sentiment in 1997 was that a failure to limit the number of residency spots would produce an oversupply of physicians and too steep a bill for Medicare's budget. But the current healthcare reality is markedly different. In spite of this, continued budgetary concerns, lack of widespread Congressional support, and a dearth of public awareness of the issue have all played prominent roles in hindering progress. With less than 10% of the bills proposed being passed into law in the last Congressional session (2019-2021), and healthcare spending focused on COVID-19-related research, testing, and economic aid, it is no surprise that sweeping residency-funding changes have been difficult.
However, this lack of funding progress is not to say that no effort has been made. Behind the scenes, former Sen. Bill Nelson (D-Fla.), former Rep. Joseph Crowley (D-N.Y.), and several others repeatedly attempted to pass legislation that would increase the residency cap more substantially. Astonishingly, eight previous iterations of their bills were proposed and rejected between 2007 and 2019. The latest iteration, introduced in March 2021 and sponsored by Sen. Robert Menendez (D-N.J.), is known as the Resident Physician Shortage Reduction Act of 2021 and seeks to increase federally funded residency spots by 14,000 over 7 years. A growth of 14,000 spots is likely too little to be a panacea for the physician shortage, but the passage of this bill would represent a sizeable first step. The addition of even more residency positions or a removal of the residency cap entirely would ultimately have a greater impact, but legislative progress is often incremental.

The failure to pass meaningful legislation may paint a rather bleak picture on the surface, but the COVID-19 pandemic, the overturning of Roe v. Wade, and now a surge in respiratory syncytial virus (RSV) in kids have undoubtedly thrust healthcare into the public spotlight. I believe the public understands the enormous value of physicians, and with incremental progress on this issue -- between the addition of 1,000 residency spots and proposed legislation for more -- Congress may be primed to finally invoke meaningful change. In its absence, we risk failing to correct a mounting crisis of our own creation: a physician shortage epidemic.
Christian Hardoy is a second-year medical student at UC Irvine School of Medicine, with an interest in healthcare policy and active involvement with medical education research, student mentorship, anemia research, and geriatrics.

"

 

[missy]

"

Our Biggest Health Insurance Concern Isn't What You Think​

— Millions remain underinsured -- could monthly out-of-pocket cost caps help?​

by Paul Shafer, PhD November 25, 2022

Only 8.3% of Americans were uninsured in 2021, a more-than 37% drop from 2013 (13.4%) -- the year before the marketplace and Medicaid expansion created by the Affordable Care Act began. So why are nearly half of working age adults (46%) still skipping care or medications? Being uninsured is no longer our biggest problem, being underinsured is -- when you have insurance, but the out-of-pocket costs are still so high that you can't afford to use it.

What Has Been Done to Address This?
President Biden and his administration have made significant strides in improving the affordability of health insurance and healthcare for millions of Americans in his first 2 years. The American Rescue Plan Act of 2021 increased premium subsidies for buying health insurance through HealthCare.gov and state-based marketplaces through the end of 2022, which the Inflation Reduction Act (IRA) passed earlier this year extended until the end of 2025. The IRA also included a cap on insulin costs at $35 per month for those on Medicare starting next year, an annual cap of $2,000 out-of-pocket on all prescriptions starting in 2025, and introduced a framework for the program to negotiate drug prices -- opposed by the pharmaceutical industry, but popular among Americans.
An amendment offered by Sen. Raphael Warnock (D-Ga.) to cap insulin costs in all commercial health insurance plans, including employer-sponsored health insurance and marketplace plans, was stripped from the bill, but reflected how far the conversation has come. During the last presidential election cycle, now Secretary of Transportation Pete Buttigieg pushed for monthly caps on seniors' prescription costs.

These proposals reflect the larger realities that healthcare is increasingly unaffordable, even for those with "good" insurance -- a majority of households below 400% of the federal poverty level can't afford their deductibles.
What Are Potential Solutions?
While health savings accounts (HSA) are often pointed to as an option to improve healthcare affordability, the reality is that they aren't -- they primarily serve as a tax shelter for already well-off Americans. Although their use has increased over the years, we found considerable disparities by race, ethnicity, and income in participation in HSAs -- that mirror those in uninsurance and difficulty affording care -- so they aren't a systemic solution to this problem.
Two years ago, my colleagues and I started to think through the pros and consof an alternative solution to underinsurance: monthly caps. Monthly out-of-pocket healthcare cost caps could potentially simplify our more complex current approach to cost-sharing, which typically starts with a deductible and then a period of co-insurance before hitting an out-of-pocket maximum based around a calendar year. Instead, monthly caps would give patients a smaller monthly deductible, after which every cost would be covered in full. We could still leave in place exemptions from cost-sharing, such as for preventive care, and co-pays for doctor visits, only changing how often and how much people are obligated to pay upfront before getting help from their plan. About a thirdof American families can't afford a $400 unexpected expense so the trend of higher and higher deductibles is just outpacing what they can cover.

Monthly caps would smooth out expenses for those with chronic conditions, leaving some out-of-pocket costs every month but would prevent a huge upfront cost every year. And for people who are young and healthy, this alternative design would still help whenever they do go for care, in the case that they need a few tests or an MRI that can run in the thousands. Additionally, if deductibles were to reset monthly, people wouldn't have to worry about losing their progress if they change jobs mid-year.
We took this a step further, publishing a study recently in JAMA Network Open, putting the idea to real-world data from health insurance claims. We found that a hypothetical $500 monthly cap on out-of-pocket costs for in-network care reduced costs for nearly a quarter (24.1%) of those commercially insured in the U.S., reducing the median out-of-pocket costs for that group by nearly half (-45.5%) over a calendar year. The benefits were even greater with a $250 monthly cap on in-network care, where 36.8% of enrollees benefit and median annual out-of-pocket costs fell by over half (-50.8%) among those benefitting. The cost decreases were even greater for those enrolled in high deductible health plans.

Of course, the money has to come from somewhere. With the costs shifted back to plans, we projected that premiums would have to rise by 5.6% for the $500 monthly cap and 7.9% for the $250 monthly cap. This isn't nothing, but it is helped by the fact that most Americans don't pay the full premium cost of their insurance alone -- usually an employer is picking up most of the tab or people get financial help in the marketplace. A key point is that our study assumes that people won't start using a lot more care just because of the monthly cap, which feels reasonable because there is only so much care you can use in a month before the cap would reset.
What Are the Limitations of Monthly Caps?
Any policies, including monthly caps on insulin or out-of-pocket costs, that only address how much patients pay won't solve the more systemic problem of rising healthcare costs. In the often-quoted words of the late economist Uwe Reinhardt, "It's the prices, stupid." It also won't solve the problem of uninsurance, with millions still lacking any coverage -- and slated to rise dramatically with the looming end of the COVID-19 public health emergency, now pushed to early next year.

Of course, we also don't know exactly what monthly caps on out-of-pocket costs look like in practice. No one has actually tried them at a large scale before. The insulin cap in Medicare won't start until next year, but we will learn about how patients respond to it and how rates of diabetic complications change as a result. On a broader scale, getting commercial insurers to shift away from an annual model of cost-sharing, basically used since health insurance began in the U.S., would not be a trivial effort.
Our hope is that an employer or insurer would be willing to pilot this model, see how patients respond to it, and then consider making it available as an option in their plan offerings. Who knows, perhaps they will even end up being the insurer to actually ensure patients can seek out care when they need it.
Paul Shafer, PhD, is an assistant professor in the Department of Health Law, Policy, and Management at Boston University.

Disclosures
Research for this piece was supported by Arnold Ventures. Shafer has received research funding during the past 12 months from the Robert Wood Johnson Foundation, Commonwealth Fund, Arnold Ventures, and Renova Health. He is also an investigator at the VA Boston Healthcare System under contract with the Boston University School of Public Health.

"

 

[missy]

"

Looming Physician Pay Cut 'Unprecedented' and 'Unconscionable,' AMA President Says​

— Number of doctors who take Medicare patients could dwindle without Congressional action​

by Cheryl Clark, Contributing Writer, MedPage Today December 2, 2022
Last Updated December 5, 2022

Every year about this time, press releases from physician groups, state medical associations, and specialty societies echo a refrain: Doctors aren't getting paid enough by Medicare. Either the latest pay bump wasn't enough, or it's a cut that's way too steep.
This year, however, their complaints have a much more desperate tone.
Physicians across the country say they are facing a serious one-two punch of cuts which -- if Congress doesn't step in soon -- will mean a reduction of 8.47% in their claims for taking care of the nation's Medicare beneficiaries starting January 1.

"Things are different this year," Jack Resneck Jr., MD, president of the American Medical Association (AMA), told MedPage Today during a phone call in which a public relations person was present. To impose cuts at this time, "3 years into a pandemic ... and with burnout rates soaring from about 38% in 2020 to 63% in 2021, and one in five physicians saying they're going to retire or do something else in the next 2 years" is, he noted, "unconscionable."
Practices are facing healthcare staffing and medical supply shortages, inflation of 7% to 8%, and 10,000-plus patients becoming Medicare-eligible every day. There's a "tripledemic" anticipated this winter. On top of all that, Resneck said, the cuts are creating an "unprecedented challenge" and "a perfect storm" that he predicts will have "a devastating impact on seniors' health."
"It's just really dangerous and incredibly difficult. [Physicians] are faced with difficult choices about selling their practices," he added. And with many of the nation's physicians now over the age of 65, there aren't enough residency training positions to feed the pipeline to replace them, he said.

Possible Solutions
Recently, the AMA has proposed a multi-pronged solution to fixing the problems, called the AMA Recovery Plan for America's Physicians.
Last month, the California Medical Association (CMA) posted its annual noticeto remind physicians that if they want to change their Medicare participation status, the deadline to opt-out is December 31.
This year, however, the CMA notice had a different second paragraph that sounded like a warning or even -- as some suggested -- a subtle threat. "Physicians should be aware that the Centers for Medicare & Medicaid Services (CMS) recently released the final rule and policies for next year," it states. "Unless Congress acts by the end of the year, physicians are again facing substantial Medicare payment cuts in 2023 due to a confluence of statutory and budget neutrality payment cuts," which the CMA is urging Congress to stop.
"As always, physicians have three choices regarding Medicare: Be a participating provider; be a non-participating provider; or opt out of Medicare entirely," the notice continued.

The looming pay cut is actually two cuts. The first, at 4.47%, reflected in the 2023 Physician Fee Schedule, stems from a policy change several years ago that increased payments for physicians who submitted claims for services involving evaluation and management of patients -- so-called E&M codes -- as opposed to procedural services. The Medicare Physician Fee Schedule must be budget-neutral, so if one group of doctors who perform E&M services gets paid more, another group that performs different services gets paid less.
Lawmakers ultimately found the money to forestall the cuts that would have come in later years, until now. But for 2023, with a lame-duck Congress, nothing has been passed, although Resneck and others hope that H.R.8800, the Supporting Medicare Providers Act of 2022, will alleviate this part of the cut.
The other cut, amounting to 4%, comes from a complicated statutory rule called the PAYGO sequester. Doctors hope Congress will find a way to reduce this cut as well.

Hanging On
In Texas, as well as many other states, some private-practice physicians are barely hanging on after last year's round of cuts, and some nearing retirement are reconsidering their future, including Houston-area ophthalmologist Kathleen Archer, MD, who specializes in oculofacial plastic and reconstructive surgery.
She lamented how Medicare's reimbursement for the supplies and services she needs barely keeps up with her costs in treating patients with migraine or facial spasms. For each vial of Botox, for example, Medicare pays her $23.20 less than what it costs her, and that's just one of many examples.
"If they go ahead with [the proposed] 8.5% reduction, it'll be at the point that I'm losing money," she said. That, and her constant battles with insurance companies, has put her on the verge of thinking it's not worth it to continue. "I'm coming up on 68 years old ... and I know doctors my age -- some older and some a little bit younger -- are basically saying, 'I just can't put up with this anymore.' They're leaving medicine."

Doctor Shortage
With doctors -- especially those who are older -- leaving medicine without replacements, the country will soon be faced with a shortage of doctors who will see Medicare patients.
Some doctors are putting caps on the number of beneficiaries they will accept in their panels, and many are now telling long-standing patients to find another physician. Some physicians said they are already seeing this happen to members of their own family.
One California physician said his wife, who recently turned 65 and needed to get a pap smear, has been turned away by four ob/gyn physicians who said they're just not accepting new traditional fee-for-service Medicare patients, which he called scary.
In New York, neurologist David Podwall, MD, president of the Nassau County Medical Society, finds it ironic. "At a time where we have this huge need for physicians, you try to call any doctor's office and you'll find a huge wait -- all across the country, and this [cut] is not going to make that any better."

"A lot of physicians are going to decide that this is the time to close up shop. Retire. And we already saw a lot of that during COVID," he added. "I think we're feeling beaten down. Everyone has had a tough time during COVID. Cutting their pay by 8.5%, that's not exactly the way you thank the people who stepped up."
Other sectors in the healthcare industry, such as hospitals and nursing homes, have gotten pay increases. "But the only group that's getting cut in healthcare is the physicians," Podwall said.
Restructure the System?
Doctors interviewed by MedPage Today want the entire structure of how physicians get paid to change. Rates now have nothing to do with the value of the medical services provided, but by obscure policies and budget formulas bound by conversion factors, sequestration rules, and PAYGO, they said.
"Every year, it's like this mishmash of factors that determine what Medicare pays physicians," Podwall said. "A business will say, 'I'm going to pay you based on the value of what you provide.' But that's not part of these [physician payment] equations. They're based on things that have nothing to do with medicine, like sequestration."

Gary Floyd, MD, president of the Texas Medical Association, said these proposed cuts "couldn't come at a worse time. Doctors are just now coming out of the pandemic, when office visits were way down. A lot of physicians had to dip into their own private funds to keep their offices running and keep their employees paid, and buy personal protective equipment," which costs more than what federal relief funds provided.
The Medicare payment system "is totally messed up" and needs a total overhaul, Floyd said. "Hospitals, insurance companies, the government makes an adjustment for inflation ... Physicians face the same thing ... and yet they cut our revenue."
"Every year, we have begged, and Congress has found monies to put in the budget to forego that. And we're hoping that will be the case this time," he added.
"


"It is not just about Physicians. You have to ask how much longer our medical system can last while it allows big corporate health insurers to over charge the Medicare by paying doctors to enhance their diagnosis so the system will pay more, and at the same time, increasing the costs to the Medicare patients and reducing payments to the frontline health providers. Add to that patients waiting weeks to get advanced diagnostic appointments and months to see specialists. I do not blame it on the medical providers, or the patients. Both sides of our medical system have good reason to complain. I do not understand why CMS is allowing the insurers to use illegal steps to over charge Medicare, underserve Patients, and treat their medical staff as if they workers on assembly line who are treating manufactured objects that are identical in their needs rather than individual that they are. It all comes down to greed. Greed that short changes everyone except those at the very top of society. We spend more on healthcare than any other rich industrial Country and yet come in last in quality and outcomes. I do not see that changing anytime soon. CMS knows that Advantage plans have been stealing money for years. They know they are breaking rules about wait times and over charging to patients and other things that will get a few more pennies in their pockets and yet bad behavior continue; I would bet people are dying from long waits and bad medical care. Its all "Unprecedented" and "Unconscionable."

"

 

[Karl_K]

Had another covid delay in care again.
The hospital is increasing pulmonologist coverage again like they did during covid peak so they are rescheduling clinic appointments.
My yearly appointment in march has been moved back.
I won't be suprised if it gets moved more than once.

 

[missy]

Had another covid delay in care again.
The hospital is increasing pulmonologist coverage again like they did during covid peak so they are rescheduling clinic appointments.
My yearly appointment in march has been moved back.
I won't be suprised if it gets moved more than once.

Sorry to hear this Karl and hopefully it won';t further delay care for you

This might be part of the reason why hospitals are becoming overwhelmed again

"

Rising Flu Cases Drive Up US Hospitalizations, CDC Says​

By Susan Heavey and Caroline Humer
December 06, 2022




WASHINGTON (Reuters) - The United States is experiencing the highest levels of hospitalizations from influenza that it has seen in a decade for this time of year, the head of the U.S. Centers for Disease Control and Prevention (CDC) said on Monday, adding that 14 children have died so far this flu season.
CDC Director Rochelle Walensky added that U.S. hospital systems also continue to be stressed with a high number of patients with other respiratory illnesses such as respiratory syncytial virus (RSV) and COVID-19.
There have been at least 8.7 million illnesses, 78,000 hospitalizations, and 4,500 deaths from flu so far this season, according to CDC estimates. It urged people to get vaccinated.
"Especially for RSV and flu, these levels are higher than we generally see this time of year," Walensky told reporters in a telephone news briefing. She said flu season started earlier and "hospitalizations for flu continue to be the highest we have seen at this time of year in a decade."

Respiratory viruses are spreading as people gather indoors due to the colder weather. People also likely have weakened defenses after not being exposed to flu and RSV while working or schooling from home during the COVID-19 pandemic.




Vaccination rates for people at higher risk from the flu - those 65 and older, children and pregnant women - are also lower than at this time last year, Walensky added.
About 12% fewer pregnant women have been vaccinated so far this season compared to last season, and about 5% fewer children, Walensky said.
Between Oct. 1 and Nov. 26, the rate of hospitalization for flu in the United States was 16.6 per 100,000 people. In the past 10 years, the cumulative rate during the same week of the year typically range from 0.1 to 2 per 100,000.

COVID-19 cases have risen following the Thanksgiving holiday and COVID-related hospitalizations have also increased about 15% to 20% over the last week, Walensky said.
Walensky, joined by Dr. Sandra Fryhofer, an internist who chairs the American Medical Association board, urged people to get flu shots now - despite possibly being wary or tired of vaccinations - saying it was not too late.
"This year's flu season's off to a rough start," Fryhofer said. "It started early, and with COVID and RSV also circulating, it's a perfect storm for a terrible holiday season."
(Reporting by Susan Heavey and Caroline Humer; Editing by Bill Berkrot)
:

 

[missy]

Just a brief interruption for some levity. I know some of you get this all too well unfortunately

 

[FL_runner]

Just a brief interruption for some levity. I know some of you get this all too well unfortunately

I have been losing my mind with this lately! Because of where I work most of my patient have the same insurance, and recently there has been a policy change and LOTS of the boring generic medications I order are suddenly requiring prior authorization paperwork. I fill everything out perfectly, the patients need the meds, and I’m a sub specialist. But they keep getting sent back! Then I have to call back and argue with someone who isn’t even working in clinical care and definitely not in my field. I HATE it because it delays care and is super annoying for the patients and it wastes my time. And they probably think I don’t care about them
it’s one of the things that annoys me the most right now in clinical medicine.

 

[missy]

I have been losing my mind with this lately! Because of where I work most of my patient have the same insurance, and recently there has been a policy change and LOTS of the boring generic medications I order are suddenly requiring prior authorization paperwork. I fill everything out perfectly, the patients need the meds, and I’m a sub specialist. But they keep getting sent back! Then I have to call back and argue with someone who isn’t even working in clinical care and definitely not in my field. I HATE it because it delays care and is super annoying for the patients and it wastes my time. And they probably think I don’t care about the

I feel your pain. It’s a game the insurance companies play.
One: delay delay delay.
And two: they hope (and some will) we’ll give up
Its unconscionable imo.
Healthcare delayed is healthcare denied for many.

The physicians in conjunction with their patients should be the ones to decide if a medication is right for each individual. Not health insurance companies who have an ulterior motive

 

[FL_runner]

I feel your pain. It’s a game the insurance companies play.
One: delay delay delay.
And two: they hope (and some will) we’ll give up
Its unconscionable imo.
Healthcare delayed is healthcare denied for many.

The physicians in conjunction with their patients should be the ones to decide if a medication is right for each individual. Not health insurance companies who have an ulterior motive

It would help if I had a medical assistant or nurse to help me with the insurance fight but we are chronically short staffed. I didn’t have any support staff at all for a few weeks last month!

Edited to add: the administrators asked me to add more appointments even though I’m at 100% of required capacity… would be easier to do if we had staffing (sigh).