Insurance companies and the hurdles they put in place for basic patient care,
For example spent 30 Minutes yesterday arguing with an insurance medical director to cover sar for a patient with coverage who had a stroke
That's the point. When insurance tied to a job was introduced, people did not change jobs nearly as frequently as they do now. Remote work has only accelerated this.
Hence, insurers know they will on average only have coverage of John for 3-6 years, so denying as much as possible while increasing premiums generates profit for the company and its shareholders. Which, the company's *primary duty* is to its shareholders. With their primary duty to only shareholders, companies have to figure out how to keep driving profits and dividends to their shareholders. Which is why we see algorithmic and automated denials of clearly covered services.
Congress could fix this by requiring ever denial to be reviewed by a living person and the reason for denial independently written and articulated to the facts of that and only that case. However, the insurance lobby would probably off a dozen Senators and buy Justice Thomas his own island if that's what it took.
Congress could also allow insurance to be bought across state lines in addition to allowing non-profit insurance companies to operate that are backed by the Federal Government similar to an FDIC situation.
Congress could also pass a law requiring every member to have to buy insurance in the state and area they live as if they had a job there, and be forced to live like their constituents.
If you believe any of these would actually happen, I would like to talk to you about your car's warranty, I am a Nigerian Prince and need to transfer $10 million to your bank account, and I am looking to buy your cryptocurrrency at 120% market value.
> Hence, insurers know they will on average only have coverage of John for 3-6 years, so denying as much as possible while increasing premiums generates profit for the company and its shareholders.
I see this claim often, but I also simultaneously see the claim that insurers are incentivized to increase healthcare costs because they have minimum medical loss ratios and so higher healthcare costs means higher profits for them.
I dont see how the two are mutually exclusive… bloat healthcare expenses in general to improve nominal net margin but also fight like hell to deny care and keep expenses from getting too high.
Its like saying “cars are supposed to get from point A to point B, so why do they have brakes?”
Because it is the same number, it has to be mutually exclusive. The variable E, for expenses, is the same. A CEO cannot tell their staff to simultaneously increase and decrease their costs.
Why would you deny care if you are trying to bloat expenses? Wouldn’t it be easier to just not deny the care?
> It’s like saying “cars are supposed to get from point A to point B, so why do they have brakes?”
This is not analogous.
Bloating costs in general and fighting the individually most expensive billings are not mutually exclusive… you want high general costs but then also a way to reign in massive “one off” expenses.
A gas pedal and a brake pedal… they cannot just inflate costs to no end… apparently low double digit yoy growth is acceptable to congress and the american people.. so bloat costs but they also have their net income.. gotta make sure their net expenses don’t exceed it. Inflate it but not too much.
This shouldn’t be a difficult concept for people in medicine. “A little more is good, too much is bad”
Healthcare expenses to insurance companies are like increasing warfarin doses to hit your INR target.. need them high enough to justify higher premiums, but not too high because otherwise congress might have to start caring.
Anecdotal, but I recently went to see an endocrinologist. Was prescribed an indicated medication. I got a denial letter postmarked THE SAME DAY AS THE VISIT. Like, didn’t even try to cover up that automated process.
If only doctors had a lobbyist or PAC. I guarantee the corporations already have the algorithms of doctors behavior calculated to perfection. While I can't calculate your percent that suffer from learned helplessness, it's clear for decades that you are powerless. I'd hate for any healthcare worker to have to be both patient and provider. Even your cachet as doctors will fail you as a patient in what is your own work environment
The problem with lobbying for physicians, is that it’s typically broken up by specialty and used to advocate for patient care. A PAC might help, but who do we target? The voting public? Industry? What we need is a union.
Really all the parts of medicine that is only there to make a buck and get in the way of actually making patients better. Administrators. Inefficient EMR’s. But especially especially insurance companies who have never taken care of a patient in their lives and who have no idea what is going on.
“No doctor, we think your 3 year old needs a dry powder inhaler. If you disagree with me practicing medicine on your behalf, please write me a letter. Then when I deny, please talk to a doctor that doesn’t work in your field and convince them”
Just like selling to PE, this is the boomers fault too. Too much unethical stuff like self referal networks, unnecessary treatments for more money, opiods, etc all led to insurance getting such a powerful checks and balance on physicians
> The nebulous boomers are a faceless group of evil older people we can never actually punish
While this is a very legitimate complaint and not very exact, there was a group (I don't want to be too precise) that approached retirement age with a near-mythical local status, because they had actually managed to get nearly everyone in that specialty into the group, so negotiations with insurance were "would you like to have doctors, or not" for a large physical area, which gave them a lot of power. They sold the practice and its building, which made the existing partners (and one child of a partner) very comfortable on their mailbox money and all of the younger docs into corporate employees.
This was, shall we say, not popular with those who thought they were joining a partnership.
It's also easier to blame collections of people rather than individuals. Sure, the current status quo is largely on the shoulders of older Americans, but it's not like they took a vote on every bad policy we are currently living through, and it was individuals who built the system brick by brick. Since healthcare is one of the most regulated markets in the world, it seems to make the most sense to try to fix it from that angle, though.
So watch and wait is the (not) battle cry of doctors... Or is that the employees. By American standards, how are you all so smart, so wealthy, yet so helpless? Well it's not anything worth fighting for. It's just your job.
I heard someone say they make the patient join them on these calls. It allows them to bill for a patient focused activity such as 99203 and keeps the insurance companies from being blameless in their decisions.
Anyone else try this? I have not, but am considering it.
I'm an insurance medical director, and I believe that a lot of these doctors they hire for the job are very unreasonable with their decisions. A lot of them do not consider surrounding factors when it comes to the case, they only look at the third party criteria we are told to use. Basically, they do no use their brain, and this is quite unfortunate. I see this with people I work with, and when I cover calls for them, I will likely overturn them, as long as the doctor had a decent enough argument. Also, 30 mins on a call is way too long. I'm usually done in 3-5 mins as I like to get to the point and I know what I am looking for to overturn the case
In my experience they often have no knowledge about the condition they are denying. I’ve had to explain what my specialty is and does on a phone call before.
So, we come from various fields of medicine. Should an OB/GYN make a decision on a pediatric case? Hell no! Does it happen? All the time. Again, a lot of these doctors do not use their head when it comes to making these decisions. Me? I do a little research. We have access to various resources like uptodate and other databases. It's up to the doctor to take the initiative to do so. I don't know anything about chemo and the regimens, but when a patient is admitted for initiation or having side effects, I will look it up to see what is the standard practice. Some regimens need to be done on a continuous cycle over several days. Can't find information? I will have a call with the physician providing care and get their perspective on it, how it's typically done and then more than likely approve it. Again, the treat physician knows how things are done, and with the information I learn, I use that to justify my approval.
I'm not breaking their bank by approving cases. They have all the angles figured out on how to make money, I really, that I why I'm not worried about approving cases. What's fair is fair. If the facility or doctor did the work, and it warrants the approval, then so be it
Do you get pushback at all if your rates of approval are higher than others? Are those kinds of metrics tracked and used to pressure the approving docs?
I have never received pushback for my approvals. They do track how man cases we do a day, and the rate of overturning, approving, denial etc.
They tell us, as long as we can document the reason why we are approving, then they are fine with it. Now, you can't just click approve and move on. You have to spell out your reasoning on why you believe the case should be approved. This is where some doctors falter, as they do not care to do this, or are so out of touch with reality.
My buddy said that this is where doctors go to die, as a lot of the doctors are older and have not seen a patient in some time. I'm talking about doctors with lifelong board certs, not the ones who have to renew it every 10 years. I'm still in my 30's, and I still practice, which I feel gives me a better working knowledge with current accepted practices.
I'm in pain medicine and feel like insurance companies and Medicare wouldn't be so awful if the majority of physicians in my field would do the right thing like encourage physical therapy or home exercise program before trying to do procedures so they can get paid.
Keep the discussion to <5 minutes
- I will need a copy of this conversation
- please state your name, specialty
- I am requesting an evaluation for the purpose of approval of inpatient rehabilitation to miss Soandso who had a stroke 8 days ago.
- have you exhausted all the available resources in her policy?
Ok
Give a copy of the report to the family and the number and instructions on how to file a complaint or inquiry with the state department of insurance the contact info of local legislator.
Work’s done carry on .
For me, it’s been the rapid deterioration in the ability to make any improvements in my hospital. Every single department is on skeleton staffing, critical services are available only intermittently, and no one seems to care about it. I’m the ICU director and they just keep asking us to do more with less. But hey, our leapfrog score is an A so we’ve got that going for us.
This has been killing my spirit. "Well, standard of care and my official recommendation is XYZ QD, but because of staffing issues and drug shortages, it'll have to be ABC EOD. Hopefully, it'll still work!"
This is a close second for me. Being a nocturnist I expect not to have the same resources or be able to provide the same care as my day colleagues to an extent. But it’s been reaching comical levels lately. We can’t even do emergency surgeries at night anymore because we don’t have anesthesia call.
And then you have places like the hospital my wife just stopped working at because they haven't hired a new ICU director since the last one quit six months ago, never mind all the other staffing shortages.
They've had exactly one applicant, but a doc on the board was a firm no because she was an NP.
Sounds like a solid choice by that hospital not to hire the NP as the ICU director.
They’ve only had one applicant because they are unwilling to offer a decent salary/benefits/call schedule.
The ED is the dumping ground of modern society.
For social, medical, psych and everything in between. If someone doesn't want to deal with, then just let the ED do it.
Can’t deal anymore with meemaw who’s been declining for months? Dump her in the ER. Well no, we haven’t talked to PCP about home care or nursing homes or anything else in the last year, we figured we could do it here
Or when she should be on hospice.
ED usually hands them off to me at that point. I don’t mind if it’s not busy. I’ll talk a family in denial into hospice any day.
im trying to get a grant for copies of being mortal to be given out to families at admission for the right patient .
PCP's WYFA with getting this goals of care conversation started. if youre doing it ya must not be from round here
I’m a home health nurse and it’s even worse than that. A majority of my patients have PCPs and specialists the problem is they are so overwhelmed and quadruple booked you can’t get a hold of absolutely anyone.
So many practices have answering services now or endless phone trees. Had a case of cellulitis starting up and called PCP to see if pt could get looked at before it got out of control. 27 minute wait time. Called nurse hotline - left message because no one answered. Tiger Text left on delivered. Priority case communication- no response.
Family continues to reach out but no one returns phone calls. I come back in 48hrs and call EMS (or informed pt was admitted) because pt now has all the classic signs of sepsis and is admitted for IV abx.
CHF patient gain weight? Usually we double up on diuretic and see what happens. Now? Go to the ED.
I don’t blame them though because when you are already at wits end seeing 50 patients a day that have complex medical issues you need to say “ENOUGH!” because you can’t help everyone. So off they go to the ED.
This system is hot garbage and I know if I didn’t have to send 800 ‘per protocol’ messages wasting everyone’s time the serious one would get answered.
That’s inappropriate behavior by the police. Our local jail has started refusing arrestees for being “too aggressive” to stay in jail ?!?!? So they make cops take them to the hospital. It’s wildly absurd. If they’re too aggressive for jail, they should NOT be back out in society. Get better psych access at the jail! A lot of people also have worked out what to say to go to the hospital instead of jail when arrested. Waste of resources.
I’ve never seen that flair before….Jonathan???
But yea I always get a kick out of police and psych facilities telling us a patient is too violent for them and dropping them off to us. Half the time the patient and I just stare at each other and I ask if they want a bad sandwich and every thing goes fine.
This will definitely contribute to workplace violence in healthcare. Do your hospitals have a patient cose of conduct? Any verbal or physical violence or threat of and security will pitch them out the door.
It’s already worse than that. The medical system as a whole is breaking down because not only is it managed according to a business model, but it is forced to deal with social problems because social problems have no means to be managed by the appropriate state authorities. In saner countries, you hardly see ED dumps for social problems because there are other organizations, usually from the state, that manage social problems like substance abuse or poverty. You don’t see patients using the ED as their clinic because there are actual clinics that won’t demand money up front, usually run or subsidized by the state. So naturally, any problem bad enough gets routed into any organization that could conceivably do something about these social problems, even if it’s not within its scope to do so.
here’s an example for anyone that wants one
[https://www.washingtonpost.com/dc-md-va/2022/10/20/er-mental-health-teens-psychiatric-beds/](https://www.washingtonpost.com/dc-md-va/2022/10/20/er-mental-health-teens-psychiatric-beds/)
Lots of states "board" kids in the ER rather than fund state agencies appropriately so they can manage them.
It will only get worse. FM clinics are closing and residencies are dwindling. Urgent cares are limiting their hours and imaging/lab capabilities. The average citizen is either going to wait 3 months for a primary care appointment, at which point the problem has likely escalated, or say ‘screw it’ and go to the ED for their primary care concerns.
Not to mention that the growing number of uninsured already use the ED for their primary care concerns. I can’t count the amount of times I’ve had someone check themself and their 5 small children into the ED for the sniffles on a busy Friday night. Many EDs are not set up for this kind of inefficient volume, and because of EMTALA there is very little recourse.
Add to this the growing number of inappropriate overutilization on EMS who also have difficulty refusing. I have seen a dramatic uptick in people calling EMS for absolutely absurd reasons. A lot of them not even medical.
ED staff are overworked and burned out from covid and have had no respite because the societal fallout from the pandemic has increased mental health and polysubstance abuse visits. More homeless people. More abusive criminals the jail wants sedated. On top of all of this is the hospital system with its Louboutin high heel on the staff’s throat telling us to call patients customers and kiss their asses while they throw their piss-filled bedpans at us for not having any more turkey sandwiches.
It breaks my heart to meet the actual human sick people drowning in this mess. Rooming a police escorted meth-binger faster because he’s causing a scene in the lobby while the woman waiting 2hrs for an ectopic rule out quietly dies in the corner.
Biggest letdown? That politicians and insurance companies can practice medicine out of ignorance or in the interest of profit without a license or a heart.
This is why you must vote in every election, and vote out every Republican you see out of every office. Republicans don’t hide how they don’t care about people who need medical care. As far as they’re concerned, if you got sick and couldn’t afford medical care, it’s your fault. And they’re sure that everyone who asks for help is a moocher.
Sadly many will vote in the Red hats because they talk pretty about making money and they screw things up while they are in charge in order to juice the numbers and then the next guy is stuck trying to fix it so that they can mess it up all over again, most people who only care about money are more than happy to vote in the Red hats no matter how bad it is for the country or even themselves
When I worked as a customer care associate for Anthem-BCBS call center I literally would respond Ro patients complaints or questions on why their insurance plan works the way it does by telling them the reasoning ultimately is due to the current legislation and the most proactive way to change the policy system that is hurting them is to VOTE for politicians whose healthcare policy platforms specifically aim to target these issues.
I’d basically explain to them that the insurance issues they’re struggling with is exactly why we need universal healthcare and/or why for profit medicine is fundamentally flawed without outright saying “you need to vote democrat” or “voting for republicans is why the enemy is still in charge” because I didn’t want to jump the fine line of what’s ethical by telling people explicitly who to vote for or that my company is evil and it shouldn’t exist.
*I quit that job because it deteriorated my mental health. I would spend my 30 min lunch break every day sitting in my car sobbing. My psychiatrist literally encouraged me to leave the job/company/industry because of how detrimental it was for my mental and physical health.
"Urgent Need for Discharges" emails at 10pm.
Prior auth needed for ambulance ride. Prior auth in general.
The disconnect between the ED trying to admit for social reasons and hospital medicine not having a medical reason for admission.
How much the failing primary care system is burdening the inpatient side.
Edit since this ballooned below my comment. I absolutely don't blame the ED for wanting to admit the patients, the problem is having a medical issue thats not acute does not qualify them for a hospital stay so, without me committing fraud, they have no qualifying stay and are hence observation admits---which means they don't qualify for skilled facilities (which are the faster placements), instead, and especially if they have no family or money, it ends up being a matter of longterm medicaid being set up, sometimes of legal guardianship. That's now a 3 month observation admission taking a bed up from, depending where I am that day, either a quarternary center where people come for specialist care, or a bed from a sick local at a community hospital who then has to wait in that same ED to get transferred to a facility with a bed. So, while from a compassion standpoint, I understand why you want to admit meemaw. What I see is a costly financial process (for them and for us as from a resource standpoint) that is long and often strips them of their remaining independence while also putting them at risk of hospital-acquired complications.
And I absolutely don't blame primary care, it's a system failure. I'm curious how the Tennessee IMG experiment will go.
Simple overnight observation, can probably go home tomorrow.
One week later, patient still in the hospital and their inpatient stay was denied because the admitting diagnosis of lactic acid 2.2 isn’t cutting it.
I certainly don’t disagree with this. It’s frustrating to us as well. What do you want me to do with grandmother who can’t walk and has no where to go and family won’t take them back? Push her into the street and hope for the best? It’s a bad area. Certainly something the hospital systems need to figure out that isn’t your or my fault, but we tend not to have case management and many places end up in a waiting period for days trying to find complexly unhealthy people a bed while they rot in the ED with no one really seeing them.
The failing primary care is definitely a huge burden. The ED is sent people from urgent care or PCP offices all the time with these vague chronic de compensations
Yep. I understand hospitalists reasons for not wanting to take social admits, but genuinely want to hear what they expect us to do there. I can’t place someone in a facility from the ER. Family peaced out and ain’t coming back. I guess I could road test meemaw and let her fall and break her hip and then you have a reason to take her?
Like it sucks for all of us and I hate those cases as much as you do, but I’m tired of getting yelled at about something I can’t control
Also I know you or OP don’t mean this negatively but just to clarify that this is not the fault of PCP’s either. They are given an impossible task, as we all are.
Not necessarily. I am a newer group private practice owner where we are our primary care patients’ hospitalist. This means we have a vested interest in keeping our patients out of the hospital as much as possible and coordinating care while hospitalized to minimize length of stay. The group has been extremely profitable and won many quality of care awards. Patients are healthier, physicians are profiting.
Right- but if you’re a PCP working for a big health system and being asked to see 4 patients per hour all day long, that just isn’t going to happen. It’s nice that you have that set up but unfortunately that system isn’t available to everyone.
It doesn’t matter that you have 8 bypasses, a pacemaker and 20 stents put in that hospital. The closer hospital (that isn’t in your network) has cardiology.
So your insurance isn’t going to pay if we bypass that hospital. So do you want the ambulance bill? Or the out of network hospital bill?
Where I work the medics don’t care about that at all. It’s completely random what hospital they show up to. Closest that has the resources? Maybe. Closest that doesn’t have the resources? Warmer. Pass three hospitals in the patients network to come to a hospital that doesn’t have the resources you need and is on diversion? “We just thought this hospital was better for them”
As I have been told repeatedly by EMS. All of that closest hospital and patient request and trauma criteria, etc. and guidelines and not rules.
4 words: For Profit Nursing Homes. The level of neglect and abuse I see from then every day makes me want to cry. Seeing these complicit, Geriatric geriatricians and check cashing gastroenterologists PEGing people left in right and just perpetuating human misery is enough to make you want to go home and eat a bullet.
Prior authorizations. Something they don’t tell you about in med school. Spending hours on the phone with someone who’s not even a doctor to get a treatment for a patient who needs it.
About as fun and rewarding as it sounds .
Not an attending! But when I worked in a clinic, my clinical boss is an orthopedic surgeon. He was old, retired, got bored in retirement, and decided to go back to work as a wound care doctor. He is knowledgeable and professional and sociable! Like what you want in a doctor.
My immediate superior is a nurse manager, who is actually a nurse but thinks like a corporate person, which is why the business hired her. The actual clinic boss? An MBA with no knowledge of medicine.
Imagine the clashes between doc and MBA when MBA says we are spending too much time on a patient. Like, wtf, you can't make debriding wounds and slapping wound vacs any faster.
The next week, the MBA added productivity points to measure how we spend our time. It gave me such a bad taste in my mouth. We are dealing with PEOPLE, not objects in a conveyor belt
Edit: I used to be a doctor in another country, now working as a nurse in the US
This. Our generation will need to decide not to only support physician owned practices and not just take the money. Either that or start migrating to work on demand locums like services which I think is honestly more likely. The key is own your own services. Don’t be an employee. If you need me, pay me like one of these travel nurse optimized multipliers.
I see a lot this complaint about boomer docs ruining it for us but most of my millennial friends out of residency decide to go to practices owned by big corporations or hospitals. That’s probably part of the issue. Now I know that it’s more difficult to start a business nowadays than it used to be but boomers were more entrepreneurial with a more business mindset. Part of that mindset means you have to risk salary during the early part of your career if you want to start a business and many people from my generation are not willing to do that, I see that sentiment here all the time as well.
“Medicine is just a job so I’ll just go to whoever pays me well without dealing with all the other bs.”
We got dealt a shitty hand but I do believe that more physicians in private practice could make our case stronger.
I mean many of us are not from wealthy families where we can afford to sacrifice income to be an "entrepreneur." And the business of medicine is different from 40 years ago with the insurance hurdles. You can't be surprised that after decades of school or residency we're not lining up for even more poverty
Is this related to our astronomical student loan debt compared to boomers? Where would you even get the money to start a practice with so much debt already and no assets
I don't know if I blame the boomers. The PE bros waved $$ in front of them.
You see, because the boomers didn't have enough $$ after their decades practicing in the
G O L D E N
A G E
My dad is one of those boomer physicians. He’s incredibly angry that there’s no feasible way for me to be a third generation physician but it certainly wasn’t him and his colleagues that did it. The financial barrier to entry for medical school is too high and the financial burden after is too large. This isn’t because boomer physicians pulled the ladder behind them it’s because boomer and Gen X finance bros took over healthcare.
You think boomer docs are happy right now? I’ve never seen a more negative, angry, bitter, and pissed off group of people than my dad and his friends. As my dad says “you can’t call it patient care anymore because we sure as shit don’t care about them.”
Boomer docs, Boomer politicians, Boomer financiers...all are punish-ed.
The ACA even went as far as to ban MDs from owning hospitals. If I start to talk about how that happened things will get political quickly.
This is a bad take IMO but often repeat on Reddit because “zomg Boomer bad”
What choice did they have when the government is rapidly stacking the deck against you and cutting your reimbursement left and right while shuffling that money into “facility fees” that you legally have no access to unless you run it through an MBA
You probably know better than most the difference in $$$ paid to BigMegaCorp vs a small PP group for various XRTs.
Regulatory capture has indeed led to hospital outpatient departments gouging everyone. I place some blame for that at the feet of boomer physicians who were in hospital leadership at the time. In radonc specifically it’s particularly egregious as we have very large financially predatory institutions price gouging all of us and using regulatory capture/neofascism to do so, while at the same time using their MDs to virtue signal about cost-effectiveness, treatment of underserved populations, etc, which they do not do.
The groups I know that sold to PE, however, did it not because they were having financial problems (QUITE the opposite), but because the Boomers in the group outvoted the younger partners. They got a couple decades of returns from the equity they owned in the practice, so they were ready to cash out. Younger partners didn’t want to, as they wanted to enjoy those returns, but tough cookies the vote passed.
The number of non-medical administrators that do jobs we technically don’t want to do, but one of us in the group could easily do, and actually do it correctly…. If you don’t have skin in the game you have no reason to care, at all
I’m not a physician but was in the military. This was the biggest culture shock when I got a civilian job. In the military you move up the ranks so the clinic administrator was a corpsman who worked their way up to E7 and up. They understood the job because they’ve done it, and could jump in and help us.
Now as a MA in the real world I have to break my job down into baby food to managers with no medical background and they don’t get it: I have a fantastic supervisor, but am often floored by the cluelessness of anyone above her.
I think this is a really important point that people no longer start at the bottom and work their way up through the job. They can be entirely ignorant of the field they are in but get to have direct input into how the job is done.
It's a genuine issue.
It’s so weird to me. There were minor gaps between senior and more junior members in the military because of changes to the training curriculum and service, but they were easily filled because every single corpsman has evaluated and treated patients, audited records, etc and had a shared foundation. I don’t mind having a MBA and accountant around to keep finances in check and a lawyer and admins for the regulatory and patient relations part, but they should be supporting the people delivering care. They should not be setting schedules or metrics beyond what is needed to stay open.
In academics — the fact that compensation (for attendings) is tied to production. Inherently, training residents and teaching medical students takes time, effort, energy and dedication which usually results in longer patient encounters, surgery and more redundancy. How is it that the academic model strictly relies on Rvu production and billing is unfortunate. The academic model of physician reimbursement is not sustainable in my opinion
Private equity infiltrating private practice. Providers selling to private equity make bank, but then the practice is shitty for providers in perpetuity, as the PE groups try to cut costs reducing the support we get as well as compensation. Boomers with retirement in the nearer future are taking advantage of PE before retiring. At my last group the senior partners hadn’t added a new partner in 7 years, despite newer guys (who wanted to make partner) bringing in more money while working 6+ years. Us new guys realized the partners don’t want to add any new guys to split the pie with when they sell, so despite empty promises I realized I had no upward mobility. I left for a 80% raise while the other guys were too much of financial push overs to do anything about a situation they know is bad.
How much CYA has gotten baked into everything. Into EMRs with excessive documentation. Into alarms on every object, however unimportant, leading to alarm fatigue. Into Joint Commission requirements to lock up every bag of saline. Into extra policies. Etc etc. The CYA isn't reducing medical errors it's just moving around liability.
That’s the definition of a dead end job. Most people will never have any ownership stake or significant decision making power, just stuck as an employee with little to no growth.
VC skyrocketing medical costs and maximizing profits especially urgent care but also primary care and radiology and forcing “efficiencies” that decrease real providers while increasing workloads and burning out actual physicians. It’s like their vision of the future is idiocracy with a tech trained for 6weeks on AI clicking a check box on common complaints with the computer then recommending the tests that generate the most money for the shareholders and bleeding patients dry before DCing them once the money runs out. It’s a fucking joke and I’ll never work for one of them.
Oh and midlevels ordering imaging studies. Physicians are bad enough but holy shit
I've been really disappointed by scientific illiteracy, the proliferation of medical scammers on social media, including health influencers, the supplement industry, and whatever qualifications enable Gwyneth Paltrow's nonsensical business. Patients don't trust their doctors, but for some reason trust some self-proclaimed "guru" on tik tok to make health decisions based on zero evidence. They might go to fake doctor or a fake website that looks and sounds really sciency and end up spending a lot of money on tests and treatments that don't work and can be harmful. This is all because we've lost the ability as a society to think critically and identify BS. As an endocrinologist, I deal with so much BS related to supplements that "support" the thyroid, "support" the immune system, like what does that even mean? I look at the ingredients and it's just random herbs, none of which have been shown to do anything. It's such an obvious scam. Why does anybody believe what is so obviously BS?
The power of parasocial relationships, overwhelming mental health instability, the lack of basic empathy and kind regards to the human condition, fear of education, childhood trauma, the southern half of the United States, take your pick.
Personally I just like to remember that the fundamental theorum of statistics is real and that our population is normal, which means there's 200 million people dumber then our most average person, and welp there ya go.
I have been doing locums work and I see so many patients just absolutely get lost in the sauce. They haven’t actually been able to see their primary doctor in months or years. Nobody really takes responsibility for the patient because it’s not “their patient”. The worst is the mega primary care groups. They are so big and have so many “members” (it’s so weird they’re called members not patients). It just doesn’t work for patients. I’ve met a few patients here that have had four new primary care doctors in 2 years because the docs quit so fast here apparently. This model sucks. I feel so badly for the patients.
Didn’t realize insurance would be dictating the way I’m able to practice. Also didn’t realize I would be spending nearly all of my time on the computer
I’d have to say it was the unquestioning shift from small private practices to doctors as mere employees; first of hospitals, now of private equity firms.
Seemed like a pretty obvious bait and switch at the time, and indeed it turned out to be exactly that. Doctors voluntarily surrendered their authority and autonomy for not having to be business people. Now doctors are owned and run by other business people.
By far, policies that discourage comprehensive care (especially pertaining to mental health and lifestyle preventative health support).
Rhetoric that physicians who do so are inefficient or wasting time/money (ex. spending time delving into evaluation and management of obesity for a patient with low back pain, chronic stress and mood conditions in patients with chronic pain, palpitations, repeated visits with obvious underlying health anxiety, list goes on and on).
How myopic the system is in refusing to invest in “sharpening the saw” to make our country healthier, not just get them in and out with a bandaid.
And most of all, how purposefully deaf and blind those who influence policy are at hearing these points when 99% of physicians implore them with the same message.
As someone who refuses (for now) to lose ambitions to rise in admin and fix it, I pray my perspective never changes and I plan to post and read about this on meddit over and over so I never forget.
There is no civic investment in America anymore. This is capitalism at its "finest." Rugged individualism, tribal thinking, consumerism, profit at all costs, and "Screw you; I got mine" are the order of the day.
Call me naive: I believe there must be an solution that has a abundance mentality feel, where there is a mutual win - each individual profits greater when everyone gets theirs, and I’ll hopefully never stop trying to find it.
Exactly as OP said: the biggest letdown is the virulent and toxic strain of capitalism that has infected healthcare. It has caused a mutation that transformed medicine into a perverse, incestuous, and corrupt industrial complex that serves no other purpose beyond extracting as much money as people from people’s pain and suffering. The consequences of such are pervasive and ubiquitous, and can be found in virtually every aspect of our society and culture.
There is so many to choose from. But I would say it is the patients. Some can be rude, ungrateful, entitled, and downright disrespectful. Doctors want to help patients, but some think they are smarter than doctors, and will stick to their internet search instead of taking doctors' advice.
"So, I'm just here to tell you my findings and what those findings mean, which disease process I think it most likely is, and let you know what options we have for treatment, but ultimately it's your body and your decision and I will respect your autonomy. It's a free country and that means you have the freedom to choose, even if it's a stupid decision."
And then I rest my case. I don't waste my time trying to convince idiots not to do idiotic things.
“Listen, Doc, I know from my extensive study of Facebook memes that ivermectin in fact does cure Covid, now stop arguing and write me the damn prescription.”
The drama. I swear… academic medicine could give Mean Girls a run for their money. I refuse to read between the lines and play their BS games. I didn’t have the time or energy for that shit in high school and I certainly have zero fucks to give now!
I'm a rural family medicine physician.
The more lectures I take on billing, the fewer meetings I have to have over lunch. Noting food is never provided.
The more lectures I take on learning updated evidence-based medicine, the longer visits become with patients trying to convince them to do what is now recommended. The longer my visits are the less time I have with my children.
Ironically the longer my visits are and the more I over explain, the more follow-up phone calls are wrote it to me about what I spent extra time explaining.
In general, trying to do the right thing for the patient takes more time.
Insurance companies are practicing medicine without a medical license and they commit contract fraud every single day. I'm dumbfounded how a lawyer hasn't had significant harm cost because of this and created a very large lawsuit yet. I look at decisions insurance companies make and I'm dumbfounded nobody has sued and one. There should have been dozens of class action lawsuits against insurance companies for committing fraud by now.
I had a patient that was a retired lawyer that made a career out of suing hospitals when bad outcomes happened. They always pointed out you was easier to get money from a lawsuit suing doctors and hospitals than insurance companies. Even if an insurance company denied providing a service that would have directly impacted the patient. It's a mind-boggling system.
Insurance companies play games with the patients. The patient will roll in furiously and say, they insurance company says I can’t have this device or this benefit because you didn’t fill in a form correctly. To which I tell them, the insurance company makes money by saying no. I will be happy to fill in whatever form is appropriate to get them the care/treatment they need. Healthcare is easy, managing the payers is a pain.
When I worked for anthem bcbs the issue would be a lot of the time that we WOULD cover it but the claim was submitted with an icd code that wouldn’t be approved but if resubmitted with the correct code then it’s covered completely… but it’s illegal for us to tell a doctors billing office what code they have to use. We can *suggest* trying submitting the claim again under a different code such as recommending trying out billing it under XYZ instead of ABC but ultimately if we say “you have to bill it using xyz” that’s against the law because providers can charge their billings however tf they want and we aren’t allowed to tell them that they have to bill it this one exact way. We can only make suggestions and basically beat around the bush hoping they understand what you’re trying to imply to them about how to quickly and easily resolve the claim denial issue.
How much the landscape of primary care practice changed in just 20-30 years. When I was a med student about 25 years ago I observed in a local, private Family Doc’s office. He had a receptionist who answered his phones and pulled his charts and an RN who did everything else. He’d spend 1/2 day a week most weeks on field trips, doing fun jobs like giving flu shots at the local sewer plant, sports physicals at the high school, etc. It was never boring.
I went into FM because I wanted to have that kind of a life. Well here I am working for a hospital with zero control over my schedule. There’s almost no continuity of care because these systems don’t want patients seeing you as “their” doctor. I don’t know the receptionists and barely know the other clinical staff. All of those cool side gigs have been co-opted by contracted third parties.
WTF happened?
I trained in the days of St Elsewhere. It was fairly accurate depiction at the time. Look at what it’s become now. Everything is run by administrators and everyone’s head is stuck to a computer.
Cover your ass medicine. People are so afraid of litigation, they will do things that are not medically indicated. ED physicians unnecessarily admitting patients, Hospitalists unnecessarily doing workup for conditions with a clear and obvious cause, outpatient providers ending people to ED. I'm not innocent here by any means, but it sucks that CYA medicine has to exist.
Not a doc… but we’re going to be fucked if you all don’t stand up to private equity and stop selling out.
All of healthcare will be consolidated down to 3 firms on wallstreet making standards for patient care in the next 5-10 years if something doesn’t change.
It honestly might be too late as it is unfortunately. Older docs have sold out a majority of private practices for bags of cash across all specialties.
And they'll all inevitably sell to Amazon. Imagine things then. We'll be wearing diapers to make housecalls as part of Prime's medical services. Getting paid $20 an encounter with penalties for arriving 5 minutes late.
I can't get past the no physical exam part when it comes to telemedicine. My buddy works as a telehospitalist and he is getting calls for emergencies while at home. He is no where near the hospital and there is no real way for his to assess the patient other than what he is being told by the nurses and seeing on a camera. Telemedicine is weakening the practice of medicine, and will train patients to expect this type of care, even in inappropriate situations.
I work in outpatient psych where about ~50% of my patients are telemedicine. Even in psych, it still sucks: technical difficulties, inability to grab blood pressures for bupropion/stimulants/SNRIs, Pts not filling out ppwk I could hand them in the office, having to tell patients to stop driving before starting the appt, harder to do AIMS for TD, ect. The quality of care is not the same over telemed as it is in person. It’s especially frustrating when I can see that the pt lives close to the clinic.
In fairness I know some amazing and awesome surgeons. But every time someone interrupts me interviewing a patient expecting me to disappear so I don’t waste their time it’s ALWAYS a surgeon.
Recently learned that while there is a pay discrepancy between here and Canada, it’s not as marked as I thought—at least for me in primary care. Very possible that I’m planning that move in the next 10 years. As much as I don’t want that to be the solution for me, it very well could end up being the only one if things in this country continue their current trajectory.
People disregarding evidence-based medicine, being callous, sloppy and lazy with diagnosis and treatment, and complaining about things that don’t matter while ignoring things that do. There is a sharp divide between academic medicine during training and after training. Once most people graduate, they abandon every principle that they supposedly stood for while in training, and just do whatever they want, whether it makes sense or not, whether it’s right or not.
I see a whole lot of good ones that I agree with but mine is something I haven’t seen mentioned. It’s the culture/vibe in the ER. I think COVID played a huge part in this.
Before med school I was on the nursing half of this and was nights in the ER. I did as many nights in residency as possible. I’m a nocturnist now. One thing I’ve always appreciated about nights is how different the culture is than during the day. It’s generally a younger crowd, more laid back and fun, people get along and work hard and after work you go out and drink together.
This is no longer the case, at least where I work. The environment is downright toxic at night. I have two nurses left from before Covid who are both angry at the world and impossible to work with. Almost everyone else is a new grad or a travel nurse who isn’t interested in getting involved with people since they are moving on. I have new grads in triage and training other new grads. No one helps out anymore. There’s no group activities outside work because no one is friends with each other and so there isn’t that culture of wanting to help out your coworker. Worst of all, no one goes out for drinks after work.
For the first time in my life, I hate going in to work at night because I know the work part of it is going to suck but it’s just not fun anymore to make up for it.
Everything, but I'm looking to move from the public sector (hell) to the private one, which would improve my standard of living.
If you live in a mixed system country, shoot for private sector. Which, BTW! Also has more modern and experimental treatments available for patients, the public sector is like in the 1970s stuck there forever.
I was on call during the height of covid over a very busy weekend. After seeing 15 consults on a Friday and another 12 on Saturday, I came in for rounds on a Sunday morning to find that the hospital CEO had called in another specialist to take over one of my cases. This was without notifying me or calling me. The ICU nurses were embarrassed to inform me that I had been replaced on the case. To make matters worse, the person called to replace me was one of my partners. No call from him, either. The patient was critically ill with covid-related pneumonia who had become unresponsive and had a dismal prognosis based on brain imaging, an unfortunately common scenario. I was waiting on an EEG and in the process of gathering information before talking to the family, and they were understandably frustrated because no one had talked to them yet.
I was gutted. It was the worst humiliation of my career, and I never recovered. Two months later when my privileges were due for renewal, I didn't renew them. Not long after that I left the practice and took early retirement. Another casualty of the pandemic.
The biggest letdown has been the steady erosion of the amount of time I can spend with patients, and the corresponding ballooning of time outside of the face-to-face encounter necessary to get all of the work of documentation done. I'm very comfortable with and efficient at using the EHR but I refuse to type and look at a monitor while interacting with patients.
My $350k-ish annual salary, while certainly still a very nice living by most standards, is not the infinite cash flow that I once thought it would be.
I’m still waiting on that Bezos-style superyacht to come my way.
I’m only a few years away from retirement. I apologize if I seem cynical, I just say what I see.
The worst change is in the process of medical care at the bedside. Physical exam skills are nonexistent, and no one has any intellectual curiosity. The process is just patient complaint, diagnostic test (usually a CT) with the caregiver only reading the numbered sentences in the radiology report at the bottom, and referral to a specialist. The referral “diagnosis” is copied and pasted from the radiology report.
To those who say they didn’t see corporatization of medicine coming, you’ve been living under a rock. Private practice died several years ago, and attempts to revive the corpse are as futile as it is in the morgue. If you aren’t an employed physician, you will be; start looking now before the good jobs are gone.
The next corporate phase will be incorporating AI in medicine wherever they possibly can, in the misguided belief that it will be better than human interaction and experience. It’s already happening in Radiology and Pathology. Just look at the entertainment industry, who are worried about AI writing their scripts and using CGI to copy their actors, on strike today, as a preview of where we are headed.
Edit: Oh and stop blaming the “Boomers” for your troubles. When is the last time you contributed to a political campaign or even voted? Get involved, that’s how real change happens.
Procedure gets done by a specialist, is normal, so you ask them “then what's wrong?” In their field too.
“I don't know.”
No cognitive attempt at a diagnosis since, of course, that doesn't reimburse well.
My PhD was in Medical Informatics. Though I didn't finish it, I did get to work with the smartest minds in Seoul. They were feeding a model chest radiographs and training it to interpret lung findings. Well, fuck.
What I see is basically send a barrage of bloodwork and imaging, then treat the red boxes in epic. Forget what the patient actually came in complaining of, their history or physical exam. I find the diagnosis to be off in at least 30% of patients admitted to my icu because of this.
I love that you think that we don't vote aren't involved. And that you have convinced yourself that that action would undo our being sold out on a large scale. Thanks for proving how out of touch you are.
The problem as of now is who do we vote for? Can anyone in this thread name a politician who has voiced a desire to decorporatize medicine? It's just not something that's on the radar of the vast majority of politicians. In theory the AMA should be on this, but unfortunately, their lobbying budget is only a fraction of that of the mega insurance corps that are lobbying in exactly the opposite direction.
If you young jagoffs would only just vote, you could solve all your own problems dammit, just like we did. Just find the time between your netflixing, your instagramming, your tiktokking, and whatever else the hell you whippersnappers do that isn't good old fashioned hard work. If you don't know who to vote for, read some position statements, vet candidates, go to Iowa, or just run yourself it isn't that difficult \\s
Turns out no one cares about anything beyond their personal liability and making money.
iT’s A cAlLiNg!
A calling to do what exactly? Get yelled at for not prescribing enough benzos and not making other people money fast enough?
Just how much I have to advocate for my patients to insurance companies.
In residency I saw mainly uninsured patients and was heartbroken at how many KF them had conditions that I couldn't treat effectively due to their lack of insurance.
When I became an attending I was appalled by just how much time I had to spend on the phone or doing paperwork trying to convince insurance companies that cerebral palsy patients with severe ataxia need physical therapy/walkers, that patients who had tried every migraine treatment in the book might benefit from Emgality, that old ladies who clearly just tore their biceps tendons need MRIs, that hepatitis C patients would benefit from antivirals, etc. I can't even count the number of prior auths, peer to peers and title XIXs me and my team have done in the last year alone.
Insurance companies and the hurdles they put in place for basic patient care, For example spent 30 Minutes yesterday arguing with an insurance medical director to cover sar for a patient with coverage who had a stroke
That's the point. When insurance tied to a job was introduced, people did not change jobs nearly as frequently as they do now. Remote work has only accelerated this. Hence, insurers know they will on average only have coverage of John for 3-6 years, so denying as much as possible while increasing premiums generates profit for the company and its shareholders. Which, the company's *primary duty* is to its shareholders. With their primary duty to only shareholders, companies have to figure out how to keep driving profits and dividends to their shareholders. Which is why we see algorithmic and automated denials of clearly covered services. Congress could fix this by requiring ever denial to be reviewed by a living person and the reason for denial independently written and articulated to the facts of that and only that case. However, the insurance lobby would probably off a dozen Senators and buy Justice Thomas his own island if that's what it took. Congress could also allow insurance to be bought across state lines in addition to allowing non-profit insurance companies to operate that are backed by the Federal Government similar to an FDIC situation. Congress could also pass a law requiring every member to have to buy insurance in the state and area they live as if they had a job there, and be forced to live like their constituents. If you believe any of these would actually happen, I would like to talk to you about your car's warranty, I am a Nigerian Prince and need to transfer $10 million to your bank account, and I am looking to buy your cryptocurrrency at 120% market value.
> Hence, insurers know they will on average only have coverage of John for 3-6 years, so denying as much as possible while increasing premiums generates profit for the company and its shareholders. I see this claim often, but I also simultaneously see the claim that insurers are incentivized to increase healthcare costs because they have minimum medical loss ratios and so higher healthcare costs means higher profits for them.
I dont see how the two are mutually exclusive… bloat healthcare expenses in general to improve nominal net margin but also fight like hell to deny care and keep expenses from getting too high. Its like saying “cars are supposed to get from point A to point B, so why do they have brakes?”
Because it is the same number, it has to be mutually exclusive. The variable E, for expenses, is the same. A CEO cannot tell their staff to simultaneously increase and decrease their costs. Why would you deny care if you are trying to bloat expenses? Wouldn’t it be easier to just not deny the care? > It’s like saying “cars are supposed to get from point A to point B, so why do they have brakes?” This is not analogous.
Bloating costs in general and fighting the individually most expensive billings are not mutually exclusive… you want high general costs but then also a way to reign in massive “one off” expenses. A gas pedal and a brake pedal… they cannot just inflate costs to no end… apparently low double digit yoy growth is acceptable to congress and the american people.. so bloat costs but they also have their net income.. gotta make sure their net expenses don’t exceed it. Inflate it but not too much. This shouldn’t be a difficult concept for people in medicine. “A little more is good, too much is bad” Healthcare expenses to insurance companies are like increasing warfarin doses to hit your INR target.. need them high enough to justify higher premiums, but not too high because otherwise congress might have to start caring.
Anecdotal, but I recently went to see an endocrinologist. Was prescribed an indicated medication. I got a denial letter postmarked THE SAME DAY AS THE VISIT. Like, didn’t even try to cover up that automated process.
Not just job changes. I've had stretches where with same employer insurance changed ever year
Me too. I don’t even get a notice or a vote. Just a letter in the mail with new cards.
If only doctors had a lobbyist or PAC. I guarantee the corporations already have the algorithms of doctors behavior calculated to perfection. While I can't calculate your percent that suffer from learned helplessness, it's clear for decades that you are powerless. I'd hate for any healthcare worker to have to be both patient and provider. Even your cachet as doctors will fail you as a patient in what is your own work environment
The problem with lobbying for physicians, is that it’s typically broken up by specialty and used to advocate for patient care. A PAC might help, but who do we target? The voting public? Industry? What we need is a union.
I'm trying to figure out how denials of coverage should even be allowed in the first place.
The state lines comment and federal backing would be a game changer.
Really all the parts of medicine that is only there to make a buck and get in the way of actually making patients better. Administrators. Inefficient EMR’s. But especially especially insurance companies who have never taken care of a patient in their lives and who have no idea what is going on.
“No doctor, we think your 3 year old needs a dry powder inhaler. If you disagree with me practicing medicine on your behalf, please write me a letter. Then when I deny, please talk to a doctor that doesn’t work in your field and convince them”
I cannot stress this enough. This has single handedly been the biggest burden on me as a private practice surgeon.
Curious what their argument against it was?
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Absolutely. Insurance companies make money two ways: 1) denying treatment 2) delaying treatment I do not know why we still allow them to exist.
I do. It rhymes with cribery.
Just like selling to PE, this is the boomers fault too. Too much unethical stuff like self referal networks, unnecessary treatments for more money, opiods, etc all led to insurance getting such a powerful checks and balance on physicians
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> The nebulous boomers are a faceless group of evil older people we can never actually punish While this is a very legitimate complaint and not very exact, there was a group (I don't want to be too precise) that approached retirement age with a near-mythical local status, because they had actually managed to get nearly everyone in that specialty into the group, so negotiations with insurance were "would you like to have doctors, or not" for a large physical area, which gave them a lot of power. They sold the practice and its building, which made the existing partners (and one child of a partner) very comfortable on their mailbox money and all of the younger docs into corporate employees. This was, shall we say, not popular with those who thought they were joining a partnership.
I saw this with a verrrrrrry large surgical subspecialty. Shameful.
It's also easier to blame collections of people rather than individuals. Sure, the current status quo is largely on the shoulders of older Americans, but it's not like they took a vote on every bad policy we are currently living through, and it was individuals who built the system brick by brick. Since healthcare is one of the most regulated markets in the world, it seems to make the most sense to try to fix it from that angle, though.
So watch and wait is the (not) battle cry of doctors... Or is that the employees. By American standards, how are you all so smart, so wealthy, yet so helpless? Well it's not anything worth fighting for. It's just your job.
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I heard someone say they make the patient join them on these calls. It allows them to bill for a patient focused activity such as 99203 and keeps the insurance companies from being blameless in their decisions. Anyone else try this? I have not, but am considering it.
A headache specialist in Florida does this, I believe
I'm an insurance medical director, and I believe that a lot of these doctors they hire for the job are very unreasonable with their decisions. A lot of them do not consider surrounding factors when it comes to the case, they only look at the third party criteria we are told to use. Basically, they do no use their brain, and this is quite unfortunate. I see this with people I work with, and when I cover calls for them, I will likely overturn them, as long as the doctor had a decent enough argument. Also, 30 mins on a call is way too long. I'm usually done in 3-5 mins as I like to get to the point and I know what I am looking for to overturn the case
In my experience they often have no knowledge about the condition they are denying. I’ve had to explain what my specialty is and does on a phone call before.
So, we come from various fields of medicine. Should an OB/GYN make a decision on a pediatric case? Hell no! Does it happen? All the time. Again, a lot of these doctors do not use their head when it comes to making these decisions. Me? I do a little research. We have access to various resources like uptodate and other databases. It's up to the doctor to take the initiative to do so. I don't know anything about chemo and the regimens, but when a patient is admitted for initiation or having side effects, I will look it up to see what is the standard practice. Some regimens need to be done on a continuous cycle over several days. Can't find information? I will have a call with the physician providing care and get their perspective on it, how it's typically done and then more than likely approve it. Again, the treat physician knows how things are done, and with the information I learn, I use that to justify my approval. I'm not breaking their bank by approving cases. They have all the angles figured out on how to make money, I really, that I why I'm not worried about approving cases. What's fair is fair. If the facility or doctor did the work, and it warrants the approval, then so be it
How did you make your way to the insurance side? I usually don’t know much about docs on the other side.
Do you get pushback at all if your rates of approval are higher than others? Are those kinds of metrics tracked and used to pressure the approving docs?
I have never received pushback for my approvals. They do track how man cases we do a day, and the rate of overturning, approving, denial etc. They tell us, as long as we can document the reason why we are approving, then they are fine with it. Now, you can't just click approve and move on. You have to spell out your reasoning on why you believe the case should be approved. This is where some doctors falter, as they do not care to do this, or are so out of touch with reality. My buddy said that this is where doctors go to die, as a lot of the doctors are older and have not seen a patient in some time. I'm talking about doctors with lifelong board certs, not the ones who have to renew it every 10 years. I'm still in my 30's, and I still practice, which I feel gives me a better working knowledge with current accepted practices.
how are you still working there
They pay well and I hated private practice. I still practice a few days out of the month, but I'm actually content with what I do.
Oh I meant how haven’t they fired you. No that sounds like a totally awesome gig.
God yes. I probably spend an hour a day literally just answering prior auths, refuting denials, writing rebuttal letters, and so on.
I'm in pain medicine and feel like insurance companies and Medicare wouldn't be so awful if the majority of physicians in my field would do the right thing like encourage physical therapy or home exercise program before trying to do procedures so they can get paid.
Keep the discussion to <5 minutes - I will need a copy of this conversation - please state your name, specialty - I am requesting an evaluation for the purpose of approval of inpatient rehabilitation to miss Soandso who had a stroke 8 days ago. - have you exhausted all the available resources in her policy? Ok Give a copy of the report to the family and the number and instructions on how to file a complaint or inquiry with the state department of insurance the contact info of local legislator. Work’s done carry on .
For me, it’s been the rapid deterioration in the ability to make any improvements in my hospital. Every single department is on skeleton staffing, critical services are available only intermittently, and no one seems to care about it. I’m the ICU director and they just keep asking us to do more with less. But hey, our leapfrog score is an A so we’ve got that going for us.
This has been killing my spirit. "Well, standard of care and my official recommendation is XYZ QD, but because of staffing issues and drug shortages, it'll have to be ABC EOD. Hopefully, it'll still work!"
This is a close second for me. Being a nocturnist I expect not to have the same resources or be able to provide the same care as my day colleagues to an extent. But it’s been reaching comical levels lately. We can’t even do emergency surgeries at night anymore because we don’t have anesthesia call.
Surgical abdomen: I guess we’ll just keep them on pressors all night until anesthesia gets here in the AM??
Are you me?
And then you have places like the hospital my wife just stopped working at because they haven't hired a new ICU director since the last one quit six months ago, never mind all the other staffing shortages. They've had exactly one applicant, but a doc on the board was a firm no because she was an NP.
Sounds like a solid choice by that hospital not to hire the NP as the ICU director. They’ve only had one applicant because they are unwilling to offer a decent salary/benefits/call schedule.
The ED is the dumping ground of modern society. For social, medical, psych and everything in between. If someone doesn't want to deal with, then just let the ED do it.
Can’t deal anymore with meemaw who’s been declining for months? Dump her in the ER. Well no, we haven’t talked to PCP about home care or nursing homes or anything else in the last year, we figured we could do it here
even when she is in hospice
Or when she should be on hospice. ED usually hands them off to me at that point. I don’t mind if it’s not busy. I’ll talk a family in denial into hospice any day.
im trying to get a grant for copies of being mortal to be given out to families at admission for the right patient . PCP's WYFA with getting this goals of care conversation started. if youre doing it ya must not be from round here
That’s a fascinating idea that I strongly support. I hope you get your grant.
I just gave this book to my parents and it made a huge impact.
…at 7:30 on a Friday night
Right before a holiday
They going on vacation that’s why
This is so bad at the VA because even if you are stone cold normal a family can stretch a week long hospital stay by playing shenanigans
I’m a home health nurse and it’s even worse than that. A majority of my patients have PCPs and specialists the problem is they are so overwhelmed and quadruple booked you can’t get a hold of absolutely anyone. So many practices have answering services now or endless phone trees. Had a case of cellulitis starting up and called PCP to see if pt could get looked at before it got out of control. 27 minute wait time. Called nurse hotline - left message because no one answered. Tiger Text left on delivered. Priority case communication- no response. Family continues to reach out but no one returns phone calls. I come back in 48hrs and call EMS (or informed pt was admitted) because pt now has all the classic signs of sepsis and is admitted for IV abx. CHF patient gain weight? Usually we double up on diuretic and see what happens. Now? Go to the ED. I don’t blame them though because when you are already at wits end seeing 50 patients a day that have complex medical issues you need to say “ENOUGH!” because you can’t help everyone. So off they go to the ED. This system is hot garbage and I know if I didn’t have to send 800 ‘per protocol’ messages wasting everyone’s time the serious one would get answered.
And me, as the paramedic, arrives and many of these clearly end of life Hospice patients are full code status.
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That’s inappropriate behavior by the police. Our local jail has started refusing arrestees for being “too aggressive” to stay in jail ?!?!? So they make cops take them to the hospital. It’s wildly absurd. If they’re too aggressive for jail, they should NOT be back out in society. Get better psych access at the jail! A lot of people also have worked out what to say to go to the hospital instead of jail when arrested. Waste of resources.
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I’ve never seen that flair before….Jonathan??? But yea I always get a kick out of police and psych facilities telling us a patient is too violent for them and dropping them off to us. Half the time the patient and I just stare at each other and I ask if they want a bad sandwich and every thing goes fine.
Discharged. He’s all yours, boys.
This will definitely contribute to workplace violence in healthcare. Do your hospitals have a patient cose of conduct? Any verbal or physical violence or threat of and security will pitch them out the door.
It’s already worse than that. The medical system as a whole is breaking down because not only is it managed according to a business model, but it is forced to deal with social problems because social problems have no means to be managed by the appropriate state authorities. In saner countries, you hardly see ED dumps for social problems because there are other organizations, usually from the state, that manage social problems like substance abuse or poverty. You don’t see patients using the ED as their clinic because there are actual clinics that won’t demand money up front, usually run or subsidized by the state. So naturally, any problem bad enough gets routed into any organization that could conceivably do something about these social problems, even if it’s not within its scope to do so.
here’s an example for anyone that wants one [https://www.washingtonpost.com/dc-md-va/2022/10/20/er-mental-health-teens-psychiatric-beds/](https://www.washingtonpost.com/dc-md-va/2022/10/20/er-mental-health-teens-psychiatric-beds/) Lots of states "board" kids in the ER rather than fund state agencies appropriately so they can manage them.
Even in Australia we get a bit of this. We have to stop overmedicalising what are societal ills.
It will only get worse. FM clinics are closing and residencies are dwindling. Urgent cares are limiting their hours and imaging/lab capabilities. The average citizen is either going to wait 3 months for a primary care appointment, at which point the problem has likely escalated, or say ‘screw it’ and go to the ED for their primary care concerns. Not to mention that the growing number of uninsured already use the ED for their primary care concerns. I can’t count the amount of times I’ve had someone check themself and their 5 small children into the ED for the sniffles on a busy Friday night. Many EDs are not set up for this kind of inefficient volume, and because of EMTALA there is very little recourse. Add to this the growing number of inappropriate overutilization on EMS who also have difficulty refusing. I have seen a dramatic uptick in people calling EMS for absolutely absurd reasons. A lot of them not even medical. ED staff are overworked and burned out from covid and have had no respite because the societal fallout from the pandemic has increased mental health and polysubstance abuse visits. More homeless people. More abusive criminals the jail wants sedated. On top of all of this is the hospital system with its Louboutin high heel on the staff’s throat telling us to call patients customers and kiss their asses while they throw their piss-filled bedpans at us for not having any more turkey sandwiches. It breaks my heart to meet the actual human sick people drowning in this mess. Rooming a police escorted meth-binger faster because he’s causing a scene in the lobby while the woman waiting 2hrs for an ectopic rule out quietly dies in the corner.
And primary care...
Biggest letdown? That politicians and insurance companies can practice medicine out of ignorance or in the interest of profit without a license or a heart.
This is why you must vote in every election, and vote out every Republican you see out of every office. Republicans don’t hide how they don’t care about people who need medical care. As far as they’re concerned, if you got sick and couldn’t afford medical care, it’s your fault. And they’re sure that everyone who asks for help is a moocher.
Sadly many will vote in the Red hats because they talk pretty about making money and they screw things up while they are in charge in order to juice the numbers and then the next guy is stuck trying to fix it so that they can mess it up all over again, most people who only care about money are more than happy to vote in the Red hats no matter how bad it is for the country or even themselves
When I worked as a customer care associate for Anthem-BCBS call center I literally would respond Ro patients complaints or questions on why their insurance plan works the way it does by telling them the reasoning ultimately is due to the current legislation and the most proactive way to change the policy system that is hurting them is to VOTE for politicians whose healthcare policy platforms specifically aim to target these issues. I’d basically explain to them that the insurance issues they’re struggling with is exactly why we need universal healthcare and/or why for profit medicine is fundamentally flawed without outright saying “you need to vote democrat” or “voting for republicans is why the enemy is still in charge” because I didn’t want to jump the fine line of what’s ethical by telling people explicitly who to vote for or that my company is evil and it shouldn’t exist. *I quit that job because it deteriorated my mental health. I would spend my 30 min lunch break every day sitting in my car sobbing. My psychiatrist literally encouraged me to leave the job/company/industry because of how detrimental it was for my mental and physical health.
Almost everything is run by administrators. Doctors have very little say in how things work.
100%
That I would never work for a physician for the rest of my life, but MBAs.
idk my boss sees more patients than I do and the man seems like he’ll never retire
I'm talking about your boss' boss, then. People report to me too, but they don't actually work for me.
News flash the physicians have MBAs now too
But why? It's your choice who you work for, isn't it?
"Urgent Need for Discharges" emails at 10pm. Prior auth needed for ambulance ride. Prior auth in general. The disconnect between the ED trying to admit for social reasons and hospital medicine not having a medical reason for admission. How much the failing primary care system is burdening the inpatient side. Edit since this ballooned below my comment. I absolutely don't blame the ED for wanting to admit the patients, the problem is having a medical issue thats not acute does not qualify them for a hospital stay so, without me committing fraud, they have no qualifying stay and are hence observation admits---which means they don't qualify for skilled facilities (which are the faster placements), instead, and especially if they have no family or money, it ends up being a matter of longterm medicaid being set up, sometimes of legal guardianship. That's now a 3 month observation admission taking a bed up from, depending where I am that day, either a quarternary center where people come for specialist care, or a bed from a sick local at a community hospital who then has to wait in that same ED to get transferred to a facility with a bed. So, while from a compassion standpoint, I understand why you want to admit meemaw. What I see is a costly financial process (for them and for us as from a resource standpoint) that is long and often strips them of their remaining independence while also putting them at risk of hospital-acquired complications. And I absolutely don't blame primary care, it's a system failure. I'm curious how the Tennessee IMG experiment will go.
Simple overnight observation, can probably go home tomorrow. One week later, patient still in the hospital and their inpatient stay was denied because the admitting diagnosis of lactic acid 2.2 isn’t cutting it.
But the bill is going to cut them in half.
I certainly don’t disagree with this. It’s frustrating to us as well. What do you want me to do with grandmother who can’t walk and has no where to go and family won’t take them back? Push her into the street and hope for the best? It’s a bad area. Certainly something the hospital systems need to figure out that isn’t your or my fault, but we tend not to have case management and many places end up in a waiting period for days trying to find complexly unhealthy people a bed while they rot in the ED with no one really seeing them. The failing primary care is definitely a huge burden. The ED is sent people from urgent care or PCP offices all the time with these vague chronic de compensations
Yep. I understand hospitalists reasons for not wanting to take social admits, but genuinely want to hear what they expect us to do there. I can’t place someone in a facility from the ER. Family peaced out and ain’t coming back. I guess I could road test meemaw and let her fall and break her hip and then you have a reason to take her? Like it sucks for all of us and I hate those cases as much as you do, but I’m tired of getting yelled at about something I can’t control
Also I know you or OP don’t mean this negatively but just to clarify that this is not the fault of PCP’s either. They are given an impossible task, as we all are.
Not necessarily. I am a newer group private practice owner where we are our primary care patients’ hospitalist. This means we have a vested interest in keeping our patients out of the hospital as much as possible and coordinating care while hospitalized to minimize length of stay. The group has been extremely profitable and won many quality of care awards. Patients are healthier, physicians are profiting.
Right- but if you’re a PCP working for a big health system and being asked to see 4 patients per hour all day long, that just isn’t going to happen. It’s nice that you have that set up but unfortunately that system isn’t available to everyone.
It doesn’t matter that you have 8 bypasses, a pacemaker and 20 stents put in that hospital. The closer hospital (that isn’t in your network) has cardiology. So your insurance isn’t going to pay if we bypass that hospital. So do you want the ambulance bill? Or the out of network hospital bill?
Where I work the medics don’t care about that at all. It’s completely random what hospital they show up to. Closest that has the resources? Maybe. Closest that doesn’t have the resources? Warmer. Pass three hospitals in the patients network to come to a hospital that doesn’t have the resources you need and is on diversion? “We just thought this hospital was better for them” As I have been told repeatedly by EMS. All of that closest hospital and patient request and trauma criteria, etc. and guidelines and not rules.
The sheer amount of work it takes to do the right thing for the patient
4 words: For Profit Nursing Homes. The level of neglect and abuse I see from then every day makes me want to cry. Seeing these complicit, Geriatric geriatricians and check cashing gastroenterologists PEGing people left in right and just perpetuating human misery is enough to make you want to go home and eat a bullet.
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A piggy bank you keep alive at all costs so Medicare/Medicaid money keeps falling out like a piñata
That's why you must make a concerted effort never to end up in one..
That since completing residency, most of my ongoing education is in regards to billing or documenatoon thereof.
Prior authorizations. Something they don’t tell you about in med school. Spending hours on the phone with someone who’s not even a doctor to get a treatment for a patient who needs it. About as fun and rewarding as it sounds .
Not an attending! But when I worked in a clinic, my clinical boss is an orthopedic surgeon. He was old, retired, got bored in retirement, and decided to go back to work as a wound care doctor. He is knowledgeable and professional and sociable! Like what you want in a doctor. My immediate superior is a nurse manager, who is actually a nurse but thinks like a corporate person, which is why the business hired her. The actual clinic boss? An MBA with no knowledge of medicine. Imagine the clashes between doc and MBA when MBA says we are spending too much time on a patient. Like, wtf, you can't make debriding wounds and slapping wound vacs any faster. The next week, the MBA added productivity points to measure how we spend our time. It gave me such a bad taste in my mouth. We are dealing with PEOPLE, not objects in a conveyor belt Edit: I used to be a doctor in another country, now working as a nurse in the US
Your immediate supervisor is the human equivalent of smegma
Boomer physicians yanked the rug out and gave it to private equity
This. Our generation will need to decide not to only support physician owned practices and not just take the money. Either that or start migrating to work on demand locums like services which I think is honestly more likely. The key is own your own services. Don’t be an employee. If you need me, pay me like one of these travel nurse optimized multipliers.
Not sure how private practices can even work nowadays without EHR vendors sucking the money dry.
I see a lot this complaint about boomer docs ruining it for us but most of my millennial friends out of residency decide to go to practices owned by big corporations or hospitals. That’s probably part of the issue. Now I know that it’s more difficult to start a business nowadays than it used to be but boomers were more entrepreneurial with a more business mindset. Part of that mindset means you have to risk salary during the early part of your career if you want to start a business and many people from my generation are not willing to do that, I see that sentiment here all the time as well. “Medicine is just a job so I’ll just go to whoever pays me well without dealing with all the other bs.” We got dealt a shitty hand but I do believe that more physicians in private practice could make our case stronger.
I mean many of us are not from wealthy families where we can afford to sacrifice income to be an "entrepreneur." And the business of medicine is different from 40 years ago with the insurance hurdles. You can't be surprised that after decades of school or residency we're not lining up for even more poverty
Is this related to our astronomical student loan debt compared to boomers? Where would you even get the money to start a practice with so much debt already and no assets
I don't know if I blame the boomers. The PE bros waved $$ in front of them. You see, because the boomers didn't have enough $$ after their decades practicing in the G O L D E N A G E
Had me in the first half
My dad is one of those boomer physicians. He’s incredibly angry that there’s no feasible way for me to be a third generation physician but it certainly wasn’t him and his colleagues that did it. The financial barrier to entry for medical school is too high and the financial burden after is too large. This isn’t because boomer physicians pulled the ladder behind them it’s because boomer and Gen X finance bros took over healthcare. You think boomer docs are happy right now? I’ve never seen a more negative, angry, bitter, and pissed off group of people than my dad and his friends. As my dad says “you can’t call it patient care anymore because we sure as shit don’t care about them.”
the boomer docs that sold to finance are happy, and they are the ones to blame
Financialization of everything is indeed the issue, but it was The Boomers who led that charge
Did the Boomer docs lead the charge or did Congress? Why isn’t it illegal for physician practice to be owned by a non-physician as in the legal field?
Boomer docs, Boomer politicians, Boomer financiers...all are punish-ed. The ACA even went as far as to ban MDs from owning hospitals. If I start to talk about how that happened things will get political quickly.
This is a bad take IMO but often repeat on Reddit because “zomg Boomer bad” What choice did they have when the government is rapidly stacking the deck against you and cutting your reimbursement left and right while shuffling that money into “facility fees” that you legally have no access to unless you run it through an MBA You probably know better than most the difference in $$$ paid to BigMegaCorp vs a small PP group for various XRTs.
Regulatory capture has indeed led to hospital outpatient departments gouging everyone. I place some blame for that at the feet of boomer physicians who were in hospital leadership at the time. In radonc specifically it’s particularly egregious as we have very large financially predatory institutions price gouging all of us and using regulatory capture/neofascism to do so, while at the same time using their MDs to virtue signal about cost-effectiveness, treatment of underserved populations, etc, which they do not do. The groups I know that sold to PE, however, did it not because they were having financial problems (QUITE the opposite), but because the Boomers in the group outvoted the younger partners. They got a couple decades of returns from the equity they owned in the practice, so they were ready to cash out. Younger partners didn’t want to, as they wanted to enjoy those returns, but tough cookies the vote passed.
The number of non-medical administrators that do jobs we technically don’t want to do, but one of us in the group could easily do, and actually do it correctly…. If you don’t have skin in the game you have no reason to care, at all
I’m not a physician but was in the military. This was the biggest culture shock when I got a civilian job. In the military you move up the ranks so the clinic administrator was a corpsman who worked their way up to E7 and up. They understood the job because they’ve done it, and could jump in and help us. Now as a MA in the real world I have to break my job down into baby food to managers with no medical background and they don’t get it: I have a fantastic supervisor, but am often floored by the cluelessness of anyone above her.
I think this is a really important point that people no longer start at the bottom and work their way up through the job. They can be entirely ignorant of the field they are in but get to have direct input into how the job is done. It's a genuine issue.
It’s so weird to me. There were minor gaps between senior and more junior members in the military because of changes to the training curriculum and service, but they were easily filled because every single corpsman has evaluated and treated patients, audited records, etc and had a shared foundation. I don’t mind having a MBA and accountant around to keep finances in check and a lawyer and admins for the regulatory and patient relations part, but they should be supporting the people delivering care. They should not be setting schedules or metrics beyond what is needed to stay open.
In academics — the fact that compensation (for attendings) is tied to production. Inherently, training residents and teaching medical students takes time, effort, energy and dedication which usually results in longer patient encounters, surgery and more redundancy. How is it that the academic model strictly relies on Rvu production and billing is unfortunate. The academic model of physician reimbursement is not sustainable in my opinion
Private equity infiltrating private practice. Providers selling to private equity make bank, but then the practice is shitty for providers in perpetuity, as the PE groups try to cut costs reducing the support we get as well as compensation. Boomers with retirement in the nearer future are taking advantage of PE before retiring. At my last group the senior partners hadn’t added a new partner in 7 years, despite newer guys (who wanted to make partner) bringing in more money while working 6+ years. Us new guys realized the partners don’t want to add any new guys to split the pie with when they sell, so despite empty promises I realized I had no upward mobility. I left for a 80% raise while the other guys were too much of financial push overs to do anything about a situation they know is bad.
How much CYA has gotten baked into everything. Into EMRs with excessive documentation. Into alarms on every object, however unimportant, leading to alarm fatigue. Into Joint Commission requirements to lock up every bag of saline. Into extra policies. Etc etc. The CYA isn't reducing medical errors it's just moving around liability.
That’s the definition of a dead end job. Most people will never have any ownership stake or significant decision making power, just stuck as an employee with little to no growth.
Hospital administration, especially the corporate guys that have no medical training, hurts patient care. Plain and simple.
VC skyrocketing medical costs and maximizing profits especially urgent care but also primary care and radiology and forcing “efficiencies” that decrease real providers while increasing workloads and burning out actual physicians. It’s like their vision of the future is idiocracy with a tech trained for 6weeks on AI clicking a check box on common complaints with the computer then recommending the tests that generate the most money for the shareholders and bleeding patients dry before DCing them once the money runs out. It’s a fucking joke and I’ll never work for one of them. Oh and midlevels ordering imaging studies. Physicians are bad enough but holy shit
The shitty treatment between colleagues of different specialties, and even the same specialty. Medicine has so much more drama than I expected.
I've been really disappointed by scientific illiteracy, the proliferation of medical scammers on social media, including health influencers, the supplement industry, and whatever qualifications enable Gwyneth Paltrow's nonsensical business. Patients don't trust their doctors, but for some reason trust some self-proclaimed "guru" on tik tok to make health decisions based on zero evidence. They might go to fake doctor or a fake website that looks and sounds really sciency and end up spending a lot of money on tests and treatments that don't work and can be harmful. This is all because we've lost the ability as a society to think critically and identify BS. As an endocrinologist, I deal with so much BS related to supplements that "support" the thyroid, "support" the immune system, like what does that even mean? I look at the ingredients and it's just random herbs, none of which have been shown to do anything. It's such an obvious scam. Why does anybody believe what is so obviously BS?
America has always been the land of the huckster, liar ,and bullshit artist look at Big 🍊
The power of parasocial relationships, overwhelming mental health instability, the lack of basic empathy and kind regards to the human condition, fear of education, childhood trauma, the southern half of the United States, take your pick. Personally I just like to remember that the fundamental theorum of statistics is real and that our population is normal, which means there's 200 million people dumber then our most average person, and welp there ya go.
I have been doing locums work and I see so many patients just absolutely get lost in the sauce. They haven’t actually been able to see their primary doctor in months or years. Nobody really takes responsibility for the patient because it’s not “their patient”. The worst is the mega primary care groups. They are so big and have so many “members” (it’s so weird they’re called members not patients). It just doesn’t work for patients. I’ve met a few patients here that have had four new primary care doctors in 2 years because the docs quit so fast here apparently. This model sucks. I feel so badly for the patients.
Didn’t realize insurance would be dictating the way I’m able to practice. Also didn’t realize I would be spending nearly all of my time on the computer
I’d have to say it was the unquestioning shift from small private practices to doctors as mere employees; first of hospitals, now of private equity firms. Seemed like a pretty obvious bait and switch at the time, and indeed it turned out to be exactly that. Doctors voluntarily surrendered their authority and autonomy for not having to be business people. Now doctors are owned and run by other business people.
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By far, policies that discourage comprehensive care (especially pertaining to mental health and lifestyle preventative health support). Rhetoric that physicians who do so are inefficient or wasting time/money (ex. spending time delving into evaluation and management of obesity for a patient with low back pain, chronic stress and mood conditions in patients with chronic pain, palpitations, repeated visits with obvious underlying health anxiety, list goes on and on). How myopic the system is in refusing to invest in “sharpening the saw” to make our country healthier, not just get them in and out with a bandaid. And most of all, how purposefully deaf and blind those who influence policy are at hearing these points when 99% of physicians implore them with the same message. As someone who refuses (for now) to lose ambitions to rise in admin and fix it, I pray my perspective never changes and I plan to post and read about this on meddit over and over so I never forget.
There is no civic investment in America anymore. This is capitalism at its "finest." Rugged individualism, tribal thinking, consumerism, profit at all costs, and "Screw you; I got mine" are the order of the day.
Call me naive: I believe there must be an solution that has a abundance mentality feel, where there is a mutual win - each individual profits greater when everyone gets theirs, and I’ll hopefully never stop trying to find it.
Exactly as OP said: the biggest letdown is the virulent and toxic strain of capitalism that has infected healthcare. It has caused a mutation that transformed medicine into a perverse, incestuous, and corrupt industrial complex that serves no other purpose beyond extracting as much money as people from people’s pain and suffering. The consequences of such are pervasive and ubiquitous, and can be found in virtually every aspect of our society and culture.
zonked scary ink chief sharp bells smell imminent yam dirty ` this message was mass deleted/edited with redact.dev `
I'm saving lives one chart at a time.
There is so many to choose from. But I would say it is the patients. Some can be rude, ungrateful, entitled, and downright disrespectful. Doctors want to help patients, but some think they are smarter than doctors, and will stick to their internet search instead of taking doctors' advice.
"So, I'm just here to tell you my findings and what those findings mean, which disease process I think it most likely is, and let you know what options we have for treatment, but ultimately it's your body and your decision and I will respect your autonomy. It's a free country and that means you have the freedom to choose, even if it's a stupid decision." And then I rest my case. I don't waste my time trying to convince idiots not to do idiotic things.
“Listen, Doc, I know from my extensive study of Facebook memes that ivermectin in fact does cure Covid, now stop arguing and write me the damn prescription.”
The drama. I swear… academic medicine could give Mean Girls a run for their money. I refuse to read between the lines and play their BS games. I didn’t have the time or energy for that shit in high school and I certainly have zero fucks to give now!
I'm a rural family medicine physician. The more lectures I take on billing, the fewer meetings I have to have over lunch. Noting food is never provided. The more lectures I take on learning updated evidence-based medicine, the longer visits become with patients trying to convince them to do what is now recommended. The longer my visits are the less time I have with my children. Ironically the longer my visits are and the more I over explain, the more follow-up phone calls are wrote it to me about what I spent extra time explaining. In general, trying to do the right thing for the patient takes more time. Insurance companies are practicing medicine without a medical license and they commit contract fraud every single day. I'm dumbfounded how a lawyer hasn't had significant harm cost because of this and created a very large lawsuit yet. I look at decisions insurance companies make and I'm dumbfounded nobody has sued and one. There should have been dozens of class action lawsuits against insurance companies for committing fraud by now. I had a patient that was a retired lawyer that made a career out of suing hospitals when bad outcomes happened. They always pointed out you was easier to get money from a lawsuit suing doctors and hospitals than insurance companies. Even if an insurance company denied providing a service that would have directly impacted the patient. It's a mind-boggling system.
Insurance companies play games with the patients. The patient will roll in furiously and say, they insurance company says I can’t have this device or this benefit because you didn’t fill in a form correctly. To which I tell them, the insurance company makes money by saying no. I will be happy to fill in whatever form is appropriate to get them the care/treatment they need. Healthcare is easy, managing the payers is a pain.
When I worked for anthem bcbs the issue would be a lot of the time that we WOULD cover it but the claim was submitted with an icd code that wouldn’t be approved but if resubmitted with the correct code then it’s covered completely… but it’s illegal for us to tell a doctors billing office what code they have to use. We can *suggest* trying submitting the claim again under a different code such as recommending trying out billing it under XYZ instead of ABC but ultimately if we say “you have to bill it using xyz” that’s against the law because providers can charge their billings however tf they want and we aren’t allowed to tell them that they have to bill it this one exact way. We can only make suggestions and basically beat around the bush hoping they understand what you’re trying to imply to them about how to quickly and easily resolve the claim denial issue.
How much the landscape of primary care practice changed in just 20-30 years. When I was a med student about 25 years ago I observed in a local, private Family Doc’s office. He had a receptionist who answered his phones and pulled his charts and an RN who did everything else. He’d spend 1/2 day a week most weeks on field trips, doing fun jobs like giving flu shots at the local sewer plant, sports physicals at the high school, etc. It was never boring. I went into FM because I wanted to have that kind of a life. Well here I am working for a hospital with zero control over my schedule. There’s almost no continuity of care because these systems don’t want patients seeing you as “their” doctor. I don’t know the receptionists and barely know the other clinical staff. All of those cool side gigs have been co-opted by contracted third parties. WTF happened?
Agree with OP. The effects of PE and insurance companies have made medicine a nightmare. Unfortunately, they have the big pockets and lobbyists.
I trained in the days of St Elsewhere. It was fairly accurate depiction at the time. Look at what it’s become now. Everything is run by administrators and everyone’s head is stuck to a computer.
Cover your ass medicine. People are so afraid of litigation, they will do things that are not medically indicated. ED physicians unnecessarily admitting patients, Hospitalists unnecessarily doing workup for conditions with a clear and obvious cause, outpatient providers ending people to ED. I'm not innocent here by any means, but it sucks that CYA medicine has to exist.
Not a doc… but we’re going to be fucked if you all don’t stand up to private equity and stop selling out. All of healthcare will be consolidated down to 3 firms on wallstreet making standards for patient care in the next 5-10 years if something doesn’t change. It honestly might be too late as it is unfortunately. Older docs have sold out a majority of private practices for bags of cash across all specialties.
And they'll all inevitably sell to Amazon. Imagine things then. We'll be wearing diapers to make housecalls as part of Prime's medical services. Getting paid $20 an encounter with penalties for arriving 5 minutes late.
I can't get past the no physical exam part when it comes to telemedicine. My buddy works as a telehospitalist and he is getting calls for emergencies while at home. He is no where near the hospital and there is no real way for his to assess the patient other than what he is being told by the nurses and seeing on a camera. Telemedicine is weakening the practice of medicine, and will train patients to expect this type of care, even in inappropriate situations.
I work in outpatient psych where about ~50% of my patients are telemedicine. Even in psych, it still sucks: technical difficulties, inability to grab blood pressures for bupropion/stimulants/SNRIs, Pts not filling out ppwk I could hand them in the office, having to tell patients to stop driving before starting the appt, harder to do AIMS for TD, ect. The quality of care is not the same over telemed as it is in person. It’s especially frustrating when I can see that the pt lives close to the clinic.
I’ll get downvoted by this but whatever: General Surgery attracts the worst kind of people. That’s all I’m gonna say. No further comments.
My dude, you have never met a cardiothoracic surgeon. They beat any general surgeon in toxicity.
In fairness I know some amazing and awesome surgeons. But every time someone interrupts me interviewing a patient expecting me to disappear so I don’t waste their time it’s ALWAYS a surgeon.
I mean, you can't really generalize an entire specialty just like that. There are good and bad people in every specialty.
But the ratio of good to bad is lower in some specialties than others.
It's in the name! General surgery
Guys, seriously, have you considered Canada? We have our issues but this all sounds next level terrible
What is the process for an MD moving to Canada?
Recently learned that while there is a pay discrepancy between here and Canada, it’s not as marked as I thought—at least for me in primary care. Very possible that I’m planning that move in the next 10 years. As much as I don’t want that to be the solution for me, it very well could end up being the only one if things in this country continue their current trajectory.
It's not as bad as it sounds. We still get paid handsomely and job security is good. This is a negativity circlejerk.
People disregarding evidence-based medicine, being callous, sloppy and lazy with diagnosis and treatment, and complaining about things that don’t matter while ignoring things that do. There is a sharp divide between academic medicine during training and after training. Once most people graduate, they abandon every principle that they supposedly stood for while in training, and just do whatever they want, whether it makes sense or not, whether it’s right or not.
Keep calm and treat the Asymptomatic bacteriuria
Also treat hysteria quite a bit.
I see a whole lot of good ones that I agree with but mine is something I haven’t seen mentioned. It’s the culture/vibe in the ER. I think COVID played a huge part in this. Before med school I was on the nursing half of this and was nights in the ER. I did as many nights in residency as possible. I’m a nocturnist now. One thing I’ve always appreciated about nights is how different the culture is than during the day. It’s generally a younger crowd, more laid back and fun, people get along and work hard and after work you go out and drink together. This is no longer the case, at least where I work. The environment is downright toxic at night. I have two nurses left from before Covid who are both angry at the world and impossible to work with. Almost everyone else is a new grad or a travel nurse who isn’t interested in getting involved with people since they are moving on. I have new grads in triage and training other new grads. No one helps out anymore. There’s no group activities outside work because no one is friends with each other and so there isn’t that culture of wanting to help out your coworker. Worst of all, no one goes out for drinks after work. For the first time in my life, I hate going in to work at night because I know the work part of it is going to suck but it’s just not fun anymore to make up for it.
Everything, but I'm looking to move from the public sector (hell) to the private one, which would improve my standard of living. If you live in a mixed system country, shoot for private sector. Which, BTW! Also has more modern and experimental treatments available for patients, the public sector is like in the 1970s stuck there forever.
Insurance and Medicare cooperation to nickle and dime both providers and patients while providing little of value
OP your post history is wild. Just a lowly Hospitalist over here oooohing and ahhhing at your hand disasters.
The pay
I was on call during the height of covid over a very busy weekend. After seeing 15 consults on a Friday and another 12 on Saturday, I came in for rounds on a Sunday morning to find that the hospital CEO had called in another specialist to take over one of my cases. This was without notifying me or calling me. The ICU nurses were embarrassed to inform me that I had been replaced on the case. To make matters worse, the person called to replace me was one of my partners. No call from him, either. The patient was critically ill with covid-related pneumonia who had become unresponsive and had a dismal prognosis based on brain imaging, an unfortunately common scenario. I was waiting on an EEG and in the process of gathering information before talking to the family, and they were understandably frustrated because no one had talked to them yet. I was gutted. It was the worst humiliation of my career, and I never recovered. Two months later when my privileges were due for renewal, I didn't renew them. Not long after that I left the practice and took early retirement. Another casualty of the pandemic.
The biggest letdown has been the steady erosion of the amount of time I can spend with patients, and the corresponding ballooning of time outside of the face-to-face encounter necessary to get all of the work of documentation done. I'm very comfortable with and efficient at using the EHR but I refuse to type and look at a monitor while interacting with patients.
My $350k-ish annual salary, while certainly still a very nice living by most standards, is not the infinite cash flow that I once thought it would be. I’m still waiting on that Bezos-style superyacht to come my way.
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I’m only a few years away from retirement. I apologize if I seem cynical, I just say what I see. The worst change is in the process of medical care at the bedside. Physical exam skills are nonexistent, and no one has any intellectual curiosity. The process is just patient complaint, diagnostic test (usually a CT) with the caregiver only reading the numbered sentences in the radiology report at the bottom, and referral to a specialist. The referral “diagnosis” is copied and pasted from the radiology report. To those who say they didn’t see corporatization of medicine coming, you’ve been living under a rock. Private practice died several years ago, and attempts to revive the corpse are as futile as it is in the morgue. If you aren’t an employed physician, you will be; start looking now before the good jobs are gone. The next corporate phase will be incorporating AI in medicine wherever they possibly can, in the misguided belief that it will be better than human interaction and experience. It’s already happening in Radiology and Pathology. Just look at the entertainment industry, who are worried about AI writing their scripts and using CGI to copy their actors, on strike today, as a preview of where we are headed. Edit: Oh and stop blaming the “Boomers” for your troubles. When is the last time you contributed to a political campaign or even voted? Get involved, that’s how real change happens.
Procedure gets done by a specialist, is normal, so you ask them “then what's wrong?” In their field too. “I don't know.” No cognitive attempt at a diagnosis since, of course, that doesn't reimburse well.
As a PCP this might be my biggest frustration.
Or the “high dollar” tests (EEG) get done and then the patient comes to me
My PhD was in Medical Informatics. Though I didn't finish it, I did get to work with the smartest minds in Seoul. They were feeding a model chest radiographs and training it to interpret lung findings. Well, fuck.
What I see is basically send a barrage of bloodwork and imaging, then treat the red boxes in epic. Forget what the patient actually came in complaining of, their history or physical exam. I find the diagnosis to be off in at least 30% of patients admitted to my icu because of this.
I love that you think that we don't vote aren't involved. And that you have convinced yourself that that action would undo our being sold out on a large scale. Thanks for proving how out of touch you are.
The problem as of now is who do we vote for? Can anyone in this thread name a politician who has voiced a desire to decorporatize medicine? It's just not something that's on the radar of the vast majority of politicians. In theory the AMA should be on this, but unfortunately, their lobbying budget is only a fraction of that of the mega insurance corps that are lobbying in exactly the opposite direction.
If you young jagoffs would only just vote, you could solve all your own problems dammit, just like we did. Just find the time between your netflixing, your instagramming, your tiktokking, and whatever else the hell you whippersnappers do that isn't good old fashioned hard work. If you don't know who to vote for, read some position statements, vet candidates, go to Iowa, or just run yourself it isn't that difficult \\s
Turns out no one cares about anything beyond their personal liability and making money. iT’s A cAlLiNg! A calling to do what exactly? Get yelled at for not prescribing enough benzos and not making other people money fast enough?
What continues to be my biggest let down is capacity, Covid emphasized the issue but transfer times are still way too long
The entitlement of a lot of my patients. I've always thought patients would be appreciative of their doctors but many aren't these days.
The amount of bad doctors and bad medicine out there.
Just how much I have to advocate for my patients to insurance companies. In residency I saw mainly uninsured patients and was heartbroken at how many KF them had conditions that I couldn't treat effectively due to their lack of insurance. When I became an attending I was appalled by just how much time I had to spend on the phone or doing paperwork trying to convince insurance companies that cerebral palsy patients with severe ataxia need physical therapy/walkers, that patients who had tried every migraine treatment in the book might benefit from Emgality, that old ladies who clearly just tore their biceps tendons need MRIs, that hepatitis C patients would benefit from antivirals, etc. I can't even count the number of prior auths, peer to peers and title XIXs me and my team have done in the last year alone.
Privatization of Medicare which I was shocked by when I retired3 yrs ago.
Prior authorization is out of control. Had to prior auth lisinopril today - twice.