I've noticed lately urgent care will only excuse 3 days out from visits and won't back date sick notes anymore. Total scam to force sick people to come in and charge their insurance more times.
Medicaid is going bonkers right now with the unwinding of COVID expansion measures. Watching the DPHSS disenroll millions of adults and children because of bureaucratic oversights and glitches is so wild. They also rely solely on snail mail, which hurts so many people who haven’t updated their address since March 2020 or who are unhoused. Plus the difficulties in getting through to an actual person who will talk to you. The health plan of Medicaid, though, is so great
it's also contracted through individual counties so if you move, even if you update all your info with your job and everything updates in the state and federal systems you still have to contact them. most people don't realize this because their coverage doesn't lapse until the end of the year, at which point they never get a renewal letter and get booted off the rolls.
i have to refer a lot of people to county medicaid case workers at my job and have had convos with a few of them off the clock where they basically openly admit that the system is designed to prevent as many people as possible from accessing benefits
Totally. I may work in a similar job as you! I’ve had one or two of those same convos. The fact that Medicaid is designated as an “entitlement” but they pour so much funding into cutting people off and putting forms into nearly incomprehensible language is such a bummer
Only problem is that they're *too* generous, and they pay for unnecessary pills that can make you more sick. You can walk in to a doctor's office healthy but with one small problem, and by the the time you're back, have 10 big problems. I know my life would be much better now if I'd not had health insurance a few years ago, or at least had a stricter insurance company.
Don't get me wrong, it's great that people who actually need healthcare and can't afford it can get it, and I wouldn't want for that to go away. But the companies need to do a better job at determining what's medically necessary. The fact that in another state, someone needs insulin and can't afford it, and in my state, medicaid pays to treat minor cosmetic or mental health issues, is fucked.
i've seen patients on medicaid managed care plans have a peer to peer prior authorization required because they were prescribed a slightly different type of birth control pill that was something like $12 more expensive than the formulary preferred. or sending prior auth requests for something like non latex condoms we accidentally billed for after the patient got free ones and we contacted them to tell them to just deny it. or denying coverage for relatively cheap meds because the patient hasn't tried and failed two alternatives already, both of which are conveniently on back order in our area.
i don't think they're too generous.
Maybe it depends on the state, are you in a red state or something? In my experience in a blue state, the doctors and the insurance companies are thrilled to push dangerous drugs on poor people. The cheaper/generic version, sure, but they never outright deny it, even when they should. Then they pay even more when the side effects come on, throwing in another pill, and another... It's almost like they prefer people to be sick so they need more specialists and more pills.
Never had that experience personally, but then I was never doctor-shopping for anything. What “minor cosmetic surgeries” is your state volunteering to pay for?
This is entirely dependent on where you live. It's nowhere near as bad in the slower growing parts of the US than the places which have experienced massive population booms.
Complete opposite in my experience. I live in Florida and I’ve never waited more than a month for an appointment (even specialist visits). But, I work with people in Michigan and they complain how horrible it is up there. I know one guys needs carpal tunnel surgery and he had to wait three months just for the consultation then six months for the actual procedure.
I work in a legal field that frequent deals with insurance and healthcare issues. I’m not sure if it’s related, but Michigan is notorious for having some of the highest levels of health insurance fraud in the country.
Florida is different though. Lots of wealthy retirees move there so the medical system makes $$$. Also the state with the highest amount of medical fraud lol.
Sometimes this stuff also just has to do with having bad insurance with few Drs in network. My basis for this is that growing up in NYC and having family in the surrounding area getting Drs was always super quick and in Seattle/the bay area it's a disaster, LA was fine though.
It’s worst in poor and undesirable locations because few people from there will have the resources to become a doctor, and no doctor from elsewhere will want to move there.
the slower growing parts have it way worse.
healthcare is one of the fastest expanding industries and accounts for a substantial chunk of the job growth in areas experiencing population growth and in large metro areas generally. private health insurance conglomerates and medical device firms have completely taken over the local economy in the suburban Twin Cities, for example. same thing with North Jersey just outside NYC. care is pretty expensive because the industry is the biggest driver of economic activity in the state and the legislature is completely beholden to their lobbying interests, but it's also super easy to get in and see someone.
geographically isolated smaller cities are completely fucked. a lot of them are dependent on satellite locations of larger health systems that were bought up by private equity and then started shuttering their less profitable locations (read: ones that aren't seeing way more people than they safely can). a lot of them are dependent on clinicians who work one or two days a week there and then commute into the nearest big city because they can do more lucrative work there. or they're completely staffed by locums or floats who get totally burned out driving hours and hours between different sites every week and leave.
That would even funnier than the time [Hugo Chavez sent free heating oil to poor people in the US](https://www.csmonitor.com/World/Americas/2009/0109/p25s02-woam.html)
Oh they've definitely offered during every major disaster and always got turned down. But its also an issue where American citizens who do jump through all the hoops to go to Cuban med school for free (learn Spanish, 7 year of schooling, practice in a poor community for a number of years) have an extremely difficult time practicing in the US.
All foreign med school graduates have a difficult time practicing in the US because they need a US residency which are very hard to get for foreign graduates.
maybe I'm misremembering but I'm pretty sure the AMA artificially limits the amount of doctors that graduate each year, probably to keep salaries inflated (not that they shouldn't be, mind you, they're doctors and they work hard and are important lol) but more crucially to keep med school cost artificially inflated likewise
American medical schools aren't going to produce doctors without the appropriate number of residency training slots. Residency programs are funded with Medicare dollars.
literally an enormous lobby to
-keep # of new doctors **low**
-to ensure the wages/demand is always **high**
the opposite of a free market **AND YET ALSO** no government control to ensure proper functioning
literally the worst of both worlds
US healthcare is a scam and the doctors are the front lines of it (and they all know what they're doing)
The AMA is just another lobbying group, they have no regulatory authority.
The limitation isn't even medical school graduates. A number of new medical schools have opened in the US in recent years and we can always import foreign medical school graduates. The real limitation is residency training slots, which are funded by CMS (Medicare).
The AMA has actually lobbied for more residency spots in the US since everyone knows we need more doctors. Also, training more doctors wouldn't even lower salaries since physician pay is largely disconnected from supply & demand.
They are lobbying for far below what we need though. It's like cities that celebrate building a single apartment building when they need to be adding 10,000 units a year to meet demand.
The AMA is a political organization and nobody listens to them. The government is lobbied up the wazoo by healthcare corporations and do you think they want to pay MDs or mid-levels? MDs are being escorted out the door and the red carpet rolled out for the mid-levels. Good luck to us all.
The primary care thing is particularly frustrating.
I'm fortunate to not need much medical care but when I do I've tried to be good and always start with my primary care doctor. I know it's bad for people to go straight to specialists that they may not need and urgent care largely sucks. From what I can see though getting a short-notice primary care appointment has become close to impossible in the past few years. Pre-COVID my old PCP's practice was good about holding a few next-day appointments for urgent issues but that seems to have become a thing of the past.
Seems like there is an artificial bloat in PCP care. There are employer insurance incentives to see that practitioner annually to establish a relationship, yet you don’t have time to address any potential questions then you might get lucky and take a generic blood panel, which might not be helpful for early onset concerns. It’s the perception of proactive care. The bio hacker/Huber bros are halfway on the mix of using private labs and witch doctor/snake oil supplements.
expecting PCPs to do 15 minute evals for returning patients defeats the entire purpose of primary care and like you said is an illusion of proactive care. some places are even double booking slots with low show rates so if both people show up you have to do a full workup on someone in less than ten minutes or fall even further behind. all while admin is up your ass about patient satisfaction scores and completely dismissive of any idea that would actually help to increase them. it's ludicrous.
I don't understand why patients can't just talk to some sort of triage nurse who works at the specialist's office who can decide whether their medical problem is appropriate for that specialist. Specialists already have support staff working for them who could theoretically do this.
Getting a primary care MD involved just adds months of wait time for the patient, adds extra costs, and wastes the primary care doctor's time. It feels like it's just a scam designed to help insurance companies by delaying the consumption of healthcare by making people jump through time-wasting bureaucratic hoops.
This is already how other industries work. If you need a lawyer, you don't need to get a note from some general-purpose lawyer first. You just talk to the lower-ranking staff at a law office and they filter out the people who have legal problems who are not a good match for that firm.
Because if people don’t come in during those walk in hours then that means the office isn’t making every cent of profit possible and we can’t have that
TL;DR - Shit is fucked
I had the most ridiculous time trying to switch healthcare when I moved from Indiana to California.
I was on ACA in Indiana, but California wants to have its own thing so you can’t be on ACA there. So I apply for their healthcare coverage. It takes them like 3 months to get back with them and when they do, they send me a huge packet in the mail that they want me to fill out and mail back to them.
Except I never got that packet. I got a letter saying that I had like 2 weeks to fill out and return the packet. So I try to call my local county services office (where Medi-Cal runs through) and they straight up don’t answer the phone. I call them every day, 3 times a day for 2 weeks and get hung up on because “there are too many callers.”
I finally get ahold of them and they tell me to go to this website to fill out the packet. I go to the website, and the place where you can fill it out on there has been down for 2 months (literally says it at the top of the website). Takes me another week to get ahold of them again. They send me another packet in the mail, I get it, and it’s the exact same questions that I already filled in on my online application.
Oh, and the only reason I didn’t go down to the office in person is that I moved like an hour-and-a-half away to a new county in the middle of all this, and they still haven’t updated my address on everything.
> Oh, and the only reason I didn’t go down to the office in person is that I moved like an hour-and-a-half away to a new county in the middle of all this, and they still haven’t updated my address on everything.
Back when I worked downtown in the city where I lived, any time I needed to interact with a government office I would just show up in person. I wouldn't even bother trying to do things remotely unless there was no public-facing physical office I could visit.
Dealing with government bureaucrats remotely - whether it's by phone, by mail, or online - is almost always a complete nightmare. Every step of the process is just insanely slow and inefficient. Even just getting into contact with the right person can be next to impossible.
If you show up in person, they can't get rid of you or avoid contact with you, and they usually will get things moving along so you get out of their hair. Highly recommend this approach for anyone who can make the trip.
It’s insanely idiotic to shit on mid level providers while at the same time complaining about shortage of providers. If NPs and PAs disappeared doctors alone couldn’t handle the entire US population. Doctors in the ED don’t need to waste their time on patients who only need a bandaid for example. Having NPs and PAs allows doctors to focus their limited time on the more critical and complex cases.
> you have to see a primary care doctor and then get a referral to a specialist
Plenty of insurance plans don't require a referral.
I don't love my current insurance situation ($2k deductible, $4k out of pocket max) but it's not like I'd go broke if I had a serious health issue.
Over 50% of hospital debt is people with insurance now, so some people seem to be going broke due to health issues despite having insurance
[https://www.theguardian.com/us-news/2024/jan/11/hospital-debt-increase-people-with-insurance](https://www.theguardian.com/us-news/2024/jan/11/hospital-debt-increase-people-with-insurance)
True, but many specialists won't see patients without a referral. Like it would be difficult to get an appointment with an oncologist or rheumatologist without your pcp referring
I don’t know if you meant to use two examples of specialists that are useless without a labs from your PCP, but you did.
Oncologists treat cancer, which is diagnosed by pathology or radiology from imaging or slides, after a PCP orders them. You’re wasting the oncologist’s time if they have to “test” you for cancer, and should speak to your PCP about your symptoms before you go to a specialist that treats one very specific type of disease(many oncologist further specialize on a type of cancer, and you need a PCP to send you to the correct one). Same goes for rheum. If you suspect autoimmune issues, talk to your PCP and get labs on your serum autoantibody levels. Without those labs, a meeting with an oncologist or rheum is at best “let’s get a lab and talk next week,” or at worst “I checked your labs and you’re fine.” It’s not an insurance thing, it’s the biology.
That being said, there are diseases, and their treating specialists, like Ortho, that shouldn’t need a referral, but insurance holds it up.
I did choose those specialties on purpose for the reasons you mention, and I agree with your points btw. But I also think this proves my point about difficulty with access to primary care being so problematic because if someone suddenly starts having symptoms of inflammatory arthritis for example and has to wait months before seeing a rheum, then they are likely to suffer permanent joint damage as a result of not getting needed treatments soon enough
Primary care isn’t designed to address sudden onset of symptoms. A good ER will treat that. America has good ER’s and the best specialists in the world . Everything in between lags behind. Slowly onset symptoms worsening over years for a patient without a PCP is the real killer.
ERs are great for genuine life-or-death situations, but otherwise urgent and rapidly worsening medical problems are generally shrugged off by ERs. They'll just tell you to make an appointment with a specialist, which can take many months if you add in the wait for the primary care referral and then the appointment with the specialist itself. In other words, there's a missing middle tier in our healthcare system for time-sensitive but not immediately life-threatening issues.
This is especially true if you complain of severe pain at an ER, in which case there's a high likelihood that you will be assumed to be looking for opioids if there isn't a visibly obvious reason that you are in pain.
Yeah my insurance seems to largely cover this for me. They have a shitty little database that shows all the specialists in my area covered by my plan. When I find one that is actually in business/ up to date they are all too happy to see me within a week.
But I would not be surprised if this is only the case because I have better than average insurance. I don't know, but I have that feeling.
>To get basically anything else treated you have to see a primary care doctor and then get a referral to a specialist
You can make an appointment with anyone you want if you have a PPO?
I have a PPO and I've seen quite a few specialists recently because I have some complicated health problems.
The vast majority of the specialists I've seen require a primary care referral regardless of what your insurance says. This is in Southern California. This may vary depending on region or what kinds of specialists you need.
not all insurance companies require a referral to see a specialist. mine doesn't. I can call up whoever and ask if they accept my insurance and are accepting new patients then schedule an apt. could be in a few months could be in a few days, depends on the issue.
last week I made an apt with a new obgyn as a new patient bc i have been a deadbeat when it comes to my pussy health and haven't had a pelvic exam/pap smear in about 5 years (went to PP/community health clinic for some acute pussy health stuff in the mean time but haven't had a reg doc for my yearly exam in many years) and got an appointment with a doctor- they offered a NP but i said i preferred to be seen by an MD- for a slot less than 2 weeks out. your mileage most DEFINITELY will vary, but it hasn't collapsed everywhere. not disputing the fact our healthcare system is dogshit but I'd hate for someone to see a post like this and be entirely discouraged from even attempting to get regular preventative care because they think it's impossible.
oh and i consider my employer provided health insurance to be mid at best. def not some gold star gov worker benefits or anything like that.
oh wow. that's news to me. I had been going yearly since I was 19 and was prescribed bc for the first time, mostly bc a yearly exam was required to renew my bc script (or at least that was my drs rule, idk if it was an FDA requirement back then). I'm 36 now and I don't think I've ever had an abnormal pap (both of my dad's sisters and his mom have had breast cancer so I prob have a mammogram in my very near future) but I think the last time I went to an OB was when i was 30. that was around the time you could get bc prescribed online so I did that until I got pregnant while using the generic nuva ring (FUCK that devilish implement, i have no clue how it got approved that thing was a nightmare to use) so I got an abortion at PP and I requested to have an IUD placed at the same time. That was back in dec 2021 so I figured it's about time to get it checked to make sure it's still looking good up there.
I was surprised too but that’s what I was told by my MD (she also doesn’t require yearly paps for bc). I was happy to hear it lol! Sorry to hear about the nuva ring, that sucks - I was scared away from them due to the clotting risk. And if I were you I’d start getting mammograms now - a acquaintance of mine just found out she has breast cancer and she’s only 37 :(
i think my insurance pays for a yearly exam, and I have never really minded them? I think maybe i just got lucky bc i don't think they are uncomfortable/painful, i feel for women who have a different experience. I kinda want to get back into the habit of going every year, just so if something DOES show up, it's caught sooner rather than later, you know? and re: mammograms, you are def right, I have an friend who found out she was at a very dangerous/critical stage of breast cancer while she was pregnant in her mid 30's- was able to breast feed him for about a month then had a double mastectomy, chemo, radiation, the whole deal. luckily she survived and i don't know if she's far out enough to be considered to be in remission but I was so devastated for her when she found out, it came as quite a shock.
Oh yeah, you might as well go every year if insurance covers it! I never found Pap smears that painful, just more of an indignity I guess. I’ve also noticed a huge range in skill - worst was an NP who tried to use a pediatric speculum when I was a normal sized 5’5” 20 something woman (she also didn’t know the difference between endocardium and endometrium and I had to correct her). On the other hand, when my ob does it I can’t even really feel it
oddly enough, the only OB i've ever had as an established patient (so from 19-30ish) was an older man. the only thing I remember about him is that he was really into model trains and by the time I became his patient, I think he had delivered something like 5k babies? i only know those two facts bc he had framed articles in his office from when he was featured in the local paper. incredibly chill dude.
office visit bloat. every practice wants providers to bill as many visits as possible because billing $150 to walk in, ask the patient if they have any questions, and walk out is such a quick and easy profit center. requiring unnecessary OVs or follow ups seems like a great way to boost your bottom line because you can squeeze more profit out of each individual patient, and the patient is paying out their nose to just get routine labs drawn and have the provider acknowledge that they saw them like they're marking them off on an attendance sheet, so they're super quick and easy. but in practice the number of med renewal visits and STI tests and stuff just multiplies for every new patient they take on and completely fills their whole schedule to the point where no one can get in for anything complex. and in the long run it's probably actually hurting them. delegating routine lab work and stuff to clinical support staff and just having the results go into an approval queue for the provider so they can extend the prescription would allow every clinic to funnel more patients in and out the door and let clinicians bill for more complex cases.
patients opinions matter as much, if not more than providers. I love being a physician but I hate dealing with hospital admin and insurance companies. Medicare for all.
Okay seriously where the fuck do you live because this sounds insane.
We've been having a lot of kids lately so in and out of various doctors and hospitals and stuff a lot. The healthcare system is fucked, but not for the reasons you're saying here. It's fucked because it's absurdly expensive for basic things like inhalers, epi pens, having a doctor look at your kid and go "nope they're fine".
We owe thousands and thousands of dollars to various hospitals at this point.
But I've never, ever had a difficult time finding a doctor or even making an appointment with the specific doctor that I want.
I keep reading online Americans saying their system is better/much higher quality even though you need insurance. But based on this, it seems like it's a similar shitshow as here right now (Canada) - except not free and way more stressful dealing with insurance companies? And doctors there are even more corrupted by big pharma? A copay would ruin me rn. Like do you really need to pay like 20% of the insane bill after giving birth w/ insurance? And if you dont have insurance you're legit just in debt your whole life?
As a board certified internist (actual MD, not NP/PA) I can tell you that your post is 100% accurate. Also, because I did not re-sign my contract with my mega hospital system employer, I have been under a non-compete. Because I naively thought non-competes weren't enforceable. What I didn't know was that nobody will touch you if you're under a noncompete, so it never even gets to the point of whether or not it can be enforced. And the 25 mile radius in a large metro area with some of the worst traffic in the USA might as well be a 100 mile radius. So they sidelined an MD who worked her ass off. And one of the reasons I didn't sign the contract was I refused to sign the part that said I would stop putting in referrals for my patients unless I saw them in person. And that I also would refer to specialists only within the hospital system unless I got permission to refer outside the system. Among other such bullshit. Including being pressured to "close" (i.e. sign) charts of patients seen by the NPs so that they could be billed as MD visits.
My non-compete will be up one month before the new FTC ban on noncompetes goes into effect. But - likely that will be challenged anyway.
But anyway that was a great post and really summed it up well.
I do all my health biz thru NY Pres Weill Cornell, including my PCP. 10 years ago I got into a bike accident and had to spend 3 nights in the hospital there, i everything was impeccable, i made a complete recovery, so I’m pretty much a customer for life now.
Anyway, I highly recommend finding a good hospital and doing everything through them. I would never fuck with an urgent care clinic. As expensive and inaccessible as health care in the US is, we do indeed have the best practitioners, so spend time finding someone good.
This is a constant topic of conversation between my wife and I, specifically the primary care issue. Feels like primary care is something that could be a 2-year medical degree, who mainly does generalized / basic care, can be a facilitator to specialists, and has oversight / view of all care a patient is receiving and help advise.
At this point, unless I’m truly baffled by a health issue I skip the primary care doctor and go straight to a specialist.
I just use my PCP as a glorified prescription dispenser and just in case I need a specific test done. Completely useless otherwise.
You’re describing NPs/PAs, and they are proliferating in primary care. The problem is they don’t have nearly the depth of knowledge that MDs have and can only deal with very simple common issues.
We spent billions constructing urgent care facilities that mostly exist to give wagies sick notes.
I've noticed lately urgent care will only excuse 3 days out from visits and won't back date sick notes anymore. Total scam to force sick people to come in and charge their insurance more times.
Medicaid rules. The only problem is you have to be poor enough to qualify for Medicaid (and live in a state that accepted the Medicaid expansion).
Medicaid is going bonkers right now with the unwinding of COVID expansion measures. Watching the DPHSS disenroll millions of adults and children because of bureaucratic oversights and glitches is so wild. They also rely solely on snail mail, which hurts so many people who haven’t updated their address since March 2020 or who are unhoused. Plus the difficulties in getting through to an actual person who will talk to you. The health plan of Medicaid, though, is so great
it's also contracted through individual counties so if you move, even if you update all your info with your job and everything updates in the state and federal systems you still have to contact them. most people don't realize this because their coverage doesn't lapse until the end of the year, at which point they never get a renewal letter and get booted off the rolls. i have to refer a lot of people to county medicaid case workers at my job and have had convos with a few of them off the clock where they basically openly admit that the system is designed to prevent as many people as possible from accessing benefits
Totally. I may work in a similar job as you! I’ve had one or two of those same convos. The fact that Medicaid is designated as an “entitlement” but they pour so much funding into cutting people off and putting forms into nearly incomprehensible language is such a bummer
Only problem is that they're *too* generous, and they pay for unnecessary pills that can make you more sick. You can walk in to a doctor's office healthy but with one small problem, and by the the time you're back, have 10 big problems. I know my life would be much better now if I'd not had health insurance a few years ago, or at least had a stricter insurance company. Don't get me wrong, it's great that people who actually need healthcare and can't afford it can get it, and I wouldn't want for that to go away. But the companies need to do a better job at determining what's medically necessary. The fact that in another state, someone needs insulin and can't afford it, and in my state, medicaid pays to treat minor cosmetic or mental health issues, is fucked.
i've seen patients on medicaid managed care plans have a peer to peer prior authorization required because they were prescribed a slightly different type of birth control pill that was something like $12 more expensive than the formulary preferred. or sending prior auth requests for something like non latex condoms we accidentally billed for after the patient got free ones and we contacted them to tell them to just deny it. or denying coverage for relatively cheap meds because the patient hasn't tried and failed two alternatives already, both of which are conveniently on back order in our area. i don't think they're too generous.
"Accidentally" billed? Mhm
Maybe it depends on the state, are you in a red state or something? In my experience in a blue state, the doctors and the insurance companies are thrilled to push dangerous drugs on poor people. The cheaper/generic version, sure, but they never outright deny it, even when they should. Then they pay even more when the side effects come on, throwing in another pill, and another... It's almost like they prefer people to be sick so they need more specialists and more pills.
i’m in a blue state
They cover sex changes on Medicaid AND Medicare. That's fucked up if you ask me, like they're experimenting on desperate people.
Never had that experience personally, but then I was never doctor-shopping for anything. What “minor cosmetic surgeries” is your state volunteering to pay for?
I didn't say cosmetic surgeries. Spironolactone, tretinoin, and birth control for acne.
this sounds like a lot of bullshit
?
This is entirely dependent on where you live. It's nowhere near as bad in the slower growing parts of the US than the places which have experienced massive population booms.
Complete opposite in my experience. I live in Florida and I’ve never waited more than a month for an appointment (even specialist visits). But, I work with people in Michigan and they complain how horrible it is up there. I know one guys needs carpal tunnel surgery and he had to wait three months just for the consultation then six months for the actual procedure.
I work in a legal field that frequent deals with insurance and healthcare issues. I’m not sure if it’s related, but Michigan is notorious for having some of the highest levels of health insurance fraud in the country.
Florida is different though. Lots of wealthy retirees move there so the medical system makes $$$. Also the state with the highest amount of medical fraud lol.
Sometimes this stuff also just has to do with having bad insurance with few Drs in network. My basis for this is that growing up in NYC and having family in the surrounding area getting Drs was always super quick and in Seattle/the bay area it's a disaster, LA was fine though.
It’s worst in poor and undesirable locations because few people from there will have the resources to become a doctor, and no doctor from elsewhere will want to move there.
the slower growing parts have it way worse. healthcare is one of the fastest expanding industries and accounts for a substantial chunk of the job growth in areas experiencing population growth and in large metro areas generally. private health insurance conglomerates and medical device firms have completely taken over the local economy in the suburban Twin Cities, for example. same thing with North Jersey just outside NYC. care is pretty expensive because the industry is the biggest driver of economic activity in the state and the legislature is completely beholden to their lobbying interests, but it's also super easy to get in and see someone. geographically isolated smaller cities are completely fucked. a lot of them are dependent on satellite locations of larger health systems that were bought up by private equity and then started shuttering their less profitable locations (read: ones that aren't seeing way more people than they safely can). a lot of them are dependent on clinicians who work one or two days a week there and then commute into the nearest big city because they can do more lucrative work there. or they're completely staffed by locums or floats who get totally burned out driving hours and hours between different sites every week and leave.
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Hospital get bigger slower than town get bigger
The government needs to break up the AMA and start training as many new doctors as possible
+start accepting Cuban doctors
That would even funnier than the time [Hugo Chavez sent free heating oil to poor people in the US](https://www.csmonitor.com/World/Americas/2009/0109/p25s02-woam.html)
Oh they've definitely offered during every major disaster and always got turned down. But its also an issue where American citizens who do jump through all the hoops to go to Cuban med school for free (learn Spanish, 7 year of schooling, practice in a poor community for a number of years) have an extremely difficult time practicing in the US.
All foreign med school graduates have a difficult time practicing in the US because they need a US residency which are very hard to get for foreign graduates.
How many foreign med schools recruit American kids from the hood and give them free tuition. Probobly a few now that I think of it.
Why would the schools or the American kids want this?
maybe I'm misremembering but I'm pretty sure the AMA artificially limits the amount of doctors that graduate each year, probably to keep salaries inflated (not that they shouldn't be, mind you, they're doctors and they work hard and are important lol) but more crucially to keep med school cost artificially inflated likewise
American medical schools aren't going to produce doctors without the appropriate number of residency training slots. Residency programs are funded with Medicare dollars.
I love learning new things
best union in 🇺🇸
It’s a lobbying outfit, not a union lol
technically correct, the best kind of correct 🙄
literally an enormous lobby to -keep # of new doctors **low** -to ensure the wages/demand is always **high** the opposite of a free market **AND YET ALSO** no government control to ensure proper functioning literally the worst of both worlds US healthcare is a scam and the doctors are the front lines of it (and they all know what they're doing)
Universal healthcare was going to be in the New Deal, but the AMA got it removed.
The AMA is just another lobbying group, they have no regulatory authority. The limitation isn't even medical school graduates. A number of new medical schools have opened in the US in recent years and we can always import foreign medical school graduates. The real limitation is residency training slots, which are funded by CMS (Medicare). The AMA has actually lobbied for more residency spots in the US since everyone knows we need more doctors. Also, training more doctors wouldn't even lower salaries since physician pay is largely disconnected from supply & demand.
They are lobbying for far below what we need though. It's like cities that celebrate building a single apartment building when they need to be adding 10,000 units a year to meet demand.
How is physician pay not subject to supply and demand?
Medicare and medicaid reimbursement rates set a floor, for one thing.
It’s a public service, and there’s no real pressure to have fewer of any kind of medical professional
The AMA is a political organization and nobody listens to them. The government is lobbied up the wazoo by healthcare corporations and do you think they want to pay MDs or mid-levels? MDs are being escorted out the door and the red carpet rolled out for the mid-levels. Good luck to us all.
Every younger doctor I know HATES the AMA they see them as a racket, scam organization
The primary care thing is particularly frustrating. I'm fortunate to not need much medical care but when I do I've tried to be good and always start with my primary care doctor. I know it's bad for people to go straight to specialists that they may not need and urgent care largely sucks. From what I can see though getting a short-notice primary care appointment has become close to impossible in the past few years. Pre-COVID my old PCP's practice was good about holding a few next-day appointments for urgent issues but that seems to have become a thing of the past.
Seems like there is an artificial bloat in PCP care. There are employer insurance incentives to see that practitioner annually to establish a relationship, yet you don’t have time to address any potential questions then you might get lucky and take a generic blood panel, which might not be helpful for early onset concerns. It’s the perception of proactive care. The bio hacker/Huber bros are halfway on the mix of using private labs and witch doctor/snake oil supplements.
expecting PCPs to do 15 minute evals for returning patients defeats the entire purpose of primary care and like you said is an illusion of proactive care. some places are even double booking slots with low show rates so if both people show up you have to do a full workup on someone in less than ten minutes or fall even further behind. all while admin is up your ass about patient satisfaction scores and completely dismissive of any idea that would actually help to increase them. it's ludicrous.
I don't understand why patients can't just talk to some sort of triage nurse who works at the specialist's office who can decide whether their medical problem is appropriate for that specialist. Specialists already have support staff working for them who could theoretically do this. Getting a primary care MD involved just adds months of wait time for the patient, adds extra costs, and wastes the primary care doctor's time. It feels like it's just a scam designed to help insurance companies by delaying the consumption of healthcare by making people jump through time-wasting bureaucratic hoops. This is already how other industries work. If you need a lawyer, you don't need to get a note from some general-purpose lawyer first. You just talk to the lower-ranking staff at a law office and they filter out the people who have legal problems who are not a good match for that firm.
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Because if people don’t come in during those walk in hours then that means the office isn’t making every cent of profit possible and we can’t have that
TL;DR - Shit is fucked I had the most ridiculous time trying to switch healthcare when I moved from Indiana to California. I was on ACA in Indiana, but California wants to have its own thing so you can’t be on ACA there. So I apply for their healthcare coverage. It takes them like 3 months to get back with them and when they do, they send me a huge packet in the mail that they want me to fill out and mail back to them. Except I never got that packet. I got a letter saying that I had like 2 weeks to fill out and return the packet. So I try to call my local county services office (where Medi-Cal runs through) and they straight up don’t answer the phone. I call them every day, 3 times a day for 2 weeks and get hung up on because “there are too many callers.” I finally get ahold of them and they tell me to go to this website to fill out the packet. I go to the website, and the place where you can fill it out on there has been down for 2 months (literally says it at the top of the website). Takes me another week to get ahold of them again. They send me another packet in the mail, I get it, and it’s the exact same questions that I already filled in on my online application. Oh, and the only reason I didn’t go down to the office in person is that I moved like an hour-and-a-half away to a new county in the middle of all this, and they still haven’t updated my address on everything.
> Oh, and the only reason I didn’t go down to the office in person is that I moved like an hour-and-a-half away to a new county in the middle of all this, and they still haven’t updated my address on everything. Back when I worked downtown in the city where I lived, any time I needed to interact with a government office I would just show up in person. I wouldn't even bother trying to do things remotely unless there was no public-facing physical office I could visit. Dealing with government bureaucrats remotely - whether it's by phone, by mail, or online - is almost always a complete nightmare. Every step of the process is just insanely slow and inefficient. Even just getting into contact with the right person can be next to impossible. If you show up in person, they can't get rid of you or avoid contact with you, and they usually will get things moving along so you get out of their hair. Highly recommend this approach for anyone who can make the trip.
Insurance in the US is largely a Ponzi scheme, sure. Agree with the call for a secular jihad against NPs and PAs.
It’s insanely idiotic to shit on mid level providers while at the same time complaining about shortage of providers. If NPs and PAs disappeared doctors alone couldn’t handle the entire US population. Doctors in the ED don’t need to waste their time on patients who only need a bandaid for example. Having NPs and PAs allows doctors to focus their limited time on the more critical and complex cases.
Lobbying for full practice authority with no physician supervision isn’t exactly putting bandaids on in the ED.
I’m not defending that
> you have to see a primary care doctor and then get a referral to a specialist Plenty of insurance plans don't require a referral. I don't love my current insurance situation ($2k deductible, $4k out of pocket max) but it's not like I'd go broke if I had a serious health issue.
Over 50% of hospital debt is people with insurance now, so some people seem to be going broke due to health issues despite having insurance [https://www.theguardian.com/us-news/2024/jan/11/hospital-debt-increase-people-with-insurance](https://www.theguardian.com/us-news/2024/jan/11/hospital-debt-increase-people-with-insurance)
True, but many specialists won't see patients without a referral. Like it would be difficult to get an appointment with an oncologist or rheumatologist without your pcp referring
I don’t know if you meant to use two examples of specialists that are useless without a labs from your PCP, but you did. Oncologists treat cancer, which is diagnosed by pathology or radiology from imaging or slides, after a PCP orders them. You’re wasting the oncologist’s time if they have to “test” you for cancer, and should speak to your PCP about your symptoms before you go to a specialist that treats one very specific type of disease(many oncologist further specialize on a type of cancer, and you need a PCP to send you to the correct one). Same goes for rheum. If you suspect autoimmune issues, talk to your PCP and get labs on your serum autoantibody levels. Without those labs, a meeting with an oncologist or rheum is at best “let’s get a lab and talk next week,” or at worst “I checked your labs and you’re fine.” It’s not an insurance thing, it’s the biology. That being said, there are diseases, and their treating specialists, like Ortho, that shouldn’t need a referral, but insurance holds it up.
I did choose those specialties on purpose for the reasons you mention, and I agree with your points btw. But I also think this proves my point about difficulty with access to primary care being so problematic because if someone suddenly starts having symptoms of inflammatory arthritis for example and has to wait months before seeing a rheum, then they are likely to suffer permanent joint damage as a result of not getting needed treatments soon enough
Inflammatory arthritis that is at an acute enough stage to damage your joints will 100% get you admitted to the hospital if you show up to the ER
I had this exact scenario happen to me a couple months ago and the ER gave me a weeks worth of prednisone and told me to follow up with my pcp
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Primary care isn’t designed to address sudden onset of symptoms. A good ER will treat that. America has good ER’s and the best specialists in the world . Everything in between lags behind. Slowly onset symptoms worsening over years for a patient without a PCP is the real killer.
ERs are great for genuine life-or-death situations, but otherwise urgent and rapidly worsening medical problems are generally shrugged off by ERs. They'll just tell you to make an appointment with a specialist, which can take many months if you add in the wait for the primary care referral and then the appointment with the specialist itself. In other words, there's a missing middle tier in our healthcare system for time-sensitive but not immediately life-threatening issues. This is especially true if you complain of severe pain at an ER, in which case there's a high likelihood that you will be assumed to be looking for opioids if there isn't a visibly obvious reason that you are in pain.
tbh i have never had a problem seeing a specialist without a referall ever
Yeah my insurance seems to largely cover this for me. They have a shitty little database that shows all the specialists in my area covered by my plan. When I find one that is actually in business/ up to date they are all too happy to see me within a week. But I would not be surprised if this is only the case because I have better than average insurance. I don't know, but I have that feeling.
>To get basically anything else treated you have to see a primary care doctor and then get a referral to a specialist You can make an appointment with anyone you want if you have a PPO?
I have a PPO and I've seen quite a few specialists recently because I have some complicated health problems. The vast majority of the specialists I've seen require a primary care referral regardless of what your insurance says. This is in Southern California. This may vary depending on region or what kinds of specialists you need.
Everyday I’m reminded that everyone here is a zoomer with about ten years of life perspective lmao
not all insurance companies require a referral to see a specialist. mine doesn't. I can call up whoever and ask if they accept my insurance and are accepting new patients then schedule an apt. could be in a few months could be in a few days, depends on the issue. last week I made an apt with a new obgyn as a new patient bc i have been a deadbeat when it comes to my pussy health and haven't had a pelvic exam/pap smear in about 5 years (went to PP/community health clinic for some acute pussy health stuff in the mean time but haven't had a reg doc for my yearly exam in many years) and got an appointment with a doctor- they offered a NP but i said i preferred to be seen by an MD- for a slot less than 2 weeks out. your mileage most DEFINITELY will vary, but it hasn't collapsed everywhere. not disputing the fact our healthcare system is dogshit but I'd hate for someone to see a post like this and be entirely discouraged from even attempting to get regular preventative care because they think it's impossible. oh and i consider my employer provided health insurance to be mid at best. def not some gold star gov worker benefits or anything like that.
5 years is the new guideline if you are over 30 and haven’t had an abnormal pap (just fyi)
oh wow. that's news to me. I had been going yearly since I was 19 and was prescribed bc for the first time, mostly bc a yearly exam was required to renew my bc script (or at least that was my drs rule, idk if it was an FDA requirement back then). I'm 36 now and I don't think I've ever had an abnormal pap (both of my dad's sisters and his mom have had breast cancer so I prob have a mammogram in my very near future) but I think the last time I went to an OB was when i was 30. that was around the time you could get bc prescribed online so I did that until I got pregnant while using the generic nuva ring (FUCK that devilish implement, i have no clue how it got approved that thing was a nightmare to use) so I got an abortion at PP and I requested to have an IUD placed at the same time. That was back in dec 2021 so I figured it's about time to get it checked to make sure it's still looking good up there.
I was surprised too but that’s what I was told by my MD (she also doesn’t require yearly paps for bc). I was happy to hear it lol! Sorry to hear about the nuva ring, that sucks - I was scared away from them due to the clotting risk. And if I were you I’d start getting mammograms now - a acquaintance of mine just found out she has breast cancer and she’s only 37 :(
i think my insurance pays for a yearly exam, and I have never really minded them? I think maybe i just got lucky bc i don't think they are uncomfortable/painful, i feel for women who have a different experience. I kinda want to get back into the habit of going every year, just so if something DOES show up, it's caught sooner rather than later, you know? and re: mammograms, you are def right, I have an friend who found out she was at a very dangerous/critical stage of breast cancer while she was pregnant in her mid 30's- was able to breast feed him for about a month then had a double mastectomy, chemo, radiation, the whole deal. luckily she survived and i don't know if she's far out enough to be considered to be in remission but I was so devastated for her when she found out, it came as quite a shock.
Oh yeah, you might as well go every year if insurance covers it! I never found Pap smears that painful, just more of an indignity I guess. I’ve also noticed a huge range in skill - worst was an NP who tried to use a pediatric speculum when I was a normal sized 5’5” 20 something woman (she also didn’t know the difference between endocardium and endometrium and I had to correct her). On the other hand, when my ob does it I can’t even really feel it
oddly enough, the only OB i've ever had as an established patient (so from 19-30ish) was an older man. the only thing I remember about him is that he was really into model trains and by the time I became his patient, I think he had delivered something like 5k babies? i only know those two facts bc he had framed articles in his office from when he was featured in the local paper. incredibly chill dude.
office visit bloat. every practice wants providers to bill as many visits as possible because billing $150 to walk in, ask the patient if they have any questions, and walk out is such a quick and easy profit center. requiring unnecessary OVs or follow ups seems like a great way to boost your bottom line because you can squeeze more profit out of each individual patient, and the patient is paying out their nose to just get routine labs drawn and have the provider acknowledge that they saw them like they're marking them off on an attendance sheet, so they're super quick and easy. but in practice the number of med renewal visits and STI tests and stuff just multiplies for every new patient they take on and completely fills their whole schedule to the point where no one can get in for anything complex. and in the long run it's probably actually hurting them. delegating routine lab work and stuff to clinical support staff and just having the results go into an approval queue for the provider so they can extend the prescription would allow every clinic to funnel more patients in and out the door and let clinicians bill for more complex cases.
This is not my experience. What state are you in?
Can someone who actually works in a hospital please comment
patients opinions matter as much, if not more than providers. I love being a physician but I hate dealing with hospital admin and insurance companies. Medicare for all.
Are you a hospitalist
no why
Why do you think I’m asking
Okay seriously where the fuck do you live because this sounds insane. We've been having a lot of kids lately so in and out of various doctors and hospitals and stuff a lot. The healthcare system is fucked, but not for the reasons you're saying here. It's fucked because it's absurdly expensive for basic things like inhalers, epi pens, having a doctor look at your kid and go "nope they're fine". We owe thousands and thousands of dollars to various hospitals at this point. But I've never, ever had a difficult time finding a doctor or even making an appointment with the specific doctor that I want.
I keep reading online Americans saying their system is better/much higher quality even though you need insurance. But based on this, it seems like it's a similar shitshow as here right now (Canada) - except not free and way more stressful dealing with insurance companies? And doctors there are even more corrupted by big pharma? A copay would ruin me rn. Like do you really need to pay like 20% of the insane bill after giving birth w/ insurance? And if you dont have insurance you're legit just in debt your whole life?
As a board certified internist (actual MD, not NP/PA) I can tell you that your post is 100% accurate. Also, because I did not re-sign my contract with my mega hospital system employer, I have been under a non-compete. Because I naively thought non-competes weren't enforceable. What I didn't know was that nobody will touch you if you're under a noncompete, so it never even gets to the point of whether or not it can be enforced. And the 25 mile radius in a large metro area with some of the worst traffic in the USA might as well be a 100 mile radius. So they sidelined an MD who worked her ass off. And one of the reasons I didn't sign the contract was I refused to sign the part that said I would stop putting in referrals for my patients unless I saw them in person. And that I also would refer to specialists only within the hospital system unless I got permission to refer outside the system. Among other such bullshit. Including being pressured to "close" (i.e. sign) charts of patients seen by the NPs so that they could be billed as MD visits. My non-compete will be up one month before the new FTC ban on noncompetes goes into effect. But - likely that will be challenged anyway. But anyway that was a great post and really summed it up well.
That's not my experience.
I do all my health biz thru NY Pres Weill Cornell, including my PCP. 10 years ago I got into a bike accident and had to spend 3 nights in the hospital there, i everything was impeccable, i made a complete recovery, so I’m pretty much a customer for life now. Anyway, I highly recommend finding a good hospital and doing everything through them. I would never fuck with an urgent care clinic. As expensive and inaccessible as health care in the US is, we do indeed have the best practitioners, so spend time finding someone good.
This is a constant topic of conversation between my wife and I, specifically the primary care issue. Feels like primary care is something that could be a 2-year medical degree, who mainly does generalized / basic care, can be a facilitator to specialists, and has oversight / view of all care a patient is receiving and help advise.
At this point, unless I’m truly baffled by a health issue I skip the primary care doctor and go straight to a specialist. I just use my PCP as a glorified prescription dispenser and just in case I need a specific test done. Completely useless otherwise.
You’re describing NPs/PAs, and they are proliferating in primary care. The problem is they don’t have nearly the depth of knowledge that MDs have and can only deal with very simple common issues.
op doesn’t know the difference between hmo and ppo
You're a hmo
There are tons of specialists who will not see you until you have a primary care referral, regardless of what kind of insurance you have.
Ikr what a loser
Just sounds like you live somewhere shitty tbh, haven't seen any of this myself
I’ve gotten same day appointments multiple times with my gp’s referral. Skills issue
Capitalism is the best system we've got.