-Laelth

If you were looking for patient habits or physician supply to change overnight, you've got trouble. If you see the ACA as a longer-term process you might not be as cynical. (Remember, Social Security did not even have a cost-of-living increase for its first 40 years.)

The Affordable Care Act does contain provisions for training and expansion of medical practitioners. Undoubtedly, it will not cover all the projected need; and undoubtedly, this expansion will be a process achieved over time and with various additional programs initiated by the government. But to start getting our collective panties in a twist because on January 5, 2014, as the program begins, people are still going to their local ER or there are not enough doctors in an underserved neighborhood--well, that's looking for problems, not solutions.

...there is a hidden problem in this assumption -- the assumption is that people have the time to take off from work to take advantage of all these new trained personnel. That's one HUGE assumption when you eke by on what you make working as many hours as humanly possible; now take a day off work PLUS the co-pay and see how it looks. Furthermore, plan on doing that with some regularity for any other family members, plus so-called 'routine care' and you're going to find most poor people -- the people using the ER's in this manner -- simply can't -afford- to do that.

You can argue that in the long run they'll save money on the preventative care, and you'd be right -- but planning for the long term is -not- the reality of these folks. If it were, they wouldn't stay poor for long. This is the harsh reality that gets overlooked because, simply put, unless you've (generic 'you') been there, you don't -think- about that kind of thing.

You have to take off just as much time from work to go to the ER as to a doctor's office (more actually--we once waited 5 1/2 hours in the ER for my husband to be seen, and it was a life-threatening situation).

The co-pay for the ER is far higher than for a doctor's visit.

The point is, people need to be trained over time that if they or a family member get sick, and it is not an emergency situation, that it is better and cheaper to go to a physician or clinic or nursing assistant. It's not more time consuming; it's not more expensive.

It is -always- more expensive in an immediate-term cash layout budget to plan for a guaranteed expense than to hope you can go 6, 8, 10, 12 months without getting sick. Let's say you need to go, on average, once every 3 months for preventative care. That's potentially 4 days off of work (you don't really think fast food joints, for instance, simply let you take off for a few hours in the middle of a business rush!), plus the doctor co-pays (and most of these poorer people have shit insurance through their job to begin with, including massive deductibles which just pushed the doctor's bill up to $160 or so, which is what my best friend pays per visit before labwork, prescriptions, and so on). So that's...*quick math using our local costs*...$1260 ($160 doctor, $110 lab, 4 times, plus the cost of 4 days work@minimum wage at 6 hours, a typical ff shift or $180) in guaranteed costs not counting prescriptions.

The emergency room, provided it needs to be used, will be a couple hundred in most circumstances. Anything that goes above and beyond that can be submitted for Financial Aid from the hospital at 100% reimbursement (which the doctor's offices alone typically won't do).

I know that this is how it works -- I just did this exact thing less than 3 weeks ago for someone close to me, at a final cost of 2 days off work and a written-off hospital bill of $6,000. It is -actively- detrimental to go to the doctor for people in these kinds of situations no matter how many well-trained folks they have. It's a harsh reality that goes unnoticed by people who don't live like they do.

I wasn't talking about preventive care (and very few people need to go to the doctor every three months for "preventive" care; perhaps you're talking about ongoing care of a chronic disease?). I was talking about having a sore throat and going to the hospital ER to see if it's strep.

Second, no one will have "shit" insurance anymore. Your minimum wage worker will be getting regulated insurance, if not expanded Medicaid.

Third, incurring $6000 worth of costs at a hospital and having them written off is precisely the general economic problem we're talking about. Plus, your example is the kind of thing that makes people with real emergency situations risk their own lives with long waits because something that is not an emergency (but a simple lab test) is taking up the time of someone with a serious medical emergency.

...referring to in my example. I'm sorry I didn't specify that; it was merely an oversight.

But sadly, you're incorrect about insurance because fully half the states didn't expand Medicaid. Furthermore, if work offers a program then you can't even get a subsidy for shopping on the healthcare exchange -- you pay full rates, which makes the 'just barely legal enough to qualify by the skin of its teeth' insurance provided by work the only option (because the others are double and triple the cost in premiums). I understand ACA helped a ton of people, and I'm happy for them. But since no one could foresee the Republicans trying to cause problems (!!!), it -really- hurt a lot of lower-pay people, particularly multi-generational poor (since being carried on their parent's insurance isn't much better than what they could get on their own, and they're paying full price plus full deductibles).

I agree that the $6,000 is problematic, but that is beside the point. You can't reasonably expect someone who has literally nothing to be overly concerned about whether or not someone else has to wait a day to find out if a sore throat is strep. In a perfect world you could, but we don't live in one of those.

I'm not trying to make you 'get' it, or understand it from an angle of 'oh, yeah, that makes sense to live that way'. I'm simply telling you how it is, at least here (and presumable elsewhere, although I suppose I could be wrong on that).

the ACA has absolutely nothing to do with the American health care industry. The effort to conflate them has numerous proponents for a wide variety of reasons, but none of them has anything to do with your health or the quality of care you will receive should you be lucky enough to get in.

Want more doctors? Ban the AMA and outlaw its function. Remove the open-ended medical industry profit motive and we will have more medical schools turning out more doctors.

Want better doctors? Make sure that it is known that a medical degree is not a ticket to the millionaire's clubhouse. Yes, you'll make a good living and become a well-regarded member of your community, but you're not going to get rich, period.

Just like any union does.

That is a part of this that is rarely mentioned. Thanks for mentioning it.

... sigh. The AMA is nothing like a union. It's an organization of dusty old farts heavily subsidized by the pharmaceutical industry.

They have trouble giving away memberships to young medical students and physicians who treat AMA crap as junk mail.

Training new physicians, setting up new medical schools and residencies, or expanding existing programs is expensive and largely limited by government funding.

What's happening now is we are importing physicians trained in other nations, in effect "outsourcing" physician training.

If we in the U.S.A. want more well trained primary care physicians then we have to pay for them -- subsidizing more U.S. medical school slots, primary care resident slots, and the medical students themselves.

New doctors often avoid primary care simply because it doesn't pay well enough to make up for the time and grind of medical school and residency, the years and years of living in student "poverty," the huge student loan debt incurred along the way, and the miserable working conditions of insurance-and-hospital corporation directed demands for assembly-line like "productivity."

It's just a professional organization that most doctors don't even belong to.

Our state AMA affiliate would love to get a new medical school here, but schools are expensive to establish and maintain. There's absolutely NO AMA lobbying against more schools on our local level; rather, M.D.s here would fully support a medical school. But new medical schools have specific needs, primarily a sufficient population base of patients and a teaching hospital with sufficient number of beds, which means urban areas. You also need both basic science and clinical faculty, and not every state has access to quality faculty.

They want to be specailists like Oncologists and Cardiologists because that's where the money is.

The "shortage" or doctors is completely manufactured, by the AMA. Why they are allowed to do this is a mystery, I thought we had a "free market" economy.

Thanks.

The bottleneck is in residencies. They haven't increased from 2008 to 2013.

No residency, no license to practice medicine.

Doesn't matter that the # of MDs has increased a bit since then.

The AMA doesn't fund residencies. It was determined in the '00s that we'd have a doctor glut by now and there was no need to expand residencies. That was a federal decision, "research based" and "data driven."

Make changes now and you'll see more doctors start surfacing in 3-4 years. You just don't say, "Let there be doctors!"

We did that with teachers in the '90s. A year later we had alternative teacher certification programs everywhere. And a few years later were up in arms at the need for tighter requirements for teacher training, since so many were basically shown a classroom and told, "There, take the certification test." It's not the way to get a highly qualified teacher corps. And it wouldn't be the way to get a cohort of well-trained physicians.

Personally, I think we need to get back to the old General practioner model, where a full residency was not required to see patients with basic complaints in an outpatient setting. In most states a full residency is not required for licensure, but malpractice insurance is impossible unless you're board-certified.

20-30% of residents will dropout of their residency programs because the lifestyle is so brutal. Currently, there is no way for these individuals to contribute to medicine, not even to function at the level of a PA or NP. You want a quick fix to the primary care practioner glut, find a way to extend malpractice insurance to non-board-certified MDs not enrolled in a residency program.

I wasn't aware of the old model for GPs. It makes sense (probably why it was dropped).

Residencies seem to be as much, if not more of a problem than the debt incurred. I live in Las Vegas and there is lots of talk right now about building a new medical school (there is one private one in the city, but the only public program is in Reno). Aside from the cost of starting a new school, I have to wonder where the residents' will go - Las Vegas only has one public, not-for-profit hospital (UMC) and already, most of the residents coming out of the existing school go elsewhere for their residencies . . . and they don't come back. The not so funny running joke in LV is that when you get sick, your first stop should be McCarran Airport.

Free medical education in return for national service as a doctor for X number of years.

Just like the military does.

I know it's impossible to threaten the AMA, but they would certainly feel some pressure if we trained our doctors for national service.

The pharmaceutical corporations essentially own it now.

I have a family member in the program right now - one more semester of medical school to go.

She got a full ride to medical school, plus living expenses for a commitment of 2 years in a underserved area upon completion.

Her medical goal was always to be a GP serving the underserved.

She's one very determined gal who will attain every dream.

Many physicians (including myself) no longer practice because the working conditions, particularly during residency, are so horrendous.

Also, regarding the use of EDs by new Medicaid recipients, people tend to return to the sources of care they are familiar with. For people who have not had insurance, that's the ED. Getting people "on the grid" for healthcare is much more than giving them an access card. I certainly hope the ACA foresaw this and has plans for dealing with it.

I know quite a few MDs who quit because they found alternative careers that were much more conducive to actually living a life.

... insane, bootcamp working conditions for interns/residents...

... and crushing student loans?

If no huge loans, maybe docs would not have to run their practices like an assembly line, and could have their own family lives.

Another source of good medical people would be corpsmen/medics from the military.

I knew guys who could do brain surgery with an Exacto knife... in the mud.... under fire... I think they could do school physicals for the kids.

continued to use. In fact, it's hard to see that they knew anything better.

AS for the ACA planners seeing this, I'm sure they did and that is why there is more to the ACA than just this important provision. An earlier post on this thread outlines the specifics of the actual delivery of health care to the population who didn't have it before, except for EDs.

The lady I work with had a mini-stroke and of course went to the ER. She was uninsured, so the paying the bill is a huge problem, but the bigger problem is that the hospital told her to get a primary care doctor to get follow up care. Without insurance, this was nearly impossible.
Thanks to ACA she now has medicaid, but she's still looking for a PCP.
I think most people who have been uninsured for a long time and are otherwise healthy won't immediately go to a doctor... until they get sick, so I wouldn't expect it to decrease ER trips immediately, but finding a doctor that takes medicaid can be problematic.
To the extent that there is a doctor shortage, it is caused by the AMA, which for reasons of maintaining their own salaries, regulates the number of people who get the training.

And so have a lot of other doctors I know. They quit because they found practicing medicine too stressful and demanding for the so-called luxury pay you think they were getting.

Maybe the pay's better in urban areas, but in rural areas, many docs are barely making it.

The AMA is more like the American Automobile Association. Does the AAA regulate the number of automobile workers trained? Does it negotiate auto worker salaries?



The facts are new physicians face brutal working conditions, salaries inadequate to pay huge student debts, etc., etc. Primary care residency slots are often filled by foreign trained physicians who must pass very difficult exams. And doctors who do make those "median" salaries often quit their jobs for other work or dissuade their own children from the profession in the rare case their own kids are not already saying "OMG! I'm never doing that!"

The situation is similar to that of teachers in rough communities. My wife and I met as Los Angeles school teachers. We were making pretty good money for young school teachers. People here might wonder why we quit and moved away when my wife was accepted to an out of state graduate school.

For me every day of teaching felt like falling into an avalanche of raw humanity. I was supposed to be teaching science, something I'm well qualified for, but that was the smallest part of the job. There were kids who couldn't read, kids who wouldn't turn anything in, kids who couldn't be motivated to write their names on a scantron quiz much less complete it, kids who were discipline problems, and then, if I managed to wrangle in a parent for a conference, hearing of home situations that explained it all.

After school I'd complete the useless administrative paperwork, grade papers, sweep my classroom floor... simply to decompress enough that I could face the freeway traffic well enough to drive home safely. Checking out of school I'd sometimes see substitute teachers breaking down in tears, never to return again.

Honestly, the only people who survive working conditions like that are the saints, the sadists, the masochists, or the dead-to-the-world zombies. We've all had teachers like those and in rough communities the difficulties are amplified. I'm no saint and I didn't want to turn into the other sorts of teacher. I found myself becoming increasingly authoritarian and I hated that.

In many places primary care medicine is much like that, but with dead babies and actively bleeding abuse victims, drug addicts, alcoholics, etc., etc.. Or else it's "assembly-line" except when something unusual comes up, and then it's losing money and wasting time arguing with knobs trained to say "NO" sitting in the cubicles of some insurance company.

Medicine in the U.S.A. is fubar but it's not because of the AMA or the supply of primary care physicians. Mostly it's a problem of Big Money corrupting our political process. The insurance companies, the hospital corporations, the pharmaceutical industry, giant corporations that don't want small businesses to be competitive in the job market, those are the real devils here.

If they feel better about using the ER due to being covered, there's a chance to educate them that now they are insured, they can get more preventive care.

The problem here is more treatment available, the solution is to go back to them not going to the ER as much?

We could always use more doctors, as that would make them cheaper.

"We need things like high-skill immigration for MDs, more urgent care clinics, and relaxed nurse practitioner licensing so they can take the lead on more cases."

"Immigration as a solution"? Here are some ways in which this is being addressed.

Affordable Care Act Section 5508
http://bhpr.hrsa.gov/grants/teachinghealthcenters/section5508.html

HHS awards $320 million to expand primary care workforce
http://www.hhs.gov/news/press/2010pres/09/20100927e.html

Creating Jobs by Addressing Primary Care Workforce Needs

And he reported that although the ER visits initially rose, they later subsided.

I.e., an excuse to bring in foreign doctors who will work for less?

It looks interesting, but it's just one paper and only appears to include two years. Moreover, I can't see enough of the paper to determine whether all possible objections were addressed. The obvious one is "Were the ER Room visits by Medicaid recipients 70% higher the first year and 10% higher the next?" In other words, did the study account for pent up demand.

Other obvious objections would be to ask if people were being treated for conditions that didn't warrant ER treatment. What if someone with a possible concussion just didn't go to the ER if they were uninsured but did go if they were covered. Are we saying that we think the latter is an indictment of Obamacare?

There are as many places in med school each year today as there were in 1972. That's absurd, and it's entirely the result of the AMA acting as a cartel.

See my post #42.

I'm not defending the AMA, btw. Time has passed it by.

Health care workers are now under the same big-money thumb as the other altruistic professions such as teaching. People want to be teachers, they want to be health care workers to help their fellow man. Therefore big money figures they can pay them less.

It's plutocracy. The very wealthy at the top, everyone else fighting for crumbs.

IMHO

Everyone should get free basic care. I know, I know, we have to pay for it somehow.

But a human being deserves to get taken care of and not being bankrupted.

Specialty medicine can be covered by supplemental insurance or cash.

I believe, OK, call me naïve,
that the only persons should go into the medical field are the ones that want to do it for the cause,
not to become rich. Medicine should not be commercial. There are more caring nurses out there than caring doctors.
Think about that.