"Medicare for All" and psychiatry

[psych_hopeful123]

Seeing as Bernie Sanders's Medicare for All plan has become a big talking point for democratic candidates, and following some discussions I've seen floating around SDN about it, I was wondering what psychiatrists specifically see as the potential pro's and con's of this plan for the future of psychiatry in the US

Just hoping to get more educated on this topic as I think about my own career so all thoughts are welcome!

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[Stagg737]

Imo it's largely a moot point for psych. There's a legitimate shortage of psychiatrists almost everywhere. Magically giving more people coverage isn't going to increase access to care if there aren't enough docs to provide it. There are other reasons I think it won't really matter as well, but I'm sure more experienced members can explain more concisely and eloquently than I could.

 

[nexus73]

Cynical perspective. I can only imagine that once there is single payer the reimbursement for doctors accepting that payer will go down. Psychiatry will see an even greater percentage of doctors not accepting insurance. There will be some type of government subsidy for community psychiatry and FQHCs to take care of the sickest patients like there is now.

 

[clausewitz2]

Cynical perspective. I can only imagine that once there is single payer the reimbursement for doctors accepting that payer will go down. Psychiatry will see an even greater percentage of doctors not accepting insurance. There will be some type of government subsidy for community psychiatry and FQHCs to take care of the sickest patients like there is now.

I would actually expect some of the funding for FQHCs and CMHCs to dry up if Medicare for all becomes a reality. It is harder to justify big grants if the vast majority of your patients are insured.

This was certainly the CMHC experience in many states that expanded Medicaid. "What do you need state funding for, you can bill now."

 

[XannyBarz]

well it probably won't hit psych as hard as ortho

 

[Evidence Based]

Bring it on, would rather deal with a more streamlined system with fewer sets of paperwork (if the system is designed correctly). Also everyone being able to get care when they need it without going bankrupt is an unambiguously good thing.

Somewhat related, we would actually expect universal healthcare to improve people's mental health. Expanding Medicaid in Oregon was associated with a big drop in rates of depression even as people gained coverage and were screened more: https://www.nejm.org/doi/full/10.1056/nejmsa1212321

 

[TexasPhysician]

It would likely create a shift in both directions. Cash practices would expand for those willing to pay for high quality care. Insurance practices would be better suited for larger groups that can minimize overhead and add midlevels. Midlevel supervision would be an expectation to grow and attempt to meet a massive influx of demand.

 

[Sushirolls]

I have recently opened a private practice. I specifically sought out a 3 year lease as opposed to more common 5 year leases in this area. I wanted the flexibility to change to what ever circumstances will unfold. What I would do is really uncertain, I'll have to wait and see what flavor of 'Medicare for All' floats to the bowl surface. In summary I'm trying to set myself up to be in good place to flexibly react - even if not in medicine.

I suspect if its implemented it'll be tantamount to handing over the medical baton to ARNPs and the medical field will be similar to the school system. A once proud institution, under funded, cost cutting, strikes, overly legislated, and further increasing bureaucratic bloat. Teaching used to be just that teaching, now it has taken on a role of baby sitting for families who fail to socially invest in their kids (love, attention, discipline, read, etc) and so too shall the medical institution shift from Doctoring (teaching, research, discovery, connecting, educating, diagnostic truth, etc) to being a keeper of the algorithm.

Depending on how its done, it would also yield substantial job losses. Those who work within insurance companies. The billers in small independent operations out of their homes, or hospital departments or large billing companies. That's a lot of middle class jobs gone. With less money in the system as a whole hospitals and large clinics won't just slash physician income but ARNP and even PA, and RN, too. Every one will be hit, and positions will be cut. Medical departments will do significant reshuffling to be less MD/DO and more PA/ARNP. So the few departments heavy in MD will be slashed with no concern for quality but merely budget and numerous physicians will be out of work. They'll choose between a rural job (Gasp!) and opening their practice (if legally allowed too...).

 

[Sushirolls]

Bring it on, would rather deal with a more streamlined system with fewer sets of paperwork (if the system is designed correctly). Also everyone being able to get care when they need it without going bankrupt is an unambiguously good thing.

Somewhat related, we would actually expect universal healthcare to improve people's mental health. Expanding Medicaid in Oregon was associated with a big drop in rates of depression even as people gained coverage and were screened more: https://www.nejm.org/doi/full/10.1056/nejmsa1212321

The bolded and color changed text above. That's the thing. It won't. The government doesn't design things correctly.

As some one who recently has been learning about medicare applications, address updates, the PECOS system and calling medicare, I can assure you its worse than the private insurance companies.

 

[PsyDr]

HR 676

Section 103 requires providers and institutions to become not-for-profit.

Section 401 indicates that the end goal is the abolition of the VA and IHS.

 

[Evidence Based]

HR 676

Section 103 requires providers and institutions to become not-for-profit.

Section 401 indicates that the end goal is the abolition of the VA and IHS.

These things are both getting changed in the new bill FWIW. 'Everybody In, Nobody Out': What We Know So Far About the Medicare for All Act of 2019

The bolded and color changed text above. That's the thing. It won't. The government doesn't design things correctly.
As some one who recently has been learning about medicare applications, address updates, the PECOS system and calling medicare, I can assure you its worse than the private insurance companies.

Saying the government "doesn't design things correctly" seems more likely an ideological statement of faith than a verifiable fact. Other countries have national health systems with less paperwork and less physician burnout (ex. Canada; Why Canada's Docs Never Burn Out). "Medicare for All" is a marketing slogan, no one actually wants to take Medicare in the exact form it exists now and just scale it up. All proposals, for instance, call for global budgets for hospitals, which would eliminate billing for inpatient admissions, and call for a single formularly that would drastically cut down on prior auths.

 

[whopper]

Some aspects people don't insert into the debate that I think are important.

If we had a European-style healthcare system, it wouldn't kill private insurance. Countries like England have private insurance side-by-side as an option in addition to the government-mandated single payer healthcare. Just that the private insurance companies have to do a real good job to convince someone to pay extra to get their insurance. When government single-payer is brought up under this context for many it doesn't sound so bad.

Another major factor-the Right keeps arguing the system is great the way it is cause it's market based. That's not true.
The current healthcare infrastructure in America was started under Nixon's administration and it had consequences that weren't predicted at that point in time. Employers are the main provider of insurance coverage that tack it on as a job benefit. The problem there is the employer often-times picks the insurance while not consulting much if at all with the employees. The employees aren't often times given a choice though there are some exceptions. Sometimes an employer can offer multiple healthcare plans while the employees choose. Also often times in several localities there's only a few if even less employers. E.g. you could live in a town with only one major big business and that one company's healthcare becomes the defacto healthcare for the majority in the area without much competition at all.

But the bottom line is it's not market-based. It's not like the customer got to choose what was the best plan for them based on the cost and what it provided. More often they get the plan, don't understand how much how it works, nor does the insurance company or employer educate the patient on how it works.

I got patients all the time coming into my office not knowing they have a large deductible, what meds are covered, which aren't etc.

So if you want to think I'm on the Left cause I just mentioned government-single payer might not sound so bad, I counter that with the above. I too believe in capitalism and what we got now ain't capitalism. Capitalism is the system where competition allows for cheaper prices and better quality. If we really had a capitalism/market based system patients would be able to choose among an array of insurance companies competing to get you the best quality at the best prices more analogous to getting car insurance. This is not happening with the current system.

Also IMHO it stymies business to add on the expense of healthcare. Its' expensive for the employer and stifles small businesses. IMHO it ought to be divorced from the the employer's responsibility and move to a more market based system. That if anything sounds more capitalistic to me but the current debate doesn't even approach this issue in this manner and not surprisingly as to why. I'm really got any system that's better than what we got now. European style healthcare gets better results with less money (yes I know there's exceptions but overall the majority of it has better results). I believe a truly capitalist market based system would work better too.

 

[PsyDr]

These things are both getting changed in the new bill FWIW. 'Everybody In, Nobody Out': What We Know So Far About the Medicare for All Act of 2019



Saying the government "doesn't design things correctly" seems more likely an ideological statement of faith than a verifiable fact. Other countries have national health systems with less paperwork and less physician burnout (ex. Canada; Why Canada's Docs Never Burn Out). "Medicare for All" is a marketing slogan, no one actually wants to take Medicare in the exact form it exists now and just scale it up. All proposals, for instance, call for global budgets for hospitals, which would eliminate billing for inpatient admissions, and call for a single formularly that would drastically cut down on prior auths.

That's not what your source says.

 

[Evidence Based]

That's not what your source says.

"The new bill will likely not include one provision previously featured in HR 676 that banned investor-owned providers from participating in the new national health plan"
"The new Medicare for All Act will keep the IHS and VA systems fully funded and intact, even while their target populations will gain access to broader range of providers and services."

I just went to a briefing on the new bill two days ago and personally know a lot of the higher ups in activist groups who also confirm this is true in conversations they've had with Rep Jayapal, who's writing the new bill. You're welcome to not believe me until the bill comes out, but the above two statements are correct.

 

[PsyDr]

"The new bill will likely not include one provision previously featured in HR 676 that banned investor-owned providers from participating in the new national health plan"
"The new Medicare for All Act will keep the IHS and VA systems fully funded and intact, even while their target populations will gain access to broader range of providers and services."

I just went to a briefing on the new bill two days ago and personally know a lot of the higher ups in activist groups who also confirm this is true in conversations they've had with Rep Jayapal, who's writing the new bill. You're welcome to not believe me until the bill comes out, but the above two statements are correct.

1) Of course I will take the written bill in front of me as evidence more than an anecdote from someone. That's no dig at you. That's just good practice.

2) That one item does not address the first clause in 103 which says all providers will "No institution may be a participating provider unless it is a public or not-for-profit institution.".

3) Yeah, that does not say they are changing 301. As it stands now, HR 676 says that the VA and IHS were reported to be on a 10 year and 5 year schedule to be phased out. That statement says the funding will remain. That was always the case in the near term. I also seem to recall that there are some issues about treaties and the IHS, but I'm not sure.

 

[FlowRate]

Saying the government "doesn't design things correctly" seems more likely an ideological statement of faith than a verifiable fact. Other countries have national health systems with less paperwork and less physician burnout (ex. Canada; Why Canada's Docs Never Burn Out). "Medicare for All" is a marketing slogan, no one actually wants to take Medicare in the exact form it exists now and just scale it up. All proposals, for instance, call for global budgets for hospitals, which would eliminate billing for inpatient admissions, and call for a single formularly that would drastically cut down on prior auths.

Canada, where the government doesn't pay for therapy...

 

[dl2dp2]

This is all going to be a game of details:
"It will not allow participating institutions and providers to offer private care for covered services to the rich."

Key word: COVERED SERVICES. As it stands, Medicare allows you to charge for NON-COVERED SERVICES at ANY PRICE through membership based programs. Sure, 99213 will be billed at $X regardless, but as soon as ANY service that's non-covered (for example, off hour phone E-mail coverage) is on the table, the physician is allowed to charge ANYTHING for that service.

My suspicion is that a properly set up private practice would actually be unaffected by this. Non-covered services will continue to be priced by market. In fact, as someone above suggested, psychotherapy (esp. non-billable such as family and couples or extended time therapy) may be not covered in the new system and will be increasingly a mechanism for provider tiering.

 

[Evidence Based]

Canada, where the government doesn't pay for therapy...

Not saying the Canadian system is perfect by any stretch of the imagination! Every single payer proposal I've seen would cover all mental health services including therapy. There's nothing intrinsic about the Canadian system that mandates it do a bad job covering mental health, it's just a bad policy choice that lots of Canadians are advocating to change.

1) Of course I will take the written bill in front of me as evidence more than an anecdote from someone. That's no dig at you. That's just good practice.

2) That one item does not address the first clause in 103 which says all providers will "No institution may be a participating provider unless it is a public or not-for-profit institution.".

3) Yeah, that does not say they are changing 301. As it stands now, HR 676 says that the VA and IHS were reported to be on a 10 year and 5 year schedule to be phased out. That statement says the funding will remain. That was always the case in the near term. I also seem to recall that there are some issues about treaties and the IHS, but I'm not sure.

Totally fine, not expecting you to just take my word for it. The above article is written by two of the main single payer advocacy groups (who have been involved in drafting the bill), which I would think is as reliable a source we're going to get until the bill drops in the next two weeks. Physicians for a National Health Program just put out a press release saying the basically same thing (looks like it's not on their website yet but was in my inbox an hour ago so should be up soon).

Also the new bill in the House is a complete rewrite, and is not based on the language of HR 676 (and will have a new bill number). So the above referenced sections(103, 301) will not exist. But again, happy to circle back once there's actually a bill text to look at.

 

[Merely]

So can anyone comment on income potential under a single payer system vs current system? I feel like income potential would go down drastically?

 

[Armadillos]

So can anyone comment on income potential under a single payer system vs current system? I feel like income potential would go down drastically?

I think it’s hard to predict. I believe Canadian psychiatrists average about the same or even slightly higher salaries than psychiatrists in my area. I imagine the procedural fields have the most at risk purely because they currently make the most under current system.

 

[dl2dp2]

So can anyone comment on income potential under a single payer system vs current system? I feel like income potential would go down drastically?

Average may not change much. Variance will probably drop. It's debatable if it's a good thing. Some lucrative subfields will persist (i.e. high end cash psychodynamic/pure cash psychopharm) but will become even smaller.

It's somewhat unlikely for single payer to go through, but I think a universal mandate with a default Medicaid-like plan is a likely outcome in the next 10 years.

 

[whopper]

Not saying the Canadian system is perfect by any stretch of the imagination!

I've first-hand seen socialized medicine for several months. It has it's pros and it's cons. Some aspects about it could be worse. The argument is artificially binary. A new system in America doesn't have to be completely socialized or private. Some aspects could improve with socialization such as public vaccinations, and health screenings. Other aspects could remain largely privatized.

The main con I saw with the system is if you sucked as a doctor there wasn't much quality control. Several bad doctors simply just referred patients with issues where they'd have to put more than 10 minutes of attention into it to another doctor within the system to avoid really dealing with the issue, causing the patient to go into a wild-goose chase where they'd not go back to the original doctor ever or for several months. This same problem I've noticed is happening in our system too but just as wrongfully handled. E.g. doctors in our system make money per patient so if it's something like they want a sleep med doctor just gives it without warning the pt of the long-term problems associated with most sleep meds. End result a patient now being dependent/addicted to Ambien.

Another problem is people ought to listen to health care professionals about how to improve the system and not the talking heads on cable news, many of whom really don't have any in-depth knowledge on the topic but do have in-depth knowledge on generating ratings by politically ticking people off.

 

[Liquid8]

As an external observer working in a single funded system with private elements, I would be interested to see the details of Bernie’s universal care model.Our Australian version of Medicare has not been good for all doctors. The rebate hasn’t kept up with inflation for many years, which has more heavily impacted non-procedural specialities.

Eg. Many GPs for example bulk bill or only accept the benefit without any out of pocket charge to the patient. It’s a very competitive environment in that space, good for the patients but not necessarily for the clinicians. Their standard consultation is rebated about $37, but the inflation adjust rate is closer to $70-80. Some practices can charge the going rate, but free alternatives are available. After deducting for practice expenses, they might take home 55-60% of that.

OTOH, there are much fewer specialists so it’s the exception rather than the norm to do things like described above. Most specialists might start that way to build their private numbers, but over time they will all charge gap payments. I.e. If the rebate for a consult is $70, the charge might be $100. The patient pays $100, and gets back $70 from medicare in an automated process. As our system is archaic, allowing the patient to pay $30 and getting back $70 for the doctor is possible but a convoluted process due to a quirk in the system. Another features is that here the private health insurance companies are banned from covering any outpatient services, which is advantageous to doctors as it prevents them from setting low prices.

With Psychiatry being unpopular as it is, there is already an existing shortage of practitioners. There is a heavy reliance on IMG doctors to fill rural and public positions, and they are limited with restrictions on their ability to practice in private. Here there is also no true public outpatient equivalent, with public community services being exclusively reserved for low prevalence conditions like treatment resistant schizophrenia or the involuntary, and a lot of referrals for depression/anxiety being rejected as not being severe enough. While psychiatry is perceived by many to be low paying relative to other fields, the irony is that supply factors allow one to act as a price setter.

Here private rates range from $250-500 for a 1 hour new appointment and $150-300 for a half hour review with the Medicare rebate for these items is approximately $220 and $114 respectively. There are a few bulk billing psychiatrists who churn through patients earning $75 for 15 minutes with patients not paying anything. However, such is the demand that the waiting period might be 18-24 months.

Depending on the single payer insurance model proposed, I think a cash only US psychiatrist could stand to benefit. If a patient is already paying $200 for a session, then I could see a scenario where the rate charged could be increased by the value of the rebate. If the service is valued at $100, then one earns $300 the patient pays the difference and is no worse off. If the rebate remains fixed over time, then blame for future rate rises can be directed towards the failure of Medicare to index their payments appropriately. Of course, there would be psychiatrists only charging the value of the rebate, but over time they would eventually get booked out and patients will have to decide whether waiting or paying is the better alternative.

It’s also worth noting that here there also seems to be a mentality that you get what you pay for, and free is not necessarily good value, with many patients going to free GPs for straightforward consults like sick certificates and script refills, while only seeing their regular “paid for” GP for more complex consultations. While psychiatric services are not your typical Veblen good, I have seen patients who declined to see a “free” psychiatrist due to concerns about their qualifications, training and a perception that they can’t be that good due to not setting what the patient felt was fair value on their services.

 

[dl2dp2]

Here private rates range from $250-500 for a 1 hour new appointment and $150-300 for a half hour review with the Medicare rebate for these items is approximately $220 and $114 respectively. There are a few bulk billing psychiatrists who churn through patients earning $75 for 15 minutes with patients not paying anything. However, such is the demand that the waiting period might be 18-24 months.

Depending on the single payer insurance model proposed, I think a cash only US psychiatrist could stand to benefit. If a patient is already paying $200 for a session, then I could see a scenario where the rate charged could be increased by the value of the rebate. If the service is valued at $100, then one earns $300 the patient pays the difference and is no worse off. If the rebate remains fixed over time, then blame for future rate rises can be directed towards the failure of Medicare to index their payments appropriately. Of course, there would be psychiatrists only charging the value of the rebate, but over time they would eventually get booked out and patients will have to decide whether waiting or paying is the better alternative.

It’s also worth noting that here there also seems to be a mentality that you get what you pay for, and free is not necessarily good value, with many patients going to free GPs for straightforward consults like sick certificates and script refills, while only seeing their regular “paid for” GP for more complex consultations. While psychiatric services are not your typical Veblen good, I have seen patients who declined to see a “free” psychiatrist due to concerns about their qualifications, training and a perception that they can’t be that good due to not setting what the patient felt was fair value on their services.

This is fascinating. Your model is actually very similar to out of network reimbursement for private insurances here in the US. However, Single payer here as envisioned currently generally would disallow out-of-network balance billing. However, I suspect there'll be many specific carve outs, and perhaps mental health will be one. In fact, this whole 90833 add-on code, I would argue, is a backdoor carve out for psychiatry for balance billing.

It sounds like doesn't matter what system you have, certain issues are universal in the practice of psychiatry:
1) nobody wants to care and very little money in the public sector for severe mental illness
2) lots of demand for private work for "well to do", "less severe" cases, that the public system wants to shed anyway
3) long waiting list for insurance based coverage, patchwork of reimbursements for treatment
4) salary disparity between private and public providers--though not as dramatic as in say procedural specialties

I suspect these core features in mental health will persist regardless of what system you end up with.

 

[FlowRate]

So can anyone comment on income potential under a single payer system vs current system? I feel like income potential would go down drastically?

If it's literally Medicare for all, it'll go down most likely. The differential between good payers and medicare is greater than what you save in billing services. And medicare is itself one of the main reasons you have billers in the first place.

If you're talking about single payer otherwise, it's highly dependent on all sorts of details. FM is actually relatively lucrative in Canada...

 

[psych_hopeful123]

If it's literally Medicare for all, it'll go down most likely. The differential between good payers and medicare is greater than what you save in billing services. And medicare is itself one of the main reasons you have billers in the first place.

If you're talking about single payer otherwise, it's highly dependent on all sorts of details. FM is actually relatively lucrative in Canada...

Are there estimates for how much salaries will go down approximately with a full blown Medicare for All?

 

[finalpsychyear]

If it's literally Medicare for all, it'll go down most likely. The differential between good payers and medicare is greater than what you save in billing services. And medicare is itself one of the main reasons you have billers in the first place.

If you're talking about single payer otherwise, it's highly dependent on all sorts of details. FM is actually relatively lucrative in Canada...

In my area medicare pays the highest for EM services other than 1 private payer. Even if somehow a single payer passed by end of 2019 it would take 5-10 years to be transitioned into. I think there is a 99% chance nothing changes at least for 10 years minimum. I suggest new grads continue to live like a resident for at least the next 5 years as i plan on doing.

 

[FlowRate]

Are there estimates for how much salaries will go down approximately with a full blown Medicare for All?

Honestly not sure. Usually various economic think tanks do legit analyses with various degrees of politically biased priors when a bill becomes a very serious consideration. I don't know if anything like that exists RN. I'd just figure out your current billing/payer mix and then compare it to what your medicare collections look like. It's different for everyone and very hard to estimate how this would affect psychiatry at large. Even more psychiatrists would probably go cash only, actually, so maybe not too much.

In my area medicare pays the highest for EM services other than 1 private payer.

Wow, that seems a little unusual.

 

[finalpsychyear]

Honestly not sure. Usually various economic think tanks do legit analyses with various degrees of politically biased priors when a bill becomes a very serious consideration. I don't know if anything like that exists RN. I'd just figure out your current billing/payer mix and then compare it to what your medicare collections look like. It's different for everyone and very hard to estimate how this would affect psychiatry at large. Even more psychiatrists would probably go cash only, actually, so maybe not too much.

Wow, that seems a little unusual.

a 99213/99214 in my area has an allowable charge of 70/104 dollars. Is that on the low end? Also, i have 1 patient in the beginning who was medicare/medicaid and you only get 80% of that allowable charge period. Everyone else if your lucky has a secondary which pays the 20% or the patient.

Medicare for all would actually boost my income lol but i would then be forced to do the MIPS or whatever quality reports they require once you have a certain number of medicare patients.

 

[Coupd'Cat]

I support Medicare because I'm a human alive with other humans, psychiatry aside.

I believe people deserve the chance to live fulfilling and healthy lives, just like they deserve clean water (socialized), fire departments (socialized), education (free if public, but tied to local property taxes and thus unequal). That's what a more just social contract would look like to me.

The flip side of that is, I believe no one deserves to have their lives shortened, their health demolished, or their life savings cannibalized because they are being held at the throat by corporations and their puppets in our government. The same power system of the elite that commits genocide both here and abroad, keeps poor people poor, ravages communities of color, and then tells them its their fault.

Medicare for all may not be sufficient, but its necessary for there to be even a semblance of equity in this country.

 

[Shufflin]

...The flip side of that is, I believe no one deserves to have their lives shortened, their health demolished, or their life savings cannibalized because they are being held at the throat by corporations and their puppets in our government. The same power system of the elite that commits genocide both here and abroad, keeps poor people poor, ravages communities of color, and then tells them its their fault. ...

Fascinating. Evil corporations and genocide. Never heard that one before. I'm curious to hear your examples explaining how current genocide in the world is due to elites in big corporations.

 

[birchswing]

Fascinating. Evil corporations and genocide. Never heard that one before. I'm curious to hear your examples explaining how current genocide in the world is due to elites in big corporations.

Genocide is a very specific term, but governments kill on behalf of corporations to cause regime change favorable to them (the US acting on behalf of the United Fruit Company in Guatemala or the US acting on behalf of British Petroleum in Iran to overthrow a democratically elected president). Nestle had a mass disinformation campaign throughout the developing world to use its instant formula instead of breast milk resulting in unnecessary cost and worse health outcomes. The military industry itself uses war for profit, but that other industries leverage use of military violence for their profit is indisputable. Again, genocide isn't the word I would use, but I would say there is a callous indifference to the suffering of people of certain parts of the world when such action is taken. I think domestically there is more indifference to the effects policy will have on the poor and unfortunate and often those of color, whether it is allowing private prisons to charge prisoners exorbitant fees to only be able to have books sent through certain companies, or can only teleface through one company's proprietary and awful communication system, or whether it's a system that sends poor children to juvenile detention centers that their parents have to pay the fees for.

There might be a case for genocide that I am unaware of, but I am aware of cases to be made for callous indifference toward poor, disadvantaged groups of people.

 

[Coupd'Cat]

Fascinating. Evil corporations and genocide. Never heard that one before. I'm curious to hear your examples explaining how current genocide in the world is due to elites in big corporations.

Our nation was born out of genocide in the name of profit. These days, corporations know they can't blatantly enslave an entire race of people under encomienda while massacring them and divesting them of land. The modern day form is covert often-government sponsored killings to maintain profit and foreign markets, whether it be Exxon hiring military forces to murder Indonesian villagers, UFC as @birchswing mentions, or maintaining a constant security threat that justifies the public subsidizing of high-tech military industry and the U.S. bombing/drone strikes/crippling economic sanctions on food and medical supplies in Iraq, Yemen, Pakistan, etc.

OP have we derailed your thread yet

 

[Sardonix]

Fascinating. Evil corporations and genocide. Never heard that one before. I'm curious to hear your examples explaining how current genocide in the world is due to elites in big corporations.

For real? Hasn't money, slavery etc. been a pretty common theme of many genocides? One could argue others are more so than others, but resource/profit gain is usually a pretty big part of it.

 

[Shufflin]

When people get killed, especially on a mass scale, we should at least have enough sensitivity and historical integrity to properly recognize what killed them. Genocides going on right now:

Darfuris in Sudan - caused by ethnic conflict - the ethnic killings began in 2003 when ethnically Arab militias supported by Sudan's President Omar Hassan al-Bashir began massacring non-Arab people and destroying their villages.

Muslims in the Central African Republic - again ethnic tensions - the Central African Republic, an African country wedged mainly between the Democratic Republic of the Congo, South Sudan, and Chad, has been embroiled in a civil war ever since 2013.

ISIS killing Christians and Yazidis in Iraq and Syria - in brutal, genocidal campaigns in both countries, ISIS sought to systematically exterminate Yazidis, Shiites, and Christians and destroy their villages. They also carried out mass rapes in these communities.

The Nuer and other ethnic groups in South Sudan - civil war - South Sudan became the world's newest country in 2011, but since 2013, the country has been mired in a brutal civil war.

The Rohingya in Myanmar - again ethnic tensions - unlike the majority of the Buddhist country, the Rohingya are Muslim, and have long suffered as second-class citizens in Myanmar because most people in the country believe they are illegal immigrants and "terrorists" from Bangladesh.

When there is tremendous money to be made from the land, especially the Oil and Precious metals industries, you do see conflicts in those areas between militia groups and governments. You could point the finger at corporations for pursuing the excavation of those resources. But blaming companies for real current genocides is kinda insulting to all those dead innocent people IMO.

 

[Stagg737]

Bring it on, would rather deal with a more streamlined system with fewer sets of paperwork (if the system is designed correctly). Also everyone being able to get care when they need it without going bankrupt is an unambiguously good thing.

Legitimate questions: Have you ever worked in a VA hospital? Have you ever seen or used CPRS? Do you know the current methods that were recently placed to attempt to decrease suicide among veterans and the actual evidence behind these tools?

If no to any of those, I suggest doing some research to see how well government-run single-payer systems in the U.S. actually work.

Saying the government "doesn't design things correctly" seems more likely an ideological statement of faith than a verifiable fact. Other countries have national health systems with less paperwork and less physician burnout (ex. Canada; Why Canada's Docs Never Burn Out). "Medicare for All" is a marketing slogan, no one actually wants to take Medicare in the exact form it exists now and just scale it up. All proposals, for instance, call for global budgets for hospitals, which would eliminate billing for inpatient admissions, and call for a single formularly that would drastically cut down on prior auths.

One of my co-residents is Canadian and a few more in other fields at my institution are Canadian and none of them have very good things to say about the Canadian healthcare system, especially the mental health fields. My n is relatively small here (~5), but talking with them has been enlightening about several issues with their system that I had no idea about. After talking to them (patients being flat out declined for elective care, chronic hospitalization for moderate mental illness, intern-residents running units with little to no attending supervision, etc) I really can't advocate for the U.S. trying to imitate their system at this time.

I support Medicare because I'm a human alive with other humans, psychiatry aside.

I believe people deserve the chance to live fulfilling and healthy lives, just like they deserve clean water (socialized), fire departments (socialized), education (free if public, but tied to local property taxes and thus unequal). That's what a more just social contract would look like to me.

The flip side of that is, I believe no one deserves to have their lives shortened, their health demolished, or their life savings cannibalized because they are being held at the throat by corporations and their puppets in our government. The same power system of the elite that commits genocide both here and abroad, keeps poor people poor, ravages communities of color, and then tells them its their fault.

Medicare for all may not be sufficient, but its necessary for there to be even a semblance of equity in this country.

Those are wonderful sentiments, but explain to me how "expanding access to care" is going to do anything when wait times are commonly 4+ months for an initial appointment and f/up appts are often unable to be scheduled for 6+ months due to patient volume. How will increasing those wait times by flooding the system really help? You can argue that "well, at least people will eventually be seen!", but I have too many examples of patients doing worse after receiving minimal, inadequate care than no care at all to take that argument seriously.

So please explain to me how in a system of very finite resources this will actually benefit the overall populace in terms of mental health (and if your answer is mid-levels then don't bother responding at all).

 

[FlowRate]

One of my co-residents is Canadian and a few more in other fields at my institution are Canadian and none of them have very good things to say about the Canadian healthcare system, especially the mental health fields.

I had a roommate who was German, then PhD-educated in the UK, post-doc'd #1 in Canada and post-doc'd #2 in the US. She preferred the US system out of all of them... n=1 but also how many people actually have multiple years spent in multiple healthcare systems?

 

[Stagg737]

I had a roommate who was German, then PhD-educated in the UK, post-doc'd #1 in Canada and post-doc'd #2 in the US. She preferred the US system out of all of them... n=1 but also how many people actually have multiple years spent in multiple healthcare systems?

Had a similar experience with one of my attendings during med school. Originally from India, worked in France for a while then met his wife while working in the UK (wife was from Pakistan, worked in UK then came to US with him when they couples matched). Both stated they'd rather be sick in the U.S. than any other country in the world. I think we like to scrutinize our own system and focus on the issue of access (which is a legitimate problem) and romanticize all these other systems without realizing how many problems these systems actually have. Granted, neither of them were in psychiatry, but there are issues with every system in the world and many of them are either amazing or crap depending on what metrics one wants to look at.

 

[deleted736562]

I had a roommate who was German, then PhD-educated in the UK, post-doc'd #1 in Canada and post-doc'd #2 in the US. She preferred the US system out of all of them... n=1 but also how many people actually have multiple years spent in multiple healthcare systems?

Yet the objective data is fairly clear. The US system is by far the most expensive and with worse outcomes. Sure if you have tons of money you'd rather be sick in MD Anderson or something.

My n=1 is an American postdoc with French citizenship who was doing his postdoc in Germany when he fell with Guillaume-Barre. He needed months of hospitalization and months after for rehab. Didn't pay a cent. As per his attestation, his life and that of his family would have been ruined if he happened to be in the US.

 

[allthingsmedical]

The same power system of the elite that commits genocide both here and abroad, keeps poor people poor, ravages communities of color, and then tells them its their fault.

In reference to the bold: When you say "here" are you referring to the U.S.? If so, what genocide is being committed in the U.S.?

 

[SmallBird]

I wonder why there isn’t more emphasis on trying the low hanging fruit first. Like how so much money is spent on the last week of life. Or how ridiculous and time consuming CMS mandates are. Or how the insurance review process works. Or why the government doesn’t just make generic medications. I feel like the system could do much better with some small tweaks that don’t seem that controversial.

 

[Mad Jack]

I wonder why there isn’t more emphasis on trying the low hanging fruit first. Like how so much money is spent on the last week of life. Or how ridiculous and time consuming CMS mandates are. Or how the insurance review process works. Or why the government doesn’t just make generic medications. I feel like the system could do much better with some small tweaks that don’t seem that controversial.

Because ultimately the private system is largely a waste of money that could go to other economic sectors while also improving access to care and hopefully outcomes if everyone were covered

 

[birchswing]

Or why the government doesn’t just make generic medications.

This one I've been advocating for years. People think I'm nuts when I say it, but it's a matter not just of pricing but of national security. We send a very limited staff from the FDA around the world to inspect drug manufacturing facilities, and like a toothless tiger we send them our "observations" (not even warnings) asking them to please get the bird population under control that's pooping in sterile areas etc (that was one recent observation letter I read).

Except for fruit and vegetables, there's not a single product you can buy at the grocery store without a bar code, lot number, and expiration number on it from the manufacturer. People demand locally sourced, made in USA, organic, etc. for everything. But when it comes to drugs we're filling pharmacy bottles with drugs of dubious quality made around the world with no tracing system.

And what doesn't make sense with regard to so much outsourcing is that drug manufacturing is not highly labor intensive.

The national security part is that we are at the whim of multinational corporations as to whether they want to make any particular drug or not. No one is compelled to make lifesaving drugs available in the US market, and that's why we have shortages.

I don't take it, but from what I understand there's literally no Buspar available in the US right now.

I do take bisoprolol and for a while after Sandoz sold all their formulas to the Chinese* there was a nationwide shortage and I had to switch to another drug.

*There is a new law in China whereby any FDA ANDA gets automatic approval by the China FDA. Therefore it's now very lucrative for MNCs to sell their US ANDAs to Chinese companies, taking them out of the US market even when they're still sold around the world. They use this loophole of not having to go through any normal approval process even though the manufacturing site is shifted to China. Source: CASI Pharmaceuticals | U.S. FDA Approved ANDAs

This is the type of thing where I understand nationalistic instinct. If only there were a coherent voice for it in charge.

Anyhow back in December, Elizabeth Warren (I kind of like her but she's so earnest it hurts) proposed this same idea of government generics:

https://www.washingtonpost.com/opin...bc0fb0-023f-11e9-b5df-5d3874f1ac36_story.html

 

[VA Hopeful Dr]

Yet the objective data is fairly clear. The US system is by far the most expensive and with worse outcomes. Sure if you have tons of money you'd rather be sick in MD Anderson or something.

My n=1 is an American postdoc with French citizenship who was doing his postdoc in Germany when he fell with Guillaume-Barre. He needed months of hospitalization and months after for rehab. Didn't pay a cent. As per his attestation, his life and that of his family would have been ruined if he happened to be in the US.

The bold is almost completely false, and in areas where it isn't its a combination of a) access and b) our highest in the developed world by a large margin obesity rate.

 

[FlowRate]

Had a similar experience with one of my attendings during med school. Originally from India, worked in France for a while then met his wife while working in the UK (wife was from Pakistan, worked in UK then came to US with him when they couples matched). Both stated they'd rather be sick in the U.S. than any other country in the world. I think we like to scrutinize our own system and focus on the issue of access (which is a legitimate problem) and romanticize all these other systems without realizing how many problems these systems actually have. Granted, neither of them were in psychiatry, but there are issues with every system in the world and many of them are either amazing or crap depending on what metrics one wants to look at.

Right, it's not that any of them are all-good or all-bad, but shades thereof. The US system overall is pretty good.

Yet the objective data is fairly clear. The US system is by far the most expensive and with worse outcomes. Sure if you have tons of money you'd rather be sick in MD Anderson or something.

My n=1 is an American postdoc with French citizenship who was doing his postdoc in Germany when he fell with Guillaume-Barre. He needed months of hospitalization and months after for rehab. Didn't pay a cent. As per his attestation, his life and that of his family would have been ruined if he happened to be in the US.

People are so catastrophic with their estimates of the financial outcome of being hospitalized. If you have health insurance (which a postdoc should), the out of pocket maximum for literally all marketplace plans is $7900 and that's for a catastrophic plan-everything else is much lower.

The bold is almost completely false, and in areas where it isn't its a combination of a) access and b) our highest in the developed world by a large margin obesity rate.

I will try and find the excel doc I made for this back in med school, but our closest competitor in terms of per capita GDP, smoking prevalence, and obesity rate is the UAE.

 

[Stagg737]

I wonder why there isn’t more emphasis on trying the low hanging fruit first. Like how so much money is spent on the last week of life.

Becuz deth panelz r bad. Seriously though, US attitude towards death and end of life care is a huge problem. It's part of why my previously mentioned attendings said they'd rather be sick here than anywhere else. In Europe and Asia, if you get really sick towards end of life you're done. Apparently in the UK when a patient would go into a nursing home after a certain age that was it. Docs would come to the NH, but the residents wouldn't get admitted to a hospital. They get to die. Call it callous, but given the amount of money we spend on futile care I don't disagree with a more limiting approach. These are the kinds of policies that would have to be implemented in order to make socialized medicine work, and some of them would never be accepted by liberals or conservatives in the US.

 

[VA Hopeful Dr]

I will try and find the excel doc I made for this back in med school, but our closest competitor in terms of per capita GDP, smoking prevalence, and obesity rate is the UAE.

We're actually not too bad on smoking:
GHO | World Health Statistics data visualizations dashboard | Tobacco smoking

We smoke less than all of Europe except the UK and Scandinavia.

Obesity is a different story: https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf

We're the worst among OECD members (basically the developed world) but a fair margin.

Similar with diabetes: OECD iLibrary | Home

We're not the worst (#3 baby!) but we're much worse than most of the countries we usually get compared to (11% of adults in the US have diabetes compared to 4.5 in the UK, 7 in Denmark, 7.5 Germany).

 

[FlowRate]

We're actually not too bad on smoking:
GHO | World Health Statistics data visualizations dashboard | Tobacco smoking

We smoke less than all of Europe except the UK and Scandinavia.

Obesity is a different story: https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf

We're the worst among OECD members (basically the developed world) but a fair margin.

Similar with diabetes: OECD iLibrary | Home

We're not the worst (#3 baby!) but we're much worse than most of the countries we usually get compared to (11% of adults in the US have diabetes compared to 4.5 in the UK, 7 in Denmark, 7.5 Germany).

You reminded me that is why I mentioned smoking--US and UAE aren't as bad as most of Europe but similarly bad in obesity/diabetes. Helpful to compare apples and what not.

 

[calvnandhobbs68]

Canada, where the government doesn't pay for therapy...

Like the US where many insurance plans dont pay for therapy either?

 

[calvnandhobbs68]

People are so catastrophic with their estimates of the financial outcome of being hospitalized. If you have health insurance (which a postdoc should), the out of pocket maximum for literally all marketplace plans is $7900 and that's for a catastrophic plan-everything else is much lower.

That's assuming your hospital/doctor doesn't bill things incorrectly or your insurance company randomly denies **** for no apparent reason. Or there's some BS like the anesthesia group for your surgery is "out of network" for insurance (even though you didn't realize that when you were knocked out!). Or you're in another state where nobody is in network for your insurance company and you have to go to the ER. Or you have a Life-flight helicopter ride which your insurance company rejects the claim for (go search that one online for some great stories). Then you get stuck in a never ending cycle of calling the insurance company, then calling the hospital/doctor, trying to figure out who ****ed up. All the while, the hospital's billing department keeps send you bills remind you they're past due and eventually sending them to collections. You can do a 10 second google search to find tons of examples of this online.

This isn't some theoretical thing. I've personally dealt with this twice myself, it was a huge pain in the ass each time and these were just outpatient office bills (few hundred bucks, not the huge amounts you'd have to deal with from a hospital). Both of them were incorrect billing by the hospital/doctor's office. The insurance company said they weren't paying for it, the doctor's office admitted they messed up the coding, they kept saying they were going to tell the hospital system billing department about it, all the while the hospital system kept sending me bills until I got the "this bill is being sent to collections" ****. They just hope you'll eventually pay it (or some part of it) and stop bothering them about it. You have essentially no recourse. The billing person I bitched at literally told me "I don't have a supervisor, I'm the only one here". What am I gonna do about that, take her name and call the non-existent hospital Customer Service department?

People are so flippant with their inability to acknowledge all the f-ups within the hospital system that could devastate a patient financially.