The unofficial Obamacare thread...

[Cavatt]

It isn't the worst idea to expand the size of medical schools. DO schools are gaining more traction these days too.

The upside is that more and more people are going to PA school. We could use a lot more PAs for primary care stuff and non-specialized treatment so that MDs and DOs are burdened with having to deal with minor, garden-variety ailments.

Yeah and Urgent care centers can do a lot. People are making money on those. I paid 75 bucks to get stitched up one time when I didn't have insurance and it was worth it. An RN did it, but those laws are different everywhere. I wouldn't mind an RN diagnosing strep since all they have to do is swab and do a culture. Other things that are unknowns, you see the doctor.

 

[Sebastian]

Yeah and Urgent care centers can do a lot. People are making money on those. I paid 75 bucks to get stitched up one time when I didn't have insurance and it was worth it. An RN did it, but those laws are different everywhere. I wouldn't mind an RN diagnosing strep since all they have to do is swab and do a culture. Other things that are unknowns, you see the doctor.

I've read several states are debating whether or not to allow licensed psychologists prescribe meds due to a serious shortage of psychiatrists and an increasing need for mental health professionals. I can see both why it would be helpful and harmful. Any thoughts, @Hydroponic3385 and @jvlgato?

 

[buzzdog]

I've read several states are debating whether or not to allow licensed psychologists prescribe meds due to a serious shortage of psychiatrists and an increasing need for mental health professionals. I can see both why it would be helpful and harmful. Any thoughts, @Hydroponic3385 and @jvlgato?

They just ought to put Prozac in the water supply and get it over with. Especially since last November, seems a lot of people could use it.

 

[Hydroponic3385]

I've read several states are debating whether or not to allow licensed psychologists prescribe meds due to a serious shortage of psychiatrists and an increasing need for mental health professionals. I can see both why it would be helpful and harmful. Any thoughts, @Hydroponic3385 and @jvlgato?

A few states already offer that for psychologists. But it requires years of additional education and training, of course. It seems to benefit those states that have many rural residents with no other realistic options for psychiatric care.

 

[jvlgato]

Yeah, that's been debated on and off for years. Obviously, I'm not unbiased, and we feel there's turf to defend.

But the typical argument from the MD side is, if you want to prescribe, go to medical school. It's not a reasonable argument that if there's a shortage of something that requires certain qualifications, then make it possible to let someone else have those qualifications in a shorter time and with different (less, in our minds) required training. It's not fair to change the rules of the game, for those who went through the hardship of qualifying, spent years training, and paid a lot of money to play by those rules, and then someone outside the profession legislates a change in the rules so that someone else can do the same thing? Also, is that really good for the patient? If there's a shortage of commercial airline pilots, do you find people who are peripherally related, and permit a faster path to license them to fly commercial airplanes?

How about other solutions to the shortage? Would it make more sense to make psychiatry more attractive to MDs? It is typically one of the lowest paid three specialties in medicine. Sure, all doctors make a nice salary, but typical med students graduate over $200,000 in debt and are starting their career after residency at age 29 or more. My college classmate who also studied engineering started making a very nice salary right out of college, 8 years before I started my 'real' career. During those 8 years, I went to 4 more years of school and then 4 years of a fairly low paying resident's salary.

I haven't read this whole thread, but I looked up a few pages, and saw a mention of the difficulty in dealing with Medicaid. It's true that many MDs opt out of both at this point, especially Medicaid. When I was in residency, I planned to take medicaid, because I was idealistic, and felt it was important for the system to work that good doctors accepted medicaid. When I started my private practice, I did accept it for a few years. But when I took a hard, honest look at it, I was making less than minimum wage for the time I spent on those patients. They were more complicated and time consuming, had a higher no show rate, and the reimbursement was about 20% of what I could collect out of pocket and 25% of what I could collect from a good insurance plan like Blue Cross.

Also these two incidents were the final straws: 1) medicaid always paid several months later than everyone else, but I once received a payment for a patient I didn't remember seeing. I looked deeper into the records, and I had seen the patient for one visit, 2 1/2 years ago, that's why I didn't remember her. No explanation for waiting 2 1/2 years to pay me, just how it is. 2) I accepted into the inpatient unit, a patient who was witnessed to take a serious overdose of Dilantin (very toxic in high doses) by her roommate, in the group home where she lived, after her BF broke up with her. She denied having done it, said she was fine, and went to bed. She was forced into the hospital by involuntary commitment (a very difficult process), admitted medically for the overdose, was indeed found to have a very toxic level of Dilantin in her bloodstream, was medically treated and then transferred to psychiatry; I ran in to see her on the weekend, treated her and saw every day over about 10 days, got her feeling better, worked with her BF to salvage the relationship, and worked with her mother to make sure she'd be safe when she got discharged, and then was able to discharge her safely back to her group home. I never got paid one dime for that entire admission, and the hospital didn't, either. Why? She had Medicaid, and when Medicaid reviewed the case, they said she was not suicidal, so she didn't fulfill criteria for a psychiatric admission. What? It was a witnessed overdose after a breakup, which was proven with a toxic blood level of Dilantin. That is way more dangerous than someone who says she is suicidal! I requested a formal review in writing by Medicaid. Nope, never said she was suicidal, buh bye. I was enraged. I never saw another Medicaid case after that. The thing is, regardless of how little you are paid or how unreasonable a case may be, you are still held to the same standard of medical care no matter what. If that case went badly, and she walked out the door and killed herself, her parents could sue me because they could make the case that I should have known she would have killed herself; she just attempted a serious overdose, after all, and I should have kept her in the hospital longer. Crazy stuff, and very scary when you're on the other side of it.

I'll add that the VA has been a system that uses PAs and NPs a fair amount, and they do a nice job. But they are tucked into a specific clinic that suits their training, and work under the supervision of an MD who is trained in the same specialty that they're working in. Also, there are both psychologists and psychiatrists who work in primary care clinics and help the primary care provider decide if it makes sense to start medication for depression or anxiety. Anything more than that, such as Bipolar Disorder, Schizophrenia, Substance/Alcohol problems, mixed medical/psychiatric pictures, and both the Psychologist and Primary Care Provider have quick access to a psychiatrist, and from what I've seen, they are more than happy to send those patients on, as it gets too complicated for them. Not that they're not smart enough ... they just don't have the time to spend, the training, or the experience.

One could argue that a Psychologist sees just as many, or maybe more depression and anxiety cases, and that may be true. So allow them restricted ability to prescribe certain limited medications for certain limited diagnoses, such as Prozac for depression and anxiety. I suppose one could be trained for a limited capacity of prescriptions and diagnoses. But would that help the problem? A good PCP can treat first line cases of depression and anxiety, and in fact, primary care providers already write more prescriptions for certain antidepressants than psychiatrists do.

So, that's my one-sided view of it. It's been discussed and debated quite a bit over the years, and it's a complicated and many faceted problem, I know. No easy answers, otherwise it would have been solved a while ago.

 

[Hydroponic3385]

I'm all about anything that results in increased access to mental health care in underserved areas. Increased mental health care is not only beneficial to the individual, it's also a huge boost to the workforce and to medical costs. So whether it's giving (a very select group of) psychologists the opportunity to pursue prescriptive privileges, or doing anything possible to make psychiatry a much more attractive path for physicians, I'm for it.

But I'll also add that psychiatric meds are often too readily prescribed (by psychiatrists and especially by general physicians). I'm all about having prescribers who understand and value the effectiveness of psychotherapy for many mental health issues (especially ADHD, anxiety disorders and more mild to moderate mood disorders), whether psychotherapy alone or in combination with medication. Whether that's the (somewhat rare) psychiatrist who also provides therapy (or at least highly recommends therapy), or a psychologist with much additional training/education who can provide therapy and prescribe (and I agree - it should be limited medications for only certain limited diagnoses).

 

[Sebastian]

Interesting insights for sure, @jvlgato and @Hydroponic3385. Who knew healthcare could be so complicated (everyone save one).

The Freedom Caucus (lol) had demanded and won a concession that pretty much axes mental health as a core area of care. Moreover, they want to make employment a requirement to qualify for Medicaid (good thing that recent veteran unemployment rate is so low...). What do you guys think about that?

I know as a veteran, those moves could be catastrophic considering the 22 vets who commit suicide every day. For all their lip-service in "Supporting the Troops" and "Support Our Vets," the Far-Right of the GOP seems to be doing everything they can to make a bad situation a lot worse.

 

[buzzdog]

Interesting insights for sure, @jvlgato and @Hydroponic3385. Who knew healthcare could be so complicated (everyone save one).

The Freedom Caucus (lol) had demanded and won a concession that pretty much axes mental health as a core area of care. Moreover, they want to make employment a requirement to qualify for Medicaid (good thing that recent veteran unemployment rate is so low...). What do you guys think about that?

I know as a veteran, those moves could be catastrophic considering the 22 vets who commit suicide every day. For all their lip-service in "Supporting the Troops" and "Support Our Vets," the Far-Right of the GOP seems to be doing everything they can to make a bad situation a lot worse.

Do all vets have access to the VA rather than having to rely on Medicaid?

 

[buzzdog]

Yeah, that's been debated on and off for years. Obviously, I'm not unbiased, and we feel there's turf to defend.

But the typical argument from the MD side is, if you want to prescribe, go to medical school. It's not a reasonable argument that if there's a shortage of something that requires certain qualifications, then make it possible to let someone else have those qualifications in a shorter time and with different (less, in our minds) required training. It's not fair to change the rules of the game, for those who went through the hardship of qualifying, spent years training, and paid a lot of money to play by those rules, and then someone outside the profession legislates a change in the rules so that someone else can do the same thing? Also, is that really good for the patient? If there's a shortage of commercial airline pilots, do you find people who are peripherally related, and permit a faster path to license them to fly commercial airplanes?

How about other solutions to the shortage? Would it make more sense to make psychiatry more attractive to MDs? It is typically one of the lowest paid three specialties in medicine. Sure, all doctors make a nice salary, but typical med students graduate over $200,000 in debt and are starting their career after residency at age 29 or more. My college classmate who also studied engineering started making a very nice salary right out of college, 8 years before I started my 'real' career. During those 8 years, I went to 4 more years of school and then 4 years of a fairly low paying resident's salary.

I haven't read this whole thread, but I looked up a few pages, and saw a mention of the difficulty in dealing with Medicaid. It's true that many MDs opt out of both at this point, especially Medicaid. When I was in residency, I planned to take medicaid, because I was idealistic, and felt it was important for the system to work that good doctors accepted medicaid. When I started my private practice, I did accept it for a few years. But when I took a hard, honest look at it, I was making less than minimum wage for the time I spent on those patients. They were more complicated and time consuming, had a higher no show rate, and the reimbursement was about 20% of what I could collect out of pocket and 25% of what I could collect from a good insurance plan like Blue Cross.

Also these two incidents were the final straws: 1) medicaid always paid several months later than everyone else, but I once received a payment for a patient I didn't remember seeing. I looked deeper into the records, and I had seen the patient for one visit, 2 1/2 years ago, that's why I didn't remember her. No explanation for waiting 2 1/2 years to pay me, just how it is. 2) I accepted into the inpatient unit, a patient who was witnessed to take a serious overdose of Dilantin (very toxic in high doses) by her roommate, in the group home where she lived, after her BF broke up with her. She denied having done it, said she was fine, and went to bed. She was forced into the hospital by involuntary commitment (a very difficult process), admitted medically for the overdose, was indeed found to have a very toxic level of Dilantin in her bloodstream, was medically treated and then transferred to psychiatry; I ran in to see her on the weekend, treated her and saw every day over about 10 days, got her feeling better, worked with her BF to salvage the relationship, and worked with her mother to make sure she'd be safe when she got discharged, and then was able to discharge her safely back to her group home. I never got paid one dime for that entire admission, and the hospital didn't, either. Why? She had Medicaid, and when Medicaid reviewed the case, they said she was not suicidal, so she didn't fulfill criteria for a psychiatric admission. What? It was a witnessed overdose after a breakup, which was proven with a toxic blood level of Dilantin. That is way more dangerous than someone who says she is suicidal! I requested a formal review in writing by Medicaid. Nope, never said she was suicidal, buh bye. I was enraged. I never saw another Medicaid case after that. The thing is, regardless of how little you are paid or how unreasonable a case may be, you are still held to the same standard of medical care no matter what. If that case went badly, and she walked out the door and killed herself, her parents could sue me because they could make the case that I should have known she would have killed herself; she just attempted a serious overdose, after all, and I should have kept her in the hospital longer. Crazy stuff, and very scary when you're on the other side of it.

I'll add that the VA has been a system that uses PAs and NPs a fair amount, and they do a nice job. But they are tucked into a specific clinic that suits their training, and work under the supervision of an MD who is trained in the same specialty that they're working in. Also, there are both psychologists and psychiatrists who work in primary care clinics and help the primary care provider decide if it makes sense to start medication for depression or anxiety. Anything more than that, such as Bipolar Disorder, Schizophrenia, Substance/Alcohol problems, mixed medical/psychiatric pictures, and both the Psychologist and Primary Care Provider have quick access to a psychiatrist, and from what I've seen, they are more than happy to send those patients on, as it gets too complicated for them. Not that they're not smart enough ... they just don't have the time to spend, the training, or the experience.

One could argue that a Psychologist sees just as many, or maybe more depression and anxiety cases, and that may be true. So allow them restricted ability to prescribe certain limited medications for certain limited diagnoses, such as Prozac for depression and anxiety. I suppose one could be trained for a limited capacity of prescriptions and diagnoses. But would that help the problem? A good PCP can treat first line cases of depression and anxiety, and in fact, primary care providers already write more prescriptions for certain antidepressants than psychiatrists do.

So, that's my one-sided view of it. It's been discussed and debated quite a bit over the years, and it's a complicated and many faceted problem, I know. No easy answers, otherwise it would have been solved a while ago.

Medicaid sounds horrible to deal with.

How does dealing with Medicare compare in your experience?

 

[Sebastian]

Do all vets have access to the VA rather than having to rely on Medicaid?

No, not all veterans qualify for the VA. There is also varying levels of care one may qualify. Many veterans do not have access to a VA facility (rural areas especially).

The VA enrollment process is not instantaneous nor easy to navigate. There is a waiting period that varies by location.

 

[jvlgato]

Medicaid sounds horrible to deal with.

How does dealing with Medicare compare in your experience?

Medicare is much better to deal with than Medicaid. However, they are also complicated, and physician enrollment has gone up and down throughout the years, depending on political climate.

My dad is a retired cardiologist. He told me that early in his career, nobody would ever take Medicare. However, toward the end of his career almost everyone took Medicare, because reimbursement outside Medicare had dropped enough that Medicare had become competitive, and with the advent of managed care, Medicare was much easier to deal with even though the reimbursement was about 30% less.

When I started my practice, almost everyone took a Medicare. They paid about 70% of what you collect out of pocket. Plus they did not hassle you. You saw the patient, you file the claim, and you were paid in less than a month. Easy Peasy. In managed-care plans, you would have to apply for a certain number of visits with a managed-care case manager, they permit you several visits, before requiring another call to them and/or forms to be filled out in order to receive several visits more. Certain managed-care companies were known to give you a horrible time in order to get paid. For example, they may require a patient to be suicidal before you could even see them once as an outpatient. Some required a patient to be seen by their work's employee assistance program before they could see you. Most of them required a patient to be seen by their primary care provider to start things. Usually they require an authorization number to be entered in the form and some of them, I'm sure of it, would generate a number that was too large to fit into the box on the form, making it impossible to enter that number in the form. They would then reject the claim saying it wasn't authorized!

I accepted Medicare for the first 15 years of my practice. I stopped accepting Medicare in the last five years of my practice. They had decided to act more like managed-care companies. In fact, there were managed-care companies who took over certain populations of Medicare. They went door to door making promises to patients that were not true and got them to sign up. Once they were enrolled, they were bound by the restrictions of managed care and the provider needed to be signed up with that managed-care company in order to see the patient. In essence, they were with managed-care company X, rather than being in Medicare anymore. Also, they started requiring any of the newer medications to be either rejected or authorized with a form being filled out justifying the need for the new medication. I understand the need to save money, however I might've chosen a new medication for a reason other than the hot pharmaceutical rep. Maybe. And toward the end, half of the prescriptions I wrote for the patients on Medicare would get rejected, and then I would receive a faxed form requiring me to justify in writing why I chose that medication. Then there was about a 50% chance that it would be approved. If it was rejected, I would then have to call the patient and explain why I chose a different medication or see if they were willing to pay for it out-of-pocket. Again, I can understand the systems's need to save money, because Congress was requiring it, and tax payers wanted it. However, for me, that time added up a lot over several hundred visits in a year. By that time in my career, after a cost analysis, I could see that I was actually losing money by seeing Medicare patients. I was delaying accepting other new patients in order to hold slots for my existing Medicare patients. Not quite minimum wage level payment, but it was significant. And again, Medicare patients tended to be more complicated. They are either older, or disabled, and that adds a lot of medical complications. Sounds insensitive as a physician, I know. However, as with anyone making a living, there comes a point where you do have to make business decisions. Plus, word had gotten out that I was a decent doc who still took Medicare, and all the other decent docs had stopped taking Medicare. So I was starting to get overwhelmed with patients who had Medicare. Sad but true.

 

[CleveRocks]

Why does country of origin matter? It isnt about GPA with graduate school specifically. He also probably didn't apply to every med school in the country.

Plus, if he went to Case, why wouldn't case take him? More to the story.

I have known the kid since 3rd grade. Top student, always wanted to be a doctor. Spent a year post grad applying to schools, no go.

But forget his situation, statistically, what are the odds? I can't see this as coincidence so I am wondering what driving that..

I have no problem with Country of origin.. my cardiologist for example is quite good. My regular doctor Bangladesh has a Nazi bedside manner.. the other two are ok, but Nigeria has very poor English. It takes some time to communicate..

 

[The Human Q-Tip]

While you're wondering where the 7.5 million number comes from, I'll be wondering where this number comes from.

How many of those nine had an insurance plan that provided them with ridiculously poor coverage or provided nothing more than borderline negligent coverage that still left them screwed in case they ended up with anything serious?

Probably very few. Some may have had catastrophic plans that served them very well, except they were banned for most people as part of ObamaCare. Many of them were paired with HSA's, that also were limited under ObamaCare. Obamacare's mandatory coverage for mental health also raised costs significantly, making some plans unaffordable. Same with adding kids to age 26, the risks of guaranteed issue etc..

But maybe the best response is to say that it should be up to those people -- not you, and not the government -- to decide what insurance works best for them.

 

[The Oi]

What kind of professionals are qualified to deal with hand-penis superglue removal?

 

[Hydroponic3385]

What kind of professionals are qualified to deal with hand-penis superglue removal?

I specialize in all things penis, but not professionally