Boy, oh, boy!!!!!  "I understand your frustration." my you-know-what!

This whole debacle started out as healthcare INSURANCE reform, til the insurance companies said--not our fault--and it soon because healthCARE reform!  I hadn't seen those obscene numbers you quoted, but it doesn't surprise me.

Healthcare workers (physicians, PA, NP) are being hung, left and right.  YOU are the cause of all this expense, don't you know?  All those damnable tests you order!!!!  What's wrong with you?  And when the pt goes down the tubes---why didn't you order that damnable test?  What's wrong with you?

Obamacare is not the answer-----insurance companies and the national organizations bought into that so quickly.  I don't know what "the" answer is---probably many started all together:  tort reform, adoption of preventive health as a viable form of medicine and way of life, slowing down on pharmaceutical R&D so that the cost of meds here in the USA could somehow begin to rival the costs in other countries, maybe going back to the old 80/20 major medical insurance where a doctor can truly perform the art of medicine and care for people..........

Melissa, I'll be behind you making faces and gesturing at that company you are on the phone with, and writing you a (worthless from me) script for  BP and anger-controlling meds!

Becky

Thanks Becky, It's always good to have you in my corner and I know I have someone to commisurate with!! It gets a little more ridiculous every day......And if the insurance companies REALLY WERE GOING BROKE, I'd be much more sympathetic, instead the only word that comes to mind in situations like these is "pathetic".  We need a change in our system but I agree...there is much to be desired with any current plan. I'm not certain why on earth our legislators don't ask those of us in the trenches what would work.  Those who are in academics see one aspect of medicine, we in the rural areas see another. Together, I think we could come up with a workable solution.

Melissa

Why have physicians handed healthcare quality over to For-profit Insurance companies (anyone whose pay is based even partly on receipts minus expenses) or their "star chambers" who make these guidelines (often out of date)?  I really appreciated asking the "messenger" whether if he/spouse was in a similar situation, would he/spouse be sastisfied with the guideline answer?  The future of healthcare appears to be headed towards something resembling socialized medicine, which I regret.  However, I think this future is better off in the hands of practicing physicians than insurance companies.

Regards,
Matt

Totally appreciate your frustration. Here in Canada we do not have overseers questioning our test odering but the problem is inordinate waiting times - e.g. 9 months for a sleep study is the norm, often a couple months for an echo, 2 weeks for an extremely urgent case that really needed on-the-spot TEE, 3-4 months to see an endocrinologist for runaway blood sugars, etc, you get the picture. Welcome to socialized medicine, where the rationing is done by virtue of the fact that demand exceeds supply. And I am practicing in an urban/suburban setting too boot.

I think the only thing that is going to save the health care system is a population-wide renewed emphasis on primary prevention (not to mention better secondary prevention). But I just don't see it coming.

Dan,

Not that we can solve anything today, but do you have ideas of how to balance the immediate needs of the population against the long term fix? 

Could you hire a group of dedicated Canadian physicians to attack the glut for a few months to shorten those eternal waiting lists? Would it just get gunked up again, or do you think it would help in the long run?

I don't think we'll ever get any American politician to look into the camera and say "America, we're fat, we're not exercising, we're smoking and we're doping. We're pregnant with kids we can never support and there are lots of you on disability and welfare who could be contributing at least some little something.  Our experiment with free love and all the premarital sex you teenagers can muster really isn't working. We need to get married and stay married and don't get married unless you really mean it and if you're going to teach your kids that anything that feels good goes, then tell them about birth control. Parents, teach your kids the "A-word", yep, that's Abstainance. It really isn't such a dirty word after all. Train for FREE how to screen BP's in every barber shop and beauty salon and grocery store in America. Make a GTT affordable. Tax breaks for every small and large business who provides AND SUPERVISES an exercise program or gives access to one. Give pharmacists a tax break and the legal impetus to directly monitor compliance with medications. Regulate the drug companies in such a way that America doensn't foot the bill for the rest of the world's medications (sorry, but that's the impression we Americans have and would like some debate on this if it's really an incorrect assumption). Cut much of the root cause of CHF by offering early PCI/lytic to every single AMI patient possible by mapping every square inch of America where Americans habitate and having a ready plan for detection and therapy of AMI. Require a certain calorie, fat gram and fiber content for every school meal and mandate an opportunity for  30 minutes of exercise daily for every student or cut funding.  Make every public building in America smoke free. TALK OUT LOUD about end of life issues. It's not legislation, it's education that will make the difference there.  Have a "talk with your elderly parent" week about exactly what their wishes are about whether they want to shocked, or CPR'd or intubated if they are nursing home bound IF they have no quality of life. By all means, be aggressive if they have a good quality of life and wish rescucitation but NEVER do that to someone you love who is suffering with no hope for recovery. Ask ourselves the question: Am I resucitating them for ME or for THEM?  My gosh, I could go on for 800 years!!!! and WHY ARE NONE OF THESE ISSUES NEVER DISCUSSED ALOUD by our POLITICAL LEADERS???? My gosh, it would be so easy to drive these campaigns, most of them at no cost. 

Why oh why don't the policy makers ask any of us who are in the trenches as to how to curb our current woes with health care? There are so many opportunities here.  I don't think the academic and research crowd have all  the answers. It's going to require guerilla warfare in the medical arena to really impact our growing problems with our health care access and the greatest contribution for this problem is not going to come from those who work in academic centers. Most patients aren't covered by academic center medicine. It will require a combined approach. We have to demand it on the county, then state then national level.   

thanks Dan. Let me know where I can send payment for this session. Somehow, I feel strangely better, kind of like after suffering a long bout of constipation,.....then relief. AHHH!!   : )  and Thank you Matt and Becky. I really appreciate your input as well! Great points.

Melissa (if I may call you that), you make many great points. I just got through a prior auth for an MRI--a waste of time. Another big problem politicians don't want to discuss is that we need to break our addiction to health insurance. Why is it being used for every little aspect of medical care? Physicians have also been complicit by allowing insurance penetration to take place. If you want an MRI, pay for it like you would in every other aspect of life. How much does an MRI cost? Why don't people know? Why is it so hard to "shop around" for labs, scans, tests, etc.? If I don't like my insurance company, why can't I just fire them like my phone company and get another one?

Competition lowers costs, plain and simple. Employer-based insurance prevents competition. Third party payers (insurance companies) limit competition because you don't know how much things cost--someone else foots the bill. Medicare is by definition a monopoly which precludes competition in any meaningful way. The inability to purchase insurance across state lines limits competition. You may have mentioned before David Goldhill's (a Dem but a business man first) article in The Atlantic in 2009 which dissects the problems well. http://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/7617/

Politicians love to compare health insurance to car insurance when discussing the requirement to have it if driving. But the analogy stops there. You don't use car insurance for gas and windshield wipers. You don't need an exchange to purchase one--just watch a commercial and call a number or go online. You are expected to pay for most stuff except for more major or catastrophic problems. And if you don't like them, you get another one and fire the other. Individual purchasing power is the key.

As I see it, things will continue to get worse until we are truly bankrupt. Then the health insurance industry along with Medicare/aid will implode and we will have a fresh start. See a doctor, pay them for their time.

MWS, here is what I would do (my long term fix for the vascular and cancer epidemics).

 Set up a vascular prevention center (VPC) in every city in the country. Staff it with a motivated physician-director, clinical psychologist, nutritionist, pharmacist, exercise trainer and kinesiologist (the last to provide the exercise prescription). The physician will assess and treat (pharmacologically) the risk factors at intake, the psychologist will help with esteem and smoking cessation, the nutritionist with weight loss and healthy food choices, the exercise trainer with am exercise program, and the pharmacist to sort out drug interactions and OTC issues, and coach on long-term adherence strategies.

Now for intake (getting patients). Whom to target? Require all people who have no family physician; or who see their PCP less than once per year; or who are on any sort of welfare or disability support to enroll - sort of like mandatory vocational training for welfare recipients. I can guarantee you a 90% cardiovascular risk reduction over 20 years with the multidisciplinary team approach and massive savings to the health care system. If your gov't implements it, you will also prevent cancers and you won't need insurance companies any more. I would also suggest advertising on the side of buses, on bus stops and billboards - ideally envelope funded so it could be free for patients to attend (yes I know, I am living a pipe dream).  Only a massive primary prevention effort can undo the toxicity our society has gotten itself into.

WOW!  Here we all go again, healing our country (world)!  Melissa, don't you remember before the 2008 election how many threads we had on this very subject?  It really does come down to prevention.  Get those inner city empty lots cleaned out and filled with gardens tended by the neighbors, where fruit and veggies would be just down the road for either no money (if you work in the garden) or a very nominal cost.  Have those community centers that DGH advocates teach cooking classes and have food fairs to try out different recipes so you can figure out what you really do and don't like.  Legislate nutritious food at school (have Jamie from England help out here) and mandatory recess/ PE times like you suggested, and take out those damnable vending machines!  Need a job?  Tend the community garden full-time.  Don't think you can do that?  Offer child-care services for someone who can.  Have mandatory drug testing for all Medicaid recipients.  Those on welfare will have to go to a food pantry and use their EBT cards there to get food so that it won't be used for non-essential items.  Have a work-for-food/shelter/clothing mandate---again if you can't do this, you will have to prove why.  Trade off times for childcare so you and a friend can get through the program and get gainfully employeed.  There is nothing wrong with cleaning up your neighborhood and being paid for it.  If you have a disability, you have to go back and prove it once every two to three years---especially back pain and certain mental health issues.  Again, you can do some sort of meaningful work here.  (I myself could probably qualify to go on disability, but I choose not to.  I just am now doing "office work" instead of bedside nursing.)

The legislators need to REALLY listen here on this website and to their constituents.  WE elected them.  Could we get this whole process down in a year?  Absolutely not.  And the ACA can't go as fast as it wants, either.  Those of us "in the trenches" do know how to fix these things, and if the powers-that-be would just back away and let us work, we'd get this fixed.

(BTW--you know the autism coverage mandates that are going on?  I wish that it didn't have to, and I'm not sure how it really is going to impact us as a nation.  My middle boy is autistic, and I know just how much his therapy cost us in the beginning.  It wasn't fun paying for it out of pocket.  But we did.  I really waffled on supporting this issue BECAUSE I didn't want society to pay for my child.  However, most people can not afford the cost of therapy, and school systems are not prepared to provide it for every child, either.  Seemy dilemma?  Either way we go, it's a slippery slope.  Coverage for everything for everyone?  Where does it end?)

I'm still here to vent at, Melissa and all.

Dear Dr. Walton-Shirley

Trying not to be cynical.  Unfortunately, the only entreperneurial spirit and innovation the insurance companies are currently specializing in is how they can rip off their policy holders and the physicians, who must battle with them to take care of patients. The insurance companies are primarily the ones who "get between the doctor and their patients", more so that the government has ever desired to do. Too bad there was not the political will for a "Public Option" in the recent Health Care Reform law. The playing field could have been leveled.