1. AMA (American Medical Association) artificially controlling the number of medical graduates based on a quota. Every doctor starts of a huge debt, and many don't get to practice. No experienced doctors from other countries can practice here.
2. Hospitals (many owned by Private Equity) - Maximize profit / patient. Don't show prices, lots of outrageous billing for basic care like Ibuprofen and bandages. The bills keep on coming for months after care.
3. Doctors - Gotta pay those debts. No prices advertised, Inflated costs for basic care. Specialists are booked for months.
5. Insurance companies - Can only make max 20% on administration costs. Love the high prices and denying claims for whatever reason they can find.
3. The politicians - Make $$ from lobbying insurance companies and big providers. Employers sponsored health insurance means individual workers don't have same bargaining power.
Essentially we are paying a fortune. ~5 trillion for healthcare. If we pooled all that money into a govt funded insurance pool, and removed artificial license quotas, market advertised prices, we'd have a much more efficient healthcare.
The corporations know the individuals can't coordinate between themselves to take them out. They have captured the market.
Instead we have a huge administrative bloat, gofundme pages, lowest mortality amongst the rich countries and a shit show.
That's completely ridiculous. The bar is pretty high for me to go to an ER, I'm pretty sure anything on that list would need treatment faster than 6-10 hours.
Hell, its not recommended to keep a tourniquet applied for more than two hours and even then there's a specific protocol to follow as there's risk of what will be released back into your system.
What are people even going to the ER for when they can wait for 10 hours?
I'm an ER doc. I work 3 nights a week and see probably 5--10 patients a week who have waited over 3 hours.
The basic answer: most people don't go to the ER for emergencies. That is, they go for something like a rash, cough, or fatigue that they know is not an emergency. Many of them just want work notes, although some are convinced they have a legit emergency.
We scoop up the real emergencies from the waiting room ASAP. Eg, no one in the waiting room is wearing a tourniquet; if they are, it's my job to either fix the bleed or get them to a vascular surgeon ASAP if I can't.
The majority of people who spend hours in the ER waiting room have vastly higher time preference than your or I, and often lower socioeconomic status and higher anxiety as well. Often they can't afford phone service or even a car, so it's hard for them to get places quickly. Others are homeless and want a place to sleep or very anxious and just want to be somewhere with other people in the middle of the night.
Attach a regular urgent care clinic to the ER, and divert patients there. Medicine is anything if not statistical, and any ER should have a clear picture of what the care needs are for the incoming patients.
Some hospitals do this and it works OK. But patients often believe that they should go to the ER rather than the urgent care part in this situation "just to make sure" or due to other myths. Also, during the day both our main ER and our urgent care are totally saturated at my hospital system.
"Well then your silly system just needs to build more facilities! It's obvious!!" You say.
One thing people need to realize is that it is not necessarily in hospital admins' best interest for all the ER patients to be seen. If it was, they would spend more money on more efficient triage systems so that we could just rake in the bucks. But, in reality they would often lose money on such a gamble in my understanding, due to how patients of different coding levels are reimbursed by payors (and whether a patient is even likely to have a payor).
It is interesting to me that a system that had good social housing and guaranteed healthcare would not be affected by this specific problem, and would most likely (looking at places where this is true, like Austria) be cheaper than what we are currently doing.
If you add a level of mandatory screening you can filter out ER to Urgent Care. The problem is still the connotation that ER is for everyone. Just put up posters in the ER lobby that make people uncomfortable things that say ER is for like car accidents. No one wants a reminder, but no one wants to be that asshole cutting in front of the guy who got a broken clavicle from a seatbelt or other various injuries.
This has been suggested many, many times in my career. The problem in the US is that such posters would violate[0] a federal law called EMTALA, which prohibits an ER from turning away any patient for any reason until I or another provider has performed a Medical Screening Exam (MSE) to assess for A Real Emergency (TM).
EMTALA and confusion around it is another common reason why patients often stay in the waiting room for many hours when really it would be in their best interest to go home and go to a clinic during the daytime. It is the main reason I try to ~break all the soft rules at night and just go out into the waiting room and MSE anything that moves so I can send it home.
EMTALA was passed in the 1980s under Reagan I believe. Good luck repealing it or revising it to make sense in our current political environment!
[0] Or appear to violate the law in the optics of some administrator, insurer, healthcare bureaucracy maintenance organization visitor, etc. In this way, in large bureaucracies, magical thinking reigns, optics becomes objectivity, and 2 + 2 = 5 .
It isn't about turning a person away, it is about enqueuing them into another emergency type care, urgent care is still a high priority but it is urgent and not deathly required.
This would allow prioritization of people needing immediate care.
I happen to agree with you. I was writing not my opinion, but my experiences with the actual EMTALA law, or more accurately and importantly my healthcare administrators' perception of said law. I cannot change either of these things.
I think that admins' interests not aligning with that of patients/consumers or with those of professionals/practitioners is making millions of people sad in a lot of other fields in addition to medicine.
Ben Hunt has written some great essays about this nebulous concept. His phrases "industrially necessary" and "raccoon" come to mind.
Is there a general solution? Dunno. But I suspect crafting even more regulation would be kinda like trying to make Wikipedia better by firing all the content experts and making all the admin-type people write all the words. It wouldn't result in a very good end product.
I seem do my best work when I am left to my own devices and my contact with admin is minimal.
A few years ago my wife had a very high fever (105°). I took her to urgent care and they determined she was too sick snd needed to go to the ER. So we shrugged and went to the ER,’where she had to wait for 3 hours before she was given some more Advil and a cold compress (and tested for a few other things).
You're welcome! Basic answer: $250/h + benefits and 4 days/week "off". Plus, working in the ER at night is the most fun job I've ever had or probably ever will have. (Programming is second.)
Despite this, I plan to pivot to my telemedicine business full-time within the next year. I know I am not invincible and the older I get, the more mistakes I am likely to make and the more working nights will become a risk factor for heart disease, diabetes, and the like. Plus, working nights wreaks havoc on the family, but it's the only option to work stable days each week in the ER. (Ie, most ER docs either work all nights or work a random rotating schedule of first, second, and third shifts.)
Having worked as an MSI (Medical Specialized Interpreter) at $4/h, I've noticed that patients are still very reluctant to accept telemedicine for anything other than reviewing lab results.Do you possess a strategy to overcome this challenge?
LATAM Subcontractor for Teleperformance/LanguageLine Solutions/Pacific Interpreters.
The strategy I possess is to use telemedicine in novel and directed ways when it suits the purpose.
Most telemedicine roles I have interest in start with a very directed patient population and a limited set of interventions. Patients at risk for HIV, obese patients, etc. In this context, these subsets of patients are happy to accept special-purpose telemedicine, in my experience.
I personally would not want to see a primary doctor or surgeon over the Internet, and if I needed follow-up testing in the lab right next door anyway, I would prefer to go in person to both places in one "quick" trip rather than dicking around with the Internet before going out to the lab anyway.
Patients are right to be reluctant. Telemedicine offers a lot of benefits, but it can never be as thorough as time in person with a primary doctor. (But this in-person time is just not possible to get for your average patient in my experience.)
Completely understand if you don’t have the time or desire to answer questions, but I’m curious whether you went programming -> MD or the other way around, and how you made the transition.
1. Grow up in the 90s and play too many video games and read the Extropians list too much.
2. Decide I want to be, like, the Hagbard Celine of pharmaceuticals and cure death, or something.
3. Learn programming because I still need a job if I fail at (2) and anyway programming is fun and people are scary.
4. Double major in CS and Bio, do bioinformatics research for minimum wage.
5. Move to Berkeley, learn more programming working at a random startup for minimum wage.
6. Get a job as a bioinformatics programmer at a lab; learn lots more programming and some bench biology and publish papers, under the theory that I need papers and a PhD to start a pharmaceutical company.
7. Look around and decide I don't want to be postdocking in SF for $40k/y when I'm in my 40s and have kid(s).
8. Enter an MD/PhD program (MSTP, ie combined and debt-free degrees) as a lowish-resistance hedge even though I dislike premeds and also the entire bloated medical system.
9. (8 years later) Do residency in Emergency Medicine because it's really fun and all the other specialties bore me. (Except radiology, but that's no fun with chronic sciatica.)
(Writing this in the middle of the night from that critical access ER I mention.)
I just don't think there's any other medical specialty that has a job as action-packed and gratifying as my job is for me. Surgery would be gratifying, for sure, but also I hate formal clinic and I have a weak bladder, so no.
Yeah, I guess I see lots of sad things. But (1) often patients are sad about things that could've happened but didn't actually happen, and I can cheer them up just by telling them the truth. (2) Often I can make patients happier if actual sad things happen to them, at least in the moment, and that makes me happy too. And (3) if I got sad every time I saw a sad thing, I'd be too sad to do my job and then I'd get fired. So, like, these things don't really make me sad because I'm here to do my job, not to get big feelings?
Maybe not for you. If I had a medical emergency, I wouldn't want to be attended to by a mopey physician - no matter how dire my circumstances. The same goes for therapists and first responders. Yes, those people don't always see people at their best, and they've seen some shit - but it's just a job, and society works best if that job is done well.
ER doctors are the SREs of physicians - some folk are wired to enjoy the same high-tempo/unpredictability aspects that repels others.
I looked up the etymology of "fun" and you are right - Middle English fonne, fon (“foolish, simple, silly”).
That said, I'll take action-packed and gratifying over fun any day.
Also, emergency medical doctors are extremely foolish people during their down time - medicine has an old tradition of utter silliness when it is time to blow off steam from the job's pressure. So there, fun too !
When I was in ERs as patient, I did enjoy doctors with a good mood. People with a good mood are also usually doing a better job and if they have fun fixing my mess, good for them and for me. Optimism is quite helpful for recovery.
I mean, I am also a fan of black humor, so mixing jokes with blood works for me, even if it is my own blood.
Of course I view you as more than pph. My job would not be very fun if I only viewed you as pph. And another part of keeping my job involves minimizing patients complaining about me to admin, which they would a whole lot more if I only [acted like I] viewed them as pph.
And, in order to allow myself to continue viewing patients who are not you as more than pph as well (and thus keep my job), I also consider a lens of pph. Because if I'm talking to you for an hour about low-carb diets or whatever and you feel like I'm the best doctor in the world, but there are 5 more people in the waiting room in pain that I haven't seen yet because I'm totally focused on you... also not doing my job.
The fact that I use this lens does not limit the services I provide to you or the empathetic positive feelings I share with you as a fellow human. (Or not, if you don't want those feelings. As a certified weirdo, I distrust people who come onto me w/ big outward empathy, personally. But most patients like it in my experience. So I tailor it really depending on who you are.)
Agree that forum is very depressing. Bunch of old ER docs who aren't looking for a way out for whatever reason. Part of the goal of my posts in that thread was to get them to smile a little, but they're too crusty. If I hated my job as much as some of them, I would just quit immediately and go back to programming.
I do some radiology in the ER. I do find this fun. The core skill of radiology is to find stuff in pictures and then communicate these findings to others. Just like I did as a scientist, which I also found fun and exciting.
I also find it fun to do research in molecular imaging. I suspect I would further have fun researching AI techniques that may allow us to replace some or all of the human work of radiologists with computers. (I suspect "all" will never happen, for the same legal reasons that I suspect we'll never have real self-driving cars. Humans need, um, human scapegoats.)
However, yes, I also have chronic sciatica, or back pain. It gets worse the longer I sit. I don't like standing still enough to use stand desks and treadmills are distracting. Clearly being a radiologist and sitting in a dark room for hours at a time would not be good for this pain.
This is yet another reason I got out of full-time programming.
Thanks for sharing all of this. Your account of a night shift gives me hope that there are still micro-cultures out there that want to get it done. Reminds me of the best parts of active duty.
Main telemedicine gig right now is diagnosing and managing HIV and other STDs. Patients love it as it's super private, and even testing can be done discreetly at home with a mailed kit.
Currently completing an online fellowship in obesity medicine and plan to start my own online practice or collaborate with midlevels who do so. Will probably get into tele-urgent care as well.
I've learned a little about all aspects of medicine as an ER doc, and it's exciting to apply that knowledge to telemedicine. Telemedicine is the Wild West right now. COVID-19 just opened it up a couple years back. We don't really know how to maximally benefit patients with it, but there are all kinds of new models being tried. When it works, it really works, without all the bloat and entrenched rentiers that can make brick & mortar medicine awful for both doctors and patients.
Reminds me of the state of the Internet around 2000. Wide open.
That tracks with what I have I assume the average wait times are. Given that its the average, I can only assume the ratio between actual emergencies and everything is worse than 10:1.
For that, I apologize. Maybe it comes down to fundamental problems in healthcare and most people not having a primary care physician, but I just can't imagine going to the ER with anything less than a very serious traumatic injury.
> As I understand it, the ER cannot refuse patients without money or insurance?
That's true, and a whole other discussion. If our ER wait times are 6+ hours primarily because they are full of people without a way to pay for treatment that's a much bigger problem.
> Also people can get sick in the middle of the night or outside of regular clinic hours.
For sure, that can absolutely happen. Though I'd argue the bar should still be high with regards to when a person should go to the ER. Unless its a true emergency one could still wait until clinics open for regular hours.
I once went to a large professional building attached to a hospital because I lost my voice and I wanted to see a doctor, any doctor, on any time frame. They said the only thing they could do is send me to the ER. These days, I would go to a walk-in clinic like Carbon Health or One Medical I guess, if I was in an American city away from home, without my own doctor. But I find it hard to blame anybody who goes to the ER for "just a cough" since I know the system won't do anything else for them.
NB when I was in the military they had the entire problem of suddenly ill people completely solved. Socialism.
Yep. We’ve only ended up in the ER once for each kid (so far … knock on wood), but both times there were sudden onset symptoms that in my mind warranted urgent care but not the ER. Both times we called and were told that we could wait two weeks for an appointment or go to the ER, no in between.
The irony that military healthcare, while far from perfect, has many advantages like it's part of the benefits to servicemembers and dependents, some retirees.
A surprising number of people, especially prior to the Affordable Care Act, would call expanding public healthcare "Socialism", even though many in Congress are veterans. The late Sen. John McCain (R-AZ), A Vietnam veteran A-4 pilot, and POW, cast the deciding vote against repealing the ACA. He earned his military healthcare, and then some.
There's a strata of use cases that left in limbo in your argument.
Im a basketball player. I may have a microtear of a ligament from a 9pm game. The ortho guy, the pain doc, the sports med and my pcp are closed at 9pm.
I have no options but to go to the ER. I know because I've been there. Multiple times.
My kid is breathing and I can see his ribcage from forced breathing? If its past 5pm, its definitely an ER trip.
I pierced my hip with a chain link fence and need irrigation for the wound? ER trip
None of these injuries are life threatening.
I'm not poor. My time is super valuable. i charge some clients $700/hour. Yet in each case, I spent > 4 hours in ER !
Now- I will literally wake up MD friends and ask them to write me a script to the 24hr pharmacy instead of waiting in ER for meds.
There's nothing in my post that disagrees with anything that you're written.
Everything you've written is correct. I was not trying to argue anything and I think I hedged my words above quite carefully. I was mainly trying to answer OP's question and in passing explain a few things that make it look to patients like me that the ER is even more messed up than it actually is. (And it is actually pretty messed up!)
I love the people with microtears who can't get into the office. I love reassuring parents that they don't need to spend $10k for their viral toddler to be admitted and get treated with nothing all day and then get discharged, but slowly and passive-aggressively. I love helping people who are in the ER for legitimate reasons. I understand that the medical system is broken and most people who are in the ER should, in a halfway sane system, not be in the ER. I understand that way too many people wait for way too long in the ER and it makes me real sad, because as I've written elsewhere on this thread, I do think there are usually fixes that are possible and even easy, from my POV as both geek and JAFERD.
Telemedicine does offer some solutions to some of these problems, but not all of them by any means.
None of those sound like ER visits, except maybe the chain link fence if you're worried about infection if you wait?
It sure sounds like your justification here is that you have to take up time in the ER because you or your time is that important - I hope I'm just misreading that and your point was different.
In Sweden there are two types of ER, real ER and "närakut" which roughly translates to "near care". It works pretty well, the few times I had to go to närakut I waited less than an hour to talk to a doctor.
Just wondering, why does an ER doctor read hackernews?
In the local ER - not your ER, probably - they only scoop up the dying. As I recall, one person near me had been in a car accident and was sitting there with very painful, unset broken bones for 9+ hours. They couldn't get painkillers until they were seen.
Everytime I've gone I see regular people spend 8 hours+. No one is looking for a roof over their head or a doctors note. The ability to pick and choose who requires care sooner is overrated.
I can assure you if you come via an ambulance you will get pushed to the front of the line over a walk in.
Easy to triage things gun shots are not so easy when the problems are internal. Easy to introduce bias. Parent poster thinks homeless and poor are only there because its warm or they have nothing better to do. It's okay to keep them waiting over someone who looks rich. They must have a serious problem, look at how well dressed they are.
In hundreddaysoff fantasyland, the solution is to fire all the bureaucrats and triage everyone immediately. But, then nursing primaries and secondaries and all the other required paperwork wouldn't get done and CMS would come shut down our hospital.
There is no shortage of practitioners, ie ~medical middle managers such as myself and other MDs/DOs/NPs/PAs, willing to work in the ER.
(In the narrative of one faction, the suits have in fact created a surplus of us, including docs, that will only get bigger in the next 5 years, possibly hitting n=10,000+ surplus ER docs by 2030. If that happens, a major reason for that in this narrative would be that the suits have directly funded more Emergency Medicine residency slots opening in that time than there are interested American medical students applying to the specialty.)
There is no shortage of bureaucrats willing to shuffle paper and create more work for themselves in the name of Quality or whatever. See this doc's blog for a relatively balanced take on this growth, but I do think there is truth to his first graphic: https://investingdoc.com/the-growth-of-administrators-in-hea...
In my understanding, there is a critical shortage of RNs willing to provide the actual hands-on patient care, for pay that will still turn a profit for the hospital.
This includes skilled ER triage nurses.
But the other side of the coin from labor shortage in this problem is, again, that hospitals simply are not reimbursed sustainably to serve many ER patients, particularly self-pay patients, in the non-literally-emergent ways that those patients should be served, would like to be served, or deserve to be served medically.
Ie, in my understanding the ER is often a loss-leader for a hospital that serves to get patients into higher-total-reimbursement clinics such as GI, cardiology, and orthopedics.
Again, I'm not trying to argue for any faction here including doctors/midlevels, RNs, hospital admin, or even patients. I'm just trying to describe the system from my view down my periscope over 8+ years of doing this.
In the past year I've gone to the ER with my late 70s dad almost once a month including multiple waits in the 6-12 hour range.
* Any time a senior (I guess anyone, really) falls and hits their head doctors want a head CT. Only place to do that is the ER, but if you aren't showing any symptoms of a brain bleed or similar problems, you're low on the priority list.
* Dad had IBS and problems with severe constipation. Twice he was having significant abdominal pain and we were told by his GI doc to go to the ER for a CT to make sure there wasn't a serious problem going on. But again, pain with a history of constipation and no other immediate symptoms lands you low on the triage list. And indeed both times he was just constipated.
* The worst time - the 12 hour wait - he was experiencing severe altered mental state. His neurologist, who normally has a 2-3 month wait for an appointment, thought it was serious enough to see him the next day. After examining asked if we could go down to the ER (their office is attached to a hospital) for a lumbar puncture and other tests to rule out a brain infection. Again, apparently the ER docs disagreed, so in the waiting room we sat.
In general though my observation from all of those hours sitting in ER waiting rooms was that a significant portion of the people there were really just sick and probably should've been at urgent care or their PCP.
My wife is a pediatric ER doctor. The majority of the patients she sees shouldn’t be there from a strictly medical perspective.
But parents can’t get off of work while anything else is open, first time mom doesn’t realize that a slight temperature and a cough isn’t an emergency, dad is finally fed up that his teenage daughter has been complaining of a tummy ache off and on for 6 months and Sunday at 2am is when he finally decided he had to have answers.
While I personally am okay with giving a pass for new parents that are scared for their child, I don't get burdening our emergency system just because.
I'd chalk new parents up to a learning experience in a new and uncertain time. For anyone going to the ER because it fits better with your work schedule, don't clog up the system for anyone that's truly in need and increase prices for everyone else.
It's not 'our' emergency system, it's the healthcare provider who now is often a for-profit. If they have a mismatch between supply and demand, the fix is obvious. It's not your problem, it's theirs.
Fairly often, a doctor told you itnis fine and then things escalated quickly. Or, you have appointment but it is weeks away. nope, people do not prefer to wait 8 hours in ER if there is an actual choice. Problems is, actual choice is often unreachable and just used to blame patients for bad system.
Like with OP, 2am tummy ache means the pain massively escalated from something undistinguishable for run of the mill cramps doctors normally don't do nothing about. (As in, cramps you walk in with, they charge money and they won't do anything at all with and fonsider minor)
> Like with OP, 2am tummy ache means the pain massively escalated from something undistinguishable for run of the mill cramps doctors normally don't do nothing about.
... and then, on average 7 years [1], later, the desperate daughter finally learns she had endometriosis all the time, and she could have been spared of years of suffering had one of the completely overworked doctors she had seen before actually had the time to delve deep into the issue rather than just hand out painkillers.
> Hell, its not recommended to keep a tourniquet applied for more than two hours
Minor note: this is somewhat outdated. They've determined now it's more like 4-6 hours before it causes any damage at all.
Per Stop the bleed, Mayo Clinic, etc.
But yea faster than 6-10 hours that's for sure. I bet if you went into that ER with an average time of 9 hrs and a tq stamped hour ago on your arm, they'd get you in pretty fast though. Triage is still a thing
I actually had 6 hours for the tourniquet limit at first and did a quick sanity check online to find the 2 hour stat. Thanks for the clarification here, I could have sworn I had seen slightly longer times more recently but haven't gone through training in a while now.
Yup, paramedic here. Several hours is entirely fine. We'll document the time of application. But (and admittedly different circumstances) ortho surgeons will regularly tourniquet limbs for several hours while doing their work.
There's some practical limits as neurons start to have irreversible injury after 6 hours of ischemia and 8 hours on muscles.
Usually we don't put tourniquets for more than 2h30min in lower limbs because after circa 2h we start to have some reperfusion injuries, lesser time on other segments.
The usual protocol is to not use tourniquets unless necessary, for ER care have the tourniquets removed each 30min for a few minutes to reduce reperfusion injuries. For surgery we generally follow this with the intervals no bigger than 2h.
(source: Ortho and Trauma surgeon)
Most people go to the ER for non-emergencies. The good news: if they have you sitting around for hours then it means it was not an emergency and you (probably) won't die.
Be worried if you check in and they hurriedly shuttle you into an exam room. That means they think you have an actual immediate life threatening emergency.
Unfortunately, at least in some regions, there is no other place to receive urgent (but non-emergency) care. Waiting a week or more for a doctor's appointment isn't going to cut it if you've broken your arm or if you've been bitten by a possibly rabid animal, and so you're stuck waiting all day or all night in the ER.
It was a revelation to me when I moved from the US to Australia. Not only do I not have to pay for insurance, but it's so much easier to receive non-emergency urgent care as well. I can typically book a doctor's appointment for the next day (there are no insurance networks to worry about, so I have my pick of doctors), or if I need care sooner than that, my local ER usually has a wait time of under 30 minutes even for super minor treatment, like removing a sliver of glass from my foot (the high availability of doctors means the local is pretty quiet).
You're seeing public GPs or what kind of doctor? In Melbourne, public bulk billed GPs are hard to book for the same day, the best ones are regularly 1 week away. Private specialties (Endocrinologist, Psychiatrist) are months away. What you're doing that I'm doing wrong?
There are also the intermediate cases. I had a blood clot in the leg. Not immediately life threatening, but certainly so over a couple of days. I waited something around 1-2 hours, which was not fun, but completely understandable.
We have private healthcare so you need medical insurance for treatment - if you don't then they stabilize you and send you to the nearest state hospital if it is warranted.
State hospital - lots of folks who got stabbed or shot due to alcohol or crime related violence - apparently overseas medical students love to come here to learn all about trauma surgery and getting to stitching people up.
Private hospital - people with babies who have fever or crying and folks with chest pains and in my case a kid who just had seizure - she got first dibs to ER because they triage cases.
That's a very different discussion. Personally, I think its bullshit if ERs are stuck with 6+ hours wait primarily with non-emergencies only there because they don't have insurance and want free care.
Don't get me wrong, its bullshit both because they're clogging up the ER resources and because they're in a position where they may be unable to get or afford insurance. Its also bullshit that insurance is effectively a must-have today. The whole system is very, very broken.
I'm not sure why at that point it's even considered an ER visit.
Clearly if you can wait 10 hours for something, it wasn't an actual emergency. Are hospitals just gambling that these people won't die in the waiting room? What's actually going on?
Is there a perverse financial incentive to drag it out?
ERs prioritize on severity, not first-come-first-serve. If you go for stomach pains and while you're waiting, someone else comes in with a severed limb, they will get seen right away and your wait just got longer.
More notably, more serious problems may require more staff. If the nurses are busy cleaning up bio material, you get to wait a little longer too before you get triaged.
The incentive is not to drag your wait out, so much as to have the minimum staff needed to keep patients stable. Stabilizing people in critical condition is literally the one job of the emergency room.
On the other hand, people go to the ER for all kinds of reasons that are more urgent than urgent care, but less than true emergencies. Sometimes, they even go because they can't be denied admittance for lack of ability to pay, when a general practitioner at regular practice would have been a more appropriate physician to see.
All of that said, a 10 hour wait either means there's an absurdly high number of non-emergencies, or they're facing severe shortages (self inflicted or otherwise).
All this is not wrong. Also, there's another huge factor: frankly, most ER triage systems are not very efficient and they don't hire enough RNs or other front-line workers.
I refuse to work day ER shifts because along with just a couple motivated RNs, I can often clear all the patients from the waiting room at night that have been there for many hours. Often, we just need a break from new patients and we need to work as a team and just focus on getting one patient out at a time. OTOH, day shifts often make me powerless as a doc just because there are so many other bodies around, each with competing agendas and pressures.
Yes, a large fraction of ER visits aren't emergencies. Typically they triage new patients, take the actually critical ones immediately and everyone else waits.
I'm not sure wait time is an informative metric, vs something like survival rate for different kinds of conditions.
Seems to be a good metric for a dysfunctional triage system. How else does a type 1 diabetic with a known non-functioning insulin pump on the verge of going into coma get labelled as non critical.
I’m not defending the hospital in TFA, per se, but my wife recently had an ER visit on a miscarriage. She was immediately admitted and tended to be a doctor for the fact that she was hemorrhaging.
During the course of our 12 hours I came and went from her room through the waiting room and to my vehicle. Saw folks waiting hours and hours. For all I know they had a faulty pump.
When it came time for dismissal, we waited hours and hours. The attending staff were handing a GSW and a head trauma on a child. While I didn’t go full-Karen I had to drop the “my wife suffered a miscarriage and is having a mental breakdown, are we going to be banned from your hostile system if we just leave?” to receive final clearance to leave.
Triage is just… complicated. You can’t plan and staff accurately for random tragedy.
I'm sorry this happened to you. I don't know what happened, but good ER docs and nurses prioritize getting people out before they get people in. (No beds left = no new patients can be seen... not that hard of a concept!)
Sometimes things happen that we can't control, but I sure do get tired of ER docs/PAs/NPs overlooking common sense stuff like this. Especially since most good ER RNs would have bugged your provider multiple times to just get y'all the hell out of there!
I assume because DKA usually takes 24-72 hours to develop. So unless said diabetic waited the good majority of that time with their non-functioning pump before showing up at the ER, then that might be their assumption (though if a BGL wasn't done, that's a problem, but not of the triage system).
Also, ER isn't really the place to handle DKA, those patients will cycle quickly through the ER to endocrinology or the ICU. It won't be "give me some insulin manually so I can get on with my day".
As someone who has far more reason to interact with ERs than the normal person, if you have a problem that needs to be seen within the next week by a specialist and not just a GP, you have to go to the ER to actually get it addressed. Otherwise you won't be seen for months.
The fact that this is even a point of investigation is very frustrating. Wait times at local restaurants in my area are basically constant and will remain so, because if there is an observable queue, someone opens a new restaurant or an existing one puts on more staff and finds space for more tables.
If people were permitted pay directly for emergency visits, and new hospitals allowed to open then it would be ridiculous for there to be a general problem with trending wait times. Someone would add more emergency capacity somehow. That isn't even in conflict with keeping a public system either, there can still be a public system. Just let people who can afford their own emergency care fund their won care.
The problem here is precisely that deliberative bodies trying to work out how much emergency care is required instead of creating an easily-joinable class of people who benefit financially from providing care and leaving decisions up to them. That works well for almost literally every service out there and there is no reason to think it would fail for emergency healthcare. These people attending clearly have hours to shop around.
The article is hazy on this point, but the monopoly agreement set an slo of 220 minutes (3 hours 40 minutes), and it was fairly stable, but worsening by tens of minutes per year.
Since then, the hospital in question increased to 10 hours 45 minutes.
Worse, the federal government stopped tracking this metric, and now, among hospitals that elected to share the number, the median is over 5 hours.
So, if you live in the US, you’re probably screwed, regardless of whether you live in appalachia.
In addition, depending on how you model ER admissions using queueing theory - the wait times very quickly goes exponential with even relatively small changes.
I imagine all the signs about don’t abuse the staff and incidents of abuse against hospital workers went up at the same rate as the wait times. Abusing the staff is wrong but you have people that have come there because they think they are about to die without attention, they really don’t have a choice
I was thinking it might be interesting to show a map of regions to the closest hospital, and color code it by the operator, like ballad health = red, banner health = green, etc. I'll see if OpenStreetMap has this data available
The roughest thing that Ballad has done is take the brand new NICU from Holston Valley in Kingsport that was opened in 2016 [1], shut it down and move it 30-45 minutes further away to Johnson City in 2019 [2]. Granted we know drive times are further up here, and helicopters are faster, but that could be precious minutes for a NICU baby.
Hospital costs are rising which is putting them out of business, which causes mergers and takeovers by organizations that specialize in extracting profit out of hospital services. These organizations do this by reducing costs by lowering nursing staff numbers to like 20% of what they were before, which pretty directly leads to lower quality service. The cost increases in the medical industry are quickly making the whole system nearly untenable. We could see a system collapse in the near future. One way of mitigating this is providing the same services outside of a hospital- for example the cardiologists leaving the hospital and starting a private practice. This leads to reduced overhead and maintains tenability of the whole system.
> One way of mitigating this is providing the same services outside of a hospital- for example the cardiologists leaving the hospital and starting a private practice
Bad idea. If anything, what you need in a hospital is short paths to transfer people from one specialist department to another (or, should the patient be too unstable to transport, to call up the specialists to get down to ER), and you need integrated IT systems to not waste time with data transfer.
There's a combination of causes... and probably they're also applicable for the US:
- rising costs of energy (electricity, gas)
- decades of underfunding of building construction and maintenance, leading to a massive backlog of issues
- same for IT
- modern machinery (ultrasounds, MRTs, CTs) costs immense amounts of money
- general staff shortages that need to be filled via expensive temp-staffing agencies on one side and cause wage rises for those employees that remain
- as a result of that, beds have to be marked as "inoperative" and they don't generate income, whereas the expenses keep piling up (there finally are reform plans to pay hospitals for providing beds, but it's a ... let's say toxic minefield)
- rising costs of administrative bullshit and legal compliance
- insurances being utterly ridiculous regarding payments, both
In the US, I'd add "more and more people unable to pay", which leads to the cost of care for these people being redistributed to everyone else.
Barbara Kingsolver's book "Demon Copperhead" is a gut punch of a look at the degree to which Appalachia has gotten fucked over over the years, and is also just an absolutely fantastic novel with some of the most beautiful writing I've read in years:
Seems ironic that Kaiser is banging on about the horrors of healthcare monopolies. Are they not themselves a giant healthcare monopoly that just happens to operate in a wealthier geographic area?
HN values intellectually curious discussion, not ideological cliches. Basic familiarity with site "about" and search features is also strongly encouraged.
Thanks. Yeah I guess I was thinking more about the content/research/advocacy that they themselves produce. The article you link is their news aggregator (kff health news) reposting a Sacramento Bee news article. Anyway, I appreciate you taking the time to respond. My impression that KFF doesn’t produce research or advocate for policy that is contrary to Kaiser the HMO’s interest weakly persists, but I suppose that needn’t signal any specific conflicts of interest so much as hint at incentives and business model issues. If I understood KFF’s business model better (are they a think tank?) it might resolve my concern about their alignment with big healthcare interests in general and Kaiser permanente in particular.
Incentives are themselves powerful, whether explicit and overt or covert and/or incidental, so that's a fair gripe.
Note too that it's not the question of whether or not KFF is or isn't biased, toward or away from, Kaiser Permanente or any of the health system's other arms and branches. (Kaiser operates in several states, I'm not sure whether or not those are independent entities, and the physician, hospital, and healthcare insurance functions are also, so far as I'm aware, at least somewhat autonomous.)
Rather it was pursing the extremely weak rhetorical tactic of 1) assuming or implying that the entities are the same and 2) that a bias does exist. I'd not known the answer to either of those questions prior to seeing your original upstream comment, but it took less than a minute to answer both questions. Again, the spirit of HN is for substantive discussion, not casual meme-slinging. Not always attained by any stretch, but the site would be much better for it.
It's not infrequent that I'll begin posting one argument here, research my points (even only casually), and ... substantively change my mind in the process. That's one of the chief values of online discussion IMO. And a good day is one in which I've learned something, so given my admission above, this was two good days, thanks.
Sutter Health is my local hospital monopoly. They're the only reason that Sacramento is the most expensive place in the country to have a baby. And the quality isn't exactly high. I know someone who just had knee replacement surgery and they were sent home a few hours after their surgery. When my grandpa had the same surgery in the 90s, they had him stay for a few days to recover. Now they just want to churn and burn their 'customers'. In addition, my wife after giving birth was only allowed to stay the bare minimum. It's shockingly gross how we've commoditized access to healthcare into this assembly line style racket. Contrast to Europe, when I hit my head on a train and needed stitched, I got a free ambulance to their ER where two nurses and a doctor immediately stitched me up for less than 40 EUR and was given world class care. We're doing something wrong in America when we pay the most extreme prices for the most basic care. We're getting gouged so executives can line their pockets. We should be rioting but we all just accept it. And it's not like Obamacare or Biden have done a single thing to change things. Obamacare just forced everyone to buy insurance... it didn't really change the fact that when you go to use it you get crappy care. And even when you go to a place like UCSF, the quality of care isn't that great. They put my wife's IUD in wrong and we ended up with a second kid. Healthcare in America is shit quality.
Sutter is not a monopoly, especially in the Sacramento area. In Sacramento there's Kaiser, Dignity, Sutter and UCD, plus numerous smaller office chains such as Hill Physicians, etc.
What you likely meant is your employer's health plan is only Sutter... which is entirely a different thing.
> I got a free ambulance to their ER where two nurses and a doctor immediately stitched me up for less than 40 EUR and was given world class care
With most health insurance plans, everything you described would cost you only a co-pay as well (usually $20-40). Uninsured people are the ones stuck with $10k ambulance ride bills... after all, someone has to pay for the services.
Even with the government funded healthcare here in Spain people don't spend thousands a month in taxes. In fact very few people pay that much anyway.
I'm genuinely shocked how much health insurance costs in the US. I'm glad we just cover this through the state here. It works fine and I never have to pull out my wallet.
Majority of people in the US don't pay thousands a month in healthcare/insurance either. Really premium, high-end health insurance plans can exceed $1K monthly for families, yes, but regular plans don't. In addition, for employer-based health insurance, the individual often pays only a small portion of the total monthly premium (1/3 is common, but varies).
> I'm glad we just cover this through the state here.
You mean you cover this through your taxes. The state does not just literally or figuratively print money to pay for health care. In the US, over 40% of the population pays $0 income taxes, yet still has access to government provided healthcare via Medicaid.
In fact, when you combine Medicaid and Medicare, the US has the largest national healthcare system in the world - in terms of dollars spent and people covered.
> Majority of people in the US don't pay thousands a month in healthcare/insurance either. Really premium, high-end health insurance plans can exceed $1K monthly for families, yes, but regular plans don't. In addition, for employer-based health insurance, the individual often pays only a small portion of the total monthly premium (1/3 is common, but varies).
yeah but I really really don't want to be dependent on my employer for health insurance. This means I'm pretty much blackmailed into staying there until I have something else lined up. And when I get fired it compounds the problems hugely.
> You mean you cover this through your taxes. The state does not just literally or figuratively print money to pay for health care. In the US, over 40% of the population pays $0 income taxes, yet still has access to government provided healthcare via Medicaid.
I know, it's my taxes. But that's fine. It's worth paying taxes for cheap healthcare for everyone. I want poor people to be healthy too. The good thing about it is that nobody has to worry about crazy bills. We spread the cost over everyone and that's great. There's no deductibles either. And we don't pay a fortune in taxes.
Also, the way the health system operates keeps it cheaper. The hospitals work together and they purchase together in bulk. General Practitioners have central offices in every neighbourhood with all standard treatment rooms so they are assigned one every day. They don't need to buy their own practice. They don't need to worry about running a business, doing accounting, finding suppliers.
It was especially ideal during covid when some of these centers were specifically assigned for covid patients and others for other things, reducing cross-contamination.
> In fact, when you combine Medicaid and Medicare, the US has the largest national healthcare system in the world - in terms of dollars spent and people covered.
But yet people can still be bankrupted if they get sick. This is the one thing that's avoided here.
My "premium" healthcare plan, whose premiums are in the four digit a month tier (to your sister comment's point, although to my good fortune, my employer covers 100%)...
the ER copay is $250. Then you will be paying for labs, DI, and medications beyond that.
In fact, as someone who has worked as a paramedic for 12 years, and worked in health insurance software for a similar period, I have -never- seen an ER stay that you'll get only a co-pay of $20 for.
I'm retired military, with a health insurance plan that most people would kill for. It may be the best you can get in the country, seeing as I pay no premiums.
My ER copay is $75 or $136, depending on my plan (HMO or Self Managed; both have the same $4200 max out of pocket per year).
No, they’re effectively a monopoly for most of the services people actually need. It’s well researched and documented. Google it. They even settled an anti-trust lawsuit with the state a few years back.
It’s a racket. They’re just ripping people off. Sutter is the sole reason healthcare in Sacramento costs more than in LA-and for worse quality care. They’re a grift.
> With most health insurance plans, everything you described would cost you only a co-pay as well (usually $20-40). Uninsured people are the ones stuck with $10k ambulance ride bills... after all, someone has to pay for the services.
You’re either uninformed, lying, or both. Have you ever called an ambulance in California? It’s $2000 minimum even with insurance. This is with an Anthem Blue Cross PPO from a tech company. I’ve had to use an ambulance twice in the last decade and it was considerably more than $20-$40… you were only off by a factor of 50x or 100x.
> No, they’re effectively a monopoly for most of the services people actually need.
No, they aren’t. There's an argument that they may have been in the past, but the practices on which that accusation was based were terminated in a settlement with the state and when the same accusations went to trial in a federal lawsuit, Sutter won outright.
> They even settled an anti-trust lawsuit with the state a few years back.
That was based pricing power for insurance contracting through having must-have hospitals in some areas in Northern California and a system of all-or-nothing insurance contracts that required insurance vendors to make all of their hospitals in-network if it wanted any of them in-network, and other similar bundling. (Interesting, they won outright at trial a federal anti-trust suit on basically the same grounds that was proceeding in parallel, reaching court later, than the state one that they settled.)
And the settlement of the state suit addressed those practices, which is important to the current monopoly accusation, because the accusation in that suit was not that Sutter had a freestanding monopoly (market/pricing power) and illegally leveraged it (in which case, addressing the ways they leveraged it would be expected to leave the freestanding monopoly) but that it had market/pricing power because of the combination of must-have hospitals for insurers and the set of anticompetitive practices that leveraged that into market power.
Living in Sac, we are not remotely in the same league as what is described in OP. Sutter may have outsized market power, but you can definitely get care at a ton of different providers in the area, on e.g. the open market CA insurance plans. I know this because I did it.
Definitely can't speak to the ambulance thing, we've been lucky enough to avoid those at least, if not the ER.
Not one of your links provides any evidence of Sutter being anything close to a monopoly. They do not own the market in California or Sacramento, and the are many other major healthcare providers here including Kaiser.
"Anti-Trust" actions cover a wide variety of anti competitive behaviors.
Additionally, you are misleading people on the cost of an ambulance ride by conflating out-of-network prices and/or medically unnecessary rides.
"Balance Billing" for out of network ambulance rides is now illegal, and uninsured people are capped at billings equal to Medi-Cal.
You’re obtuse. They’re charging more for comparable services in a lower cost of living area of the state, they get away with it because they are effectively a monopoly and there are no real alternatives or competition. They have even been sued and settled anti-competitive behaviors which is evidence to my point… They may not be the literal only healthcare provider but they are clearly able to use their size and scale to rip off locals. Otherwise there’s no other reason Sacramento should be the most expensive place to give birth… it’s a no brainer. You probably work for them or some other PR firm to spread propaganda like this.
> Additionally, you are misleading people on the cost of an ambulance ride by conflating out-of-network prices and/or medically unnecessary rides.
How am I misleading? Those were my real experiences. It’s not like the 911 operator asks about your insurance and makes sure the ambulance is in network. What about when the ambulance is called for you? How is that “unnecessary” if you don’t even have a choice?
I bet you get paid to spread propaganda and lies. This shit is why America sucks—we all get worse healthcare so some rip off company can pay shills like you to spread lies and misinformation. The only people who benefit from the US system are insurance and healthcare executives. We get objectively worse care for objectively higher costs. It’s lose lose for the average person.
> They have even been sued and settled anti-competitive behaviors which is evidence to my point…
No, its not. Its actually evidence against your point that the conditions alleged in the suit – which even in the accusations in the suit were the product of practices discontinued in the settlement – are the current conditions.
(The fact that of the two parallel suits on largely the same allegations covering the same time period under state and federal law, they won the federal suit outright at trial after settling the state suit, is also evidence against the conditions alleged in those suits having been facts even at the time covered by the suits.)
> you are misleading people on the cost of an ambulance ride by conflating out-of-network prices
So I get in an accident and break my leg, someone calls me an ambulance, and while I'm screaming in pain I also need to ask to make sure they get an "in-network ambulance"?
> So I get in an accident and break my leg, someone calls me an ambulance, and while I’m screaming in pain I also need to ask to make sure they get an “in-network ambulance”?
No, because as stated in GP, “‘Balance Billing’ for out of network ambulance rides is now illegal.”
On top of the highway robbery of private health insurance we have a defacto single payer public healthcare system for retirees and those on public assistance that is the government's largest expense, currently sitting in the #2 spot (a major issue that keeps getting kicked down the road), after that you have interest on the debt that is borrowed to fund everything, and then defense (and no, defense can't be cut, don't even go there). We are heading for a surprise failed bond auction (where private investors cause a government shutdown because they refuse to purchase bonds).
Biden is going after a major elephant in the room: the sprawling UnitedHealth monopoly. And Trump took the first stab at the other sprawling healthcare monopoly: regional hospitals.
If the people do not start voting in moderate statesman and serious legislators then all their petty dumb ass concerns are going to get crushed out of existence in one fell swoop of mandatory fascist-socialism...if they are lucky. Honestly, I can't venture to guess the fallout of a bond auction hiccup. All I know is that it will involve pain for everyone in the world.
Oh look, it's my neighborhood healthcare system. Kinda weird to see the tri-cities and Neal on HN.
On topic: They're literally the worst, nothing here is an exaggeration, Ballad is utter dogshit. It's so bad that the Tennessee legislature, famously fans of non-interference, are considering breaking them up.
The hospitals would have shut down without it, so it was rubber-stamped as "let's not bail out the hospitals". If the monopoly functioned, there would be no issue.
I generally have zero issues with the Tennessee legislature, they do their jobs well and don't really mess with my life. They made a bad decision and are trying to figure out how to fix it without shuttering all the local hospitals, which is fine by me.
I wonder if anything else might have happened around 2020 to increase ER wait times due to lack of beds in the hospital?
They might be awful scum; don't know. But ER's are very, very expensive places to keep patients waiting for a bed. The claim that nursing shortages in the hospital drove this is not implausible. And when nurses can make several times as much money doing travel nursing in big cities, how's a place like Bristol going to compete? They wouldn't have left their families for $10-20 more per hour; they left for four to five times the money per hour. Or even more.
Rich, big cities absolutely used their financial means to make sure they had nurses. Where did they come from? Small, poor cities and rural areas. In peak COVID, there were nurses being offered $10k/week with free housing. A brutal schedule to match the pay, of course, but if you live in Bristol, a month away would pay for a year of college for a child.
They are also bad places to work. My sister is an NP who quit because the caseload was too high as she was afraid that someone would die and she’s lose her license.
The South's war on women and women's healthcare is another reason that's driving medical professionals to leave for richer, bigger cities... or at least areas that don't threaten you with the pit and gallows for providing life-saving care.
Eh. I’m at a Catholic hospital in the South. No abortions, no tubal ligations, no vasectomies. Are OB’s leaving? Some. But I already made my own peace with that. It’s a good job. I think that the stories are, shall we say, overtold. There are a lot of doctors who don’t deal with abortions at all, and it hasn’t changed our practice one whit.
Women’s healthcare is a lot more than just abortions, even if they are the most obvious and prominent portion.
Greed has taken big notice of an ageing population, in need of more medical interventions or long term care as they age, ready to be sucked dry of every little $ to the cent.
The callousness of a system like this, it's tendency to rob people of their dignity, and the seeming indifference of any people or organizations with the power or capacity to intervene, is profoundly depressing. A system that holds healthcare behind a tollbooth, equating quality of care with wealth, implying only the rich deserve quality care and the nonrich deserve whatever they can get, is inhumane and plain mean.
Well, the "nice" side effect of robbing people of their dignity is that they will also treat institutions and others with the same lack of dignity, perpetuating a vicious cycle.
You don't want to be a part of American society when social trust hits 0 and a majority of people have nothing to lose, with how many guns are floating around.
You'd think that if you were maybe 12 years old. Screeching about the end times didn't feature prominently (read: at all) in election coverage during saner times. That said, given a prior attempt to literally overthrow the government I'd say the stakes are higher than usual this go around.
Good thing there is no ad hominem then. An individual who's sole experience with the presidential election cycle spans the last 12 years would correctly assume that the majority of people believe (with varying degrees of accuracy) that the fate of society writ large hangs in the balance. Rewind the clock a couple decades and nobody was shouting from the rooftops that the world was coming to an end when Reagan was elected (in this country anyway, his cowboy-ass demeanor scared the shit out of the soviets, with cause). Very little at all was said about Bush Sr's election. Same with Clinton. The muttering started in earnest after that, and has continued to get more shrill as both major political parties have opted to abandon the concept of actually governing (eg. let's get some shit done here) in favor of veering towards the fringiest ideology they can find that makes column inches.
I don't want to defend medical care in the USA. I lived in a different country for a long time and loved the access it provided though not every thing was good. But, even there, Japan, they are struggling to provide the care needed.
I'm curious how you would resolve the limited supply (# of doctors) to the infinite demand (population of people needing medical attention)
Yup, this is basically the best starting point. It is just a different kind of monopoly, which also often gives the illusion of achieving an elite, illustrious lifestyle when the reality is that many physicians start in serious debt.
There should continue to be high standards on doctors. We’d be better off giving doctors with degrees from the top 50 colleges in the EU and UK a license to practice here. Today they can’t and would need to redo years of school here.
I don't get any sense that the limits on slots actually keep the standard of doctors high. Rather, it makes getting into the profession a lottery for otherwise perfect students. Better to maintain the standards by maintaining the standards of the process (i.e. keep med school and qualifying exams difficult) than to arbitrarily limiting how many people you allow into the funnel.
What certainly degrades the standard of care is the current situation, where issues that should be treated by well-trained and well-rested doctors are instead shunted off to overworked nurses or not treated at all.
Sure, do that too if possible. But importing doctors from the EU and UK, and Canada means we don't have to spend resources training them - those countries do. And then we brain drain them to the superior place for them to earn like we do for engineers from India and China - and doctors for that matter who are willing to do more school here to get licensed.
The EU and UK, and Canada have created an artificial market that underpays their medical professionals. For instance, in Germany or the UK the typical physician salary is less than half that of an American doctor. Hell, entry level software engineers in America make more than a doctor in Germany!
Clearly the margin here is the USA's opportunity to outcompete them for the talent. We already take many of their best engineers, why not their doctors too?
I'm pretty sure these megahospitals would enjoy that glut of workforce. You should probably also want to encourage the return to private practices as much as is possible.
So.. school slots.. and actual cash investments in new business.
I’d make it easier for foreign doctors to come here. For example there are tens of thousands of doctors from EU countries that would move to the USA to practice (and make more money) but don’t because their medical degrees aren’t valid here and they’d have to go to school here for a few years.
Doctors from poorer places line China and India will put up with this but others won’t.
> Greed has taken big notice of an ageing population
Pet theory: That's also related to the burst of autonomous-vehicle investment over the last decade: Investors spurred by the idea that the baby-boom generation will simultaneously (A) be unable to drive themselves and (B) will have enough wealth to afford fancy cars that cater to that need.
I don't think related companies have to hit that opportunity-window to be profitable, but I think it factored into when/why some of them were founded or pivoted.
A (non)friendly reminder to libertarians that a society where "It's a private company, they can do what they want", is against the best interests of society
I never understood the desire to be ruled over by private organizations designed to exploit you leaving you basically powerless to do anything about it. You aren't allowed to vote for the CEO of a billion dollar multinational.
Governments on the other hand are something that every person has the power to change and influence directly. For all the effort that has gone into making it harder for people to change their government effectively, we're still better poised to do that than we are when up against massive corporations.
The theory is that competition will solve the problem, if you don’t like one company you can go to another. There are a lot of areas where this doesn’t seem to work though, for various reasons.
Healthcare is almost the farthest thing from a free market in the US. There are 35 states with certificate of need laws which allow existing hospitals to veto the opening of new hospitals. The US government sets funding for residencies and in effect sets the supply of doctors. In poor states Medicaid and Medicare are the largest payers into health systems. The FDA controls what medicines can be prescribed and for what reasons.
You’re not going to find any libertarians who have anything nice to say about US healthcare.
Governments still have budgets. At the end of the day it's just money in, money out, except private healthcare has someone siphoning money in the middle.
Yeah, a libertarian would let you buy penicillin from a pharmacist without a prescription, so you wouldn't need an ER visit to see a doctor to get the obvious prescription written before next week.
I think part of it is that insurance companies gouge hospitals too. They are an even bigger monopoly with a lot of leverage against any ordinary city hospital.
Hospitals are businesses in developed countries too. Here in Japan, the hospitals and clinics are all private businesses, but the prices are very low, ambulance rides are free, etc. The keys, as far as I can tell, are 1) no consolidation/monopolization and 2) lots of regulation.
We were. Then a few decades of legislative capture, private equity, and neoliberal gibberish about "service economies" drained all of the opportunity out of rural and semi-rural America, consolidating what was left in major metro areas.
It's very hard to make money as a small, independent hospital with all the healthcare bureaucracy and other requirements. The only way to turn a profit is to merge with other hospital systems and get bigger.
This trend applies to many industries in the US besides healthcare. Agriculture and education, for example.
No, because they were permitted to violate the law by legislators.
> In the six years since lawmakers in both states waived anti-monopoly laws...
> Ballad Health was formed in 2018 after state officials approved the nation’s biggest hospital merger based on a so-called Certificate of Public Advantage, or COPA, agreement. COPAs have been used in about 10 hospital mergers over the past three decades, but none has involved as many hospitals as Ballad’s.
> State lawmakers in Tennessee and Virginia waived federal anti-monopoly laws so rival hospital systems — Mountain States Health Alliance and Wellmont Health System — could merge into a single company with no competition. Ballad is now the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina.
Even 20 years ago, I experienced this directly as someone who paid for their ER care while others came in for non-ER care, and knowing they would not have to ultimately pay for the care they received.
1. AMA (American Medical Association) artificially controlling the number of medical graduates based on a quota. Every doctor starts of a huge debt, and many don't get to practice. No experienced doctors from other countries can practice here.
2. Hospitals (many owned by Private Equity) - Maximize profit / patient. Don't show prices, lots of outrageous billing for basic care like Ibuprofen and bandages. The bills keep on coming for months after care.
3. Doctors - Gotta pay those debts. No prices advertised, Inflated costs for basic care. Specialists are booked for months.
5. Insurance companies - Can only make max 20% on administration costs. Love the high prices and denying claims for whatever reason they can find.
3. The politicians - Make $$ from lobbying insurance companies and big providers. Employers sponsored health insurance means individual workers don't have same bargaining power.
Essentially we are paying a fortune. ~5 trillion for healthcare. If we pooled all that money into a govt funded insurance pool, and removed artificial license quotas, market advertised prices, we'd have a much more efficient healthcare.
The corporations know the individuals can't coordinate between themselves to take them out. They have captured the market.
Instead we have a huge administrative bloat, gofundme pages, lowest mortality amongst the rich countries and a shit show.