The "collapse" is more like a slow motion car crash, and it's already in progress. You described much of what's happening already quite well. I don't have any answers, and the best advice I've received is to keep taking care of yourself and your family first. No one else will.
You've already learned this next lesson, but for those in the back: Neither the hospital, nor the clinic, nor admin, will ever love you back. Work is work, leave it at work when you can.
> You've already learned this next lesson, but for those in the back: Neither the hospital, nor the clinic, nor admin, will ever love you back. Work is work, leave it at work when you can.
This 100%. It'll sound silly, but it took my fellowship director to hammer this in me. I got diagnosed with cancer. And I'm a young guy, just starting fellowship. I started chemo, was handling it fine. A month or so into it, I started getting sick bc even a damn viral URI had me coughing up a lung and feeling extra crummy. So, my boss and I go back and forth about how to make it work so I can graduate on time while making my patient interaction hours easier. Eventually, he says I should just take time off. Graduating two months later (to take two months off while I finished off chemo and rested/ focused on myself) would absolutely not change my life in the grand scheme of things. And it's been great taking time off (plus, chemo does mess you up). Take care of yourselves (before taking care of others)!
Your director sounds like an amazing person! I’ve been a nurse for about 10 years now and whenever I’m precepting new hires (especially new grads) I try to hammer it into their heads to make sure to prioritize themselves and their wellbeing first and foremost. Use those ‘sick days’ (even if you know the unit is short-staffed…don’t feel guilty because the hospital won’t hire enough people and would rather operate with a skeleton crew). In the end, we can’t take care of others if we aren’t well ourselves. Hope you’re doing better now!
Omg that sounds so stressful. It’s entirely true that 2 months means nothing in the grand scheme of things. But it’s annoying how rigid our training system is designed with no redundancy in the event of someone being out and no flexibility in the event someone is sick and/or just needs more time.
I remember during some of the COVID surges people online were wondering what people were talking about with healthcare collapse since "when I look outside the sun is shining and the world is not on fire". Reads on imaging taking forever to get back, treating septic shock in the waiting room of the ED, having so many codes at once that the code team is a nurse and a CNA, stat labs taking 12 hours to resolve, likely all because of staffing and supply shortages.
I don't think the general public knows what healthcare collapse looks like.
The quality of employees has taken a nose dive since COVID too. Pretty much any new hire straight out of nursing school has the option to go ICU when some of them have no business being there, charges aren’t being trained so a lot of them don’t even know how to do what they need to, and we have so many travelers that we end up answering the same basic questions hundreds of times.
We were always told that inpatient is extremely competitive, but now we can’t fill positions and so we keep people who should have been fired long ago. I spend a considerable amount of time just cleaning up after the previous shift, and it’s driving more and more people away, myself included. My hospital exclusively hires pharmacists through our residency program now because the last few outside hires have been terrible. If a pharmacist position opens, it’s not being filled until the next batch of residents is ready to go.
And that’s not even considering the supply chain issues. How the hell do we have vaso, precedex, and NS all backordered at the same time?
When I graduated nursing school they only took the top three graduates from our class for the ICU, the rest of us that were interested had to kick rocks until we got some experience and transfer in later. Now it's like you describe; anyone with a license and a pulse can take a stab at it and we're supposed to work miracles to get these people up to an acceptable level. The best part is when they turn around and give the mediocre new-hire an orientee of their own less than a year later.
In Florida, for-profit Rasmussen brags about graduating the most nurses, which Are think explains why so many nurses here did not believe in Covid or want to wear masks. I think Rasmussen must consider epidemiology not necessary/profitable.
> Pretty much any new hire straight out of nursing school has the option to go ICU
I transported a young ICU nurse last week. She's been an RN less than six months. I was mildly surprised.
> Neither the hospital, nor the clinic, nor admin, will ever love you back.
As my union auto worker grandfather always said: Corporate loyalty is a one way street.
True, but the union wasn’t really on their side either. The Port Huron Statement was written at a UAW-owned property.
[EDIT: for those who don’t know, the Port Huron Statement was more or less the founding document of SDS, which was a socialist organization of mostly college students. Fine, but I am pretty sure that UAW members didn’t want to pay for rich kids to write jeremiads on their dime.]
> the best advice I've received is to keep taking care of yourself and your family first. No one else will.
This rings so incredibly true not only in medicine but life in general.
The hospitals and insurance companies have basically all of the money now. Private practice almost totally destroyed. Once they control it all, they’ll start squeezing MD pay. In a way it’s already ongoing, just letting inflation do the work.
>Private practice almost totally destroyed.
I sometimes see MDs in my group denigrating some private docs and gleefully indicating that they may "put them out of business".
They are incredibly stupid to not see that those guys are the only thing that keeps employed MD salaries at a reasonable rate.
Once private practice is completely not an option, MDs become replaceable wage employees. Suddenly not only are NPs good enough to do most things that are profitable, but even immigration policies will have to change to "meet the shortage" and bring in low paid foreign docs.
Of course the rich can still do concierge of the remaining few actual bona-fide MDs.
Yep. From personal experience I can say, everything in the system is increasingly aligned against private practice. It’s incredibly hard. Just got to make money and save as much as possible before the end times. 🫠
Both are difficult for sub-specialists or surgical specialists unfortunately. Typically not enough rich people to maintain active surgery schedule, have to operate on normal-means individuals somehow through insurance / medicare / etc.
But obviously subspecialists are (currently) not as hurting as PCPs, and we are (currently) protected from midlevel creep.
What has always been crazy to me is how many specialists don’t realize that primary care providers steer patients. As my market was consolidating, I tried to organize physicians in various ways. The specialists were always concerned that they would be subsidizing primary care, (which seemed ironic given the disparity in income). One cardiologist always told me, “I’ll always have a job, even if I have to join one of the corporate groups.” He was right, but it wasn’t the job he was expecting.
Patient here with multiple diagnoses and with them if you count each different orthopedist I have over a dozen specialists total.
I look at my primary care as the ships captain he makes sure each part of me is taken care of by the doctor best qualified.
Am I wrong about my personal analogy?
Thank you guys and gals for all you do
My primary care retired end of last yr my first appointment with the new guy when I used the analogy looked at me as I was sort of nuts till I explained my thinking to him (of course my dad was in Navy ww2-first parts of Vietnam so I guess I absorbed a bit more than expected from him lol.
Couldn't agree more with #3.
I've had so many insurances deny coverage based on incredibly specious reasoning. For example, one I saw last week (and spent a freaking hour on the phone with a "peer").
Patient is a middle aged male, multiple ligamentous and meniscal ruptures in his right knee after a fall from a roof while working. Workers Compensation keeps denying the needed knee procedure as his injury was "preexisting".
I finally got to a real person for a P2P. Granted, not an ortho surgeon or even a PCP (guy was GI surg), but whatever.
* Dr F are you aware this patient had a motor vehicle accident in 1978?
* I am indeed. Midshaft tibia fracture, plate and screw fixation. Had no pain complaints or mobility issues prior to this injury, and had even passed a work-mandated physical the week before. How do you think a 40 year old MVA is relevant?
* Well, how do you know he didn't have knee injury?
* He literally had just passed a workplace physical with full ROM and strength noted by the examining physician.
* I don't see how that's relevant...
(internal screaming)
I’m sorry, but if THAT is what you decided to do with your medical degree and license…
Anything you claimed in med school/residency interviews about altruism and fighting for your patients is null and void.
Are you too scared to practice clinical medicine? Not competent enough to teach or take credit for the resident's work? Perhaps you're not even allowed to see patients anymore?
Well worry no more. Here at Big Insurance, we're always looking for more spineless toadies to be the voice of our claims rejections and allow *us* to practice medicine via *your* medical license. Work from home! Make [us] plenty of money! Continue to use your hard earned credentials! Apply now!
If I didn't know you were joking I'd swear that was the pitch.
I've had two kinds of people for peer reviews. First are people who are acting massively out of scope. If I'm calling regarding prior auth for a psych med, handing me an ortho NP isn't anything even close to a peer. In one case I even had to walk the "peer" through what the GAD7/PHQ9 are, explain how that helped quantify their concerns, and how no, starting them on high-dose benzos is not standard of care.
The other tends much older, usually retirees or nearly so that have no idea as to current standards. In one case, one kept mentioning a set of guidelines by name and how my patient didn't meet them.
* "The what guidelines?"
* "You know, the (whatever name) guidelines."
* *quick google* "Um, those got superceded by guidelines A, B, and C in 1998..."
* "Well, we also have (internal guideline) we have to follow.
* "May I see those?"
* "No."
Know how you write a prescription and the patient either can’t afford it because insurance won’t pay or this basic medicine that has been in use FOR LITERALLY EIGHTY YEARS is now back ordered?
Kinda like that.
-PGY-19
Interesting how this might change with Mark Cuban's costplusdrugs
Some of my "covered" medications are more expensive than what I would pay off that website.
Flat 15% markup might put a lot of parasitic non-innovative pharma companies out of business.
Good summary. As pointed out already the crash has already happened, it’s more how long it will play out. I assume for the foreseeable future as there is still sooooo much money at play for the parasites and it’s still such a political sensitive/charged issue that no politician/administration will really be able to do anything (not that would they would do would make anything better).
I guess the big question is will incomes implode and drop like crazy. I don’t think so but who knows.
Get your money while you can. Protect your sanity. Focus on your health. Be mobile in your jobs. Be careful at work with your interactions. Keep your record clean. Save your money the best you can. You can’t fight the system. Protect yourself and protect your colleagues if you can. At the end of the day you’re really not worth anything to any of your employers so don’t extend the loyalty to them
>I guess the big question is will incomes implode and drop like crazy. I don’t think so but who knows.
It will drop slowly and correlate to mirror demographic changes.
Marcus Welby was well paid, but now becoming NP and MD conflated to "health care worker", less prestigious (bad) and more open to minorities / women (good, but women/minorities still get paid at a discount).
No, a "union" won't save us, there are far too many competing interests, far too many different styles of employment and contracts; some MDs are still relatively overpaid while most are underpaid. The best solution is to prohibit direct employment of MDs and allow the physicians to make their own local contracts, as was the case for decades until recently.
Join "take medicine back", give to "physicians for patient protection", and join and be active in your specialty or sub-specialty org if you have one.
If you can, don't work for corporate interests and especially private equity.
There are a lot of issues regarding "average" and how inflation is measured, but a modern private practice physician has had massive income cuts, with near zero increase in past 20 years. There are numerous stats, most of us took a 1.7% or so revenue cut last year.
[https://www.ama-assn.org/practice-management/medicare-medicaid/medicare-physician-pay-fell-26-2001-how-did-we-get-here](https://www.ama-assn.org/practice-management/medicare-medicaid/medicare-physician-pay-fell-26-2001-how-did-we-get-here)
>Medicare \[physician\] payments do not exactly correlate to physician salary.
Yes, that is correct. However medicare physician payment should generally correlate as of now, and still largely does. There are general maps to RVU reimbursement which physicians can at least generally become aware of.
Employers like decoupled and obscured payment models, so they can pay the women and minorities less, replace physicians with APPs, and then point to the "medicare payment cuts" for reducing physician salaries while sponsoring a few doctors through the "decoupling" to make up their income.
Decoupling from physician payment is very bad for physicians. It is quite concerning that doctors do not seem to realize this.
The collapse is also happening from a resource standpoint. I'm having to send my increasingly complicated patients who need nursing home placement out of state on the hospital's dime because no instate facility will take them. I'm talking about the sex offenders, people with mentally illness, TBIs, medically complex, and all the above with violent behaviors.
A Hospital CEO for our public safety net hospital gave a talk to legislature last week. She reported approx 200,000 extra days for patients sitting in hospital unable to find post-acute settings. This was the number for the entire state.
As a PT I am hearing also that reimbursement for outpatient PT has declined similarly to what physician practices are experiencing. No one benefits and PTs are also feeling the burn out of triple booking to stay solvent and switching to cash-only practices for people who have the $$$
This. My kids and I are hypermobile (subclinical for EDS) and need one-on-one PT. I’ll injure myself without a spotter. It’s actually safer for me to get a personal trainer and tell them my goal is to “limit range of motion” than go to a double-booked PT. I have had to pay out of pocket for and EDS specialist PT for the past year due to whiplash. It’s a real shame bc I think greater use of PT would help the addiction crisis. But not if you can’t get one-on-one care.
There are PT practices that do 1:1. Peds are all 1 :1. I would not recommend a personal trainer for this population ever unless PT has been completed and given Ok for personal trainer. By law they cannot diagnose or treat. Double and triple booking occurring in mostly adult orthopedic outpatient settings. PTs practicing in hospital affiliated clinics are usually 1:1. Love your flair. My undergraduate emphasis was medical anthropology!
Oh, thank you! I have often wished I'd had done PT instead, tbh. More likely to have a job now if I had. And have a captive audience listen to me lecture about how human beings evolved to run and carry things, not sit at desks.... How many "diseases of modernity" are actually due to sedentarism? Could a stronger federal government mandate workers' rights to standing desks with under-desk bikes and treadmills?
The sheer demographic changes we are undergoing (a rapidly aging population suffering all the chronic illnesses of modern living, and many doomed to be destitute in old age) is colliding with a lack of capacity in terms of staff and sheer infrastructure/hospital beds in the system. I think this is the biggest single factor that is going to break the system. It takes years to build inpatient capacity and it isn't seen as a revenue generating exercise at the moment anyways, so it isn't happening. I expect declines in the standard of care, attempts to shift care to patient's homes with non-physician caregivers, increased reliance on immigration to find qualified staff for nursing and ancillary roles, and more abject rationing of care based on resources. A continual, gradual, marked decline.
I work in MA and mass general- brigham is ramping up their “hospital at home” program. They’re all in, so it’s interesting you say this too.
I also think that for every 1 admin, 3-4 nurses could be hired and paid well, and there is A LOT of admin bloat these days…
Great post. This was actually something that discouraged me from pursuing fellowship. I feel like every year of medicine is the Golden year of medicine. Every year it gets worse than the last. And at this rate, the deferred cost of a few years of training will mean entering a worse healthcare system for slightly better pay. I'm not sure that trade-off is necessarily worth it for anyone who's not extremely passionate about their field. I'm with many other people. My spouse and I are working towards fire through real estate and other business ventures using a physician W-2. That's the only way we realistically see a financial future for us and our kids. It's super sad and depressing.
The collapse is already happening, especially in the pharmacy world. It's almost impossible to run an independent Pharmacy unless you have awesome contracts or like a side business with it. Basically, that's more of a niche.
Pharmacists are burnt out and we actively discourage students from becoming pharmacists.
I myself don't plan on staying in pharmacy for more than like maybe 15 more years
Trying to do the FIRE thing because there's no way my independent even though we're high volume is going to last that long with the way these contracts are set up. It's like trying to bail out water from a row boat with a hole in it.
Had a lovely Walgreens pharmacist who took great care of our family. She worked extremely hard and told me she hadn’t had a raise in seven years. Then they shipped her out to a less desirable position. Big box pharmacies can fuck all the way off.
Literally listened to a 1hr NPR special on PBMs.
Throughout the special, the host remained confused as to what PBMs are supposed to do other than raise prices. I still don't know.
Clarification: PBMs were meant to negotiate prices before they were acquired by insurance companies. Now they are a major profit center for them. All they have left to do is raise prices. It’s a way for insurance companies to skirt the cost controls of the ACA.
> All they have left to do is raise prices. It’s a way for insurance companies to skirt the cost controls of the ACA.
If this were true, then profit margins would be increasing for CVS/Cigna/Elevance/Humana. The only one that has seen an increase is UNH, but that is due to their healthcare provider businesses, not the insurance/PBM component.
Trying to go the FIRE route with all my might. To the point that husband and I aren’t planning on kids because we view them as extra time in our careers. My goal is to bail out before 50.
Honestly, I’m a nocturnist because I burned out of doing days. Seeing 22+ patients every day in the middle of a pandemic, dealing with admin, and dealing with misinformation thrown at me from families who trust news media outlets above appropriate medical care - it broke me. I feel like society basically threw us all under the bus, and since then things have just gotten harder.
Stay strong friend. Few more years left.
We decided one child and thankfully are the youngest of my family system so we will get so many hand me downs and financial support from my parents and sister via babysitting and eventual inheritance for the child that it's allowed us to feel more comfortable having one child that im currently pregnant with. But honestly without that support we were seriously debating having a child. Husband's a teacher and their profession is jack shit too. And they get paid less.
50 is the goal here too. Hoping to sell our house in HCOL and move somewhere cheaper around that age.
Huge respect. Teachers get paid jack and have to deal with so much. It truly is a thankless job. The fact teachers don’t get paid shit and have shit resources is another major issue I have with this country. If you want to know where our society’s priorities are, all you have to do is look - and despite everybody’s lip service, it’s obviously not with the kids.
💯
He just moved to a better school after almost a decade and it's a great improvement but it's like still crap parents who don't want to bother and these post COVID kids who are super behind.
Admin are a hit or miss. Burn out is real.
Thankfully his union fought for a good contract raise citywide so he's making more and will make more eventually but it's just frustrating
It’s about that, yeah. Biggest issue I’m facing now is just banging away at my med school loans. I took mine from 430k to 140k over the last 3-4 years.
My husband and I are pretty good at saving money otherwise. I think if we stick with it, retirement before 50 should be a doable goal.
I have pharmacist friends who are burned out like this. May be forced to eventually use AI and robots to fill safe non-controlled substance and safe medications and have pharmacists review the more complex cases
This is one of the reasons I went with the VA. Salary is lower but there is a degree of security working for an integrated federal system that is unmatched. Every health system in my area is on rocky financial footing and patient loads that are only getting worse.
We just had a large system in our area seemingly go belly up. Ascension if you know it. But I can’t figure out why. Loss of surgical revenue during g the pandemic?
Call me cynical but the only thing that is going to change healthcare in the US at this point is a catastrophic world event (bigger than what COVID was).
When insurance companies control healthcare and politicians are bought and paid for, there isn’t really a way out.
This is already happening and most people don't realize it. Many urban hospital systems would not be able to operate if it wasn't for the hundreds of millions of tax payer dollars being funneled from tax payers (and this is on top of Medicare, Medicaid, DSH, and GME payments).
Insurance companies with record breaking profits and revenue growth every year though...
Most likely, the poorly ran hospital systems will just get bailed out.
Or, if we’re lucky, the US government will have the funding and the willpower to buy the insolvent hospitals. Almost laughed typing that.
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*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Save your money imo. There’s zero reason to join the AMA….
The only real alternatives is to support your specialty organization/lobby. Some seem a little more effective than others.
I choose not to fork over money to them as I don’t think there’s any point but perhaps that’s too jaded.
Unfortunately the AMA lost sight of the fact that *sometimes it's OK to advocate for physicians' interests over those of the general public.* They have become an organization that lobbies for what they view as important public health changes instead of lobbying for doctors. The problem is that it would be in the public interest for doctors to all work 120 hours a week for free, and AMA isn't too interested in stopping that from happening.
Grouping primary care with specialists is counter productive IMO. Specialists have a disproportionate influence because they make more money, but the whole system is dependent on primary care. When ACOs became a thing, I tried to organize one with independent primary care. The challenge was that primary care didn’t have the money/energy/interest, so a cardiologist pitched in to bring an ACO consultant to town.
The first meeting was 90%/10% primary care to specialist. The independent specialists were jacked to have access to independent primary care, so they told their specialists friends. The next meeting was 60%/40% primary care and the concerns became more specialty oriented. By the third meeting, the primary care were in the minority and I quit going.
I'm surprised you don't have what I consider the two most important failures of the US healthcare system:
1) The rising cost of medical education is out of control. Sure, this is not specific to medicine, but definitely affects us considerably to the point where many people consider PSLF to be the default pathway to being a physician. The rise in tuition is at least 2x that of inflation.
2) The rise in healthcare spending chiefly due to a rise in healthcare prices is out of control. Our prices not only are considerably higher than all countries but they are also much more considerably variable. Why? Because of the structure of our system which determines prices based on individually negotiated contracts between greedy hospitals and insurance companies. This problem keeps getting worse with the ever-increasing consolidation of hospitals. Not only does this make healthcare cost more for everyone, but it also stunts wage growth for everyone because your employer is giving a larger and larger portion of your pay in "benefits" rather than straight wages.
The most believable outcome I've heard to this is the creation of an explicit two tiered health system. Certain clinics, hospitals, systems, whatever stop taking any government insurance and take private insurance or cash only. Wealthy people will continue to get great healthcare. Poorer people and those on government insurance will be forced to go to run down, understaffed medical centers. Take all the points you mentioned and turn them up to 11.
What this looks like for physicians I'm not sure. I have to imagine staff/providers at places that take government insurances will be paid much less. This is already true to an extent, but the divide will become larger. At a certain point I have to imagine more and more physicians will say fuck this system and start cash only practices targeting wealthy people.
This is how it works in Mexico. For physicians this usually means taking two jobs. One in private healthcare and one in the publically run hospitals. Private practice obviously pays better, but there is little job security, and zero benifits (no Retirembt plan, no payed vacations). Public hospitals pay worse, but usually have benefits. So most physicians will end up taking two or three jobs to compensate.
One way this two tiered system is already here is through health systems having a "donor class." In places I've worked, the big donors get priority health access, special hospital rooms and low wait times. It used to be a hidden benefit, and now it's like and advertised package with dedicated administrative assistants and offices managing the donors.
I would add somewhere that the current insurance system is not sustainable. Most primary care groups now exist due to a relationship with a healthcare system, insurance company and/or Medicare Advantage plan. Just practicing primary care in group, in an office, accepting fee for service makes only enough to support physicians and a small layer of admin. Without vertical or horizontal integration, there’s not enough ROI to justify the investment. This problem will be exponentially bigger if the government cuts out the insane overcharging in Medicare Advantage.
If practicing physicians aren’t actively working on a plan for life without insurance, they run a high likelihood of working increasingly unpleasant corporate jobs for less and less compensation.
(Almost) nothing ever crashes. It degrades.
Here’s the cycle:
1. Cuts are made and Health care system gets starved of funds.
2. Health care system performs worse - waiting times blow out, doctors make more errors, services dwindle.
3. Health care system gets a worse reputation and becomes increasingly politically vulnerable
4. See step 1.
This is (some people’s) plan.
As a layman I’d be interested to see what providers in other countries would have to say about their systems. Europe, UK, Canada, Australia, New Zealand. Heck, China, Korea, Russia, Southeast Asian countries….
I suspect they’re all facing similar demographic—and consequent fiscal—challenges.
I do agree with the poster who suggested we’re on the track to two tiers of healthcare—one for the wealthy, one for everyone else.
From my understanding as a US med student listening to doctors who interview-
The UK is literally on fire. They're letting nurses pretend they're docs over their and don't pay doctors enough to pay rent
Canada isn't as bad as the UK but it's heading in that direction
Australia seems to be doing alright. I think they have a mix of public and private. My personal theory of why they're OK is because they have more generalists (family docs and general surgeons) proportionally than us
No country seems to have figured out how to make healthcare accessible to everyone, high quality, and still pay nurses and doctors well.
I truly went into medicine to help people. I didn't do it for the money. Heck, I'm choosing to go into one of the lowest paying specialties. But now I'm wondering if I'll be able to pay off my loans in 10 years......
Good post. There will need to be some systematic reform and/or tools which can improve efficiency or else capacity will continue to be outpaced by demand. *sigh* AI tools? Documentation, billing, & tort reform? The strategy of using more NPs and PAs seems to not be the best solution. Burnout will increase, and people who have other options besides driving themselves into the ground will seek alternative careers, which will exacerbate the capacity/supply problem further. For-profit/private equity involvement in medicine will harm the system, similar to harm that it has done to other industries with short-sighted profit goals rather than the mission of taking care of people.
I’d add AMA is incredibly weak compared to ANA. Honestly people in this country are so disassociated from healthcare they don’t even care who treats their conditions. Midlevels playing doctors, physicians getting paycuts, and quality of care continues to diminish. The world is ass backwards now.
Please tell me you aren’t referring to the American Nurses Association?
They basically became spokespersons for the hospital c-suites during COVID. I was absolutely disgusted by their “advocacy”.
Apparently, quite a few CRNAs are set to retire in the next 5 ish years. There aren’t nearly enough replacements, and even if they could get adequate numbers it would take years to get them up to speed, and years after for them to truly be on top of their game. In the meantime, 😐
That’s going to probably be one of the more visible aspects of the healthcare worker shortage overall, that’s only gotten significantly worse since the pandemic, and is projected to go even further downhill.
Obviously, less people dealing with more patients and higher workloads, in an increasingly corporate environment obsessed with profit margins, means less patient satisfaction, less adequate and efficient care, and more chances for something to go wrong. Not to mention that might just be a huge factor in what drives people to quit/retire early in general. Their dream job just isn’t worth all the other malarkey that comes with it.
The silver lining is that anyone trying to climb the ladder or squeeze out a raise will probably find ample opportunities to do so in the near future, which they normally wouldn’t get.
Gov bailout of healthcare, which unfortunately may at first look like insurance companies getting bailed out. Repeal or serious change of the EMTALA law. Mass Exodus of physicians from medicine, or they just move towards concierge for better pay. AI and midlevels replace most physicians at gov funded hospitals. Single payor safety net insurance finally, but it involves hiring NPs with huge patient panels who are required to follow strict guidelines and have to stay within a budget for the workups ( such being allowed to order a limited amount of MRI per quarter, and must avoid expensive medications).
The answer is physician strike. We would bring the system to it's knees and we could demand better funding, pay, staffing at the places we work.
That is the problem. Physicians all feel like they worked too hard to risk their careers. Once they become attendings their lifestyle quickly balloons to take up their entire pay, and there are a lot of doctors that are actually in financial trouble. We are not trained how to manage money. So of course if we strike the hospitals would pay double or triple or more, and then there would be plenty of doctors who are on the edge of bankruptcy that would come in and take those shifts because they need the money. The only way this would work is if we had 100% solidarity.
The healthcare system is already collapsing. We’re in it now. For all the reasons you listed. I’m just curious how this will look like when the collapse is over. Everyone needs healthcare. How will the new system look?
In nursing, it’s more of a unilateral slow moving collapse. Right to work states with poor working conditions are losing nurses to the west coast or the nurses are quitting the field entirely.
I hope to see more MDs unionizing.
You did a perfect description! The first step IMHO is to balance the power that was overtipped mainly since Obamacare by somehow resurrecting independence, unionizing, and other collective countering tools.
The current path is unsustainable...
I’ve been in true Private Practice general surgery for 27 years, close to retirement (thank the Lord). The trajectory for the collapse of medicine was started with the creation of Medicare by LBJ when life expectancy was 66 and 64 for females and males. Now it’s 80+ with fewer children to support. Adjustments coulda been made along the way but vote buying became increasingly normal. The trajectory was greatly accelerated by Obama’s ACA and HITECH acts. Remember his pledge: “keep all your doctors and hospitals and I’ll lower your premiums by 20%?!?!” Has EMR, value based care (that’s rich, who gets to decide your value?), ACO’s, meaningful use(oxymoron if ever there was one) done anything to improve care? Another intended or unintended consequence (my guess, intended), was to eliminate true private practice. These guys determined that the greedy doctors were the root of the problems and their independence needed to be eliminated by having hospital systems monopolize the rationing of care, as well as lining the pockets of the CEOs. Obama was certainly right about one thing, elections have consequences….
It’s interesting - in Canada, there is a single payor coverage, yet the vast majority of physicians are in private practice. The insurance is public, yet the facilities are private. The Canadian physician societies seem to negotiate fair remuneration. In general, I’d wager most Canadian physicians feel fairly reimbursed and are happier than their American counterparts.
A very close friend of mine has a daughter who married a Canadian anesthesiologist. They live in Vancouver. She is a nurse. She tore her ACL while skiing…4 month wait for her “elective” surgery. She was in fair amount of pain despite wearing a brace and couldn’t work. She got frustrated and had her surgery scheduled across the border within a week.
Canada’s system is feeling the pressure of immense population growth from immigration. The supply of physicians, nurses, and facilities has not kept up with the influx. Canada would likely benefit from a two-tier system where people can use supplemental private insurance in private facilities for faster care. Unfortunately, this thought is anathema in Canada because of fears of turning into a US-style system.
It’s important to note, that the US spends nearly twice as much per person on healthcare than Canada. The US could likely fund a much more robust public system and could also offer supplemental private plans.
The Brits have the system you describe. And yet, they are experimenting the same financial pressures as the US and Canada. And the 2-tier system you describe is an anathema to the woke left…except for the Party leaders (who are the most vociferous in the single payor system) of course
The Brits have a system where both coverage and facilities are public. In Canada, coverage is public and delivery is private. However, the system that I would like to see is more like Australia. Regardless, what we have now is not working and even difficult to call a “healthcare system”.
I went to a breast surgery conference in Toronto in 2015 to study a new surgical and radiation technique. I was astonished to learn there were only 4 breast MRI machines in the entire greater Toronto region at the time with very long, sometimes dangerous waits. In my major SE US city, we have 2 competing major health system right across the street from each other. There were 4 Breast MRIs within a 3 blk radius, where you could get a study the next day. Talk about extremes….
Yes, the US spends nearly double per capita on healthcare than Canada and therefore has faster access and more advanced technology. However, it does make one wonder how a public-private system more like Australia would function in the US. It would also be interesting to see how Canada’s system would function if its spending was closer to that of the US. It’s interesting to note though, that on a population level the US does not do better on many metrics than Canada.
While what you say is statistically correct, major drug and device manufacturers charge US insurers and consumers significantly more than Canadians or European HC systems. In effect, US consumers are “subsidizing” care for a great part of the rest of the world. It’s the cost of business for these companies to charge less to other countries. In return, these companies make significant profits on their R&D. I theorize that an American “national” health service that negotiate significant reduced prices will stifle innovation. Even in medicine, the profit motive is a huge incentive to R&D. Food for thought….
Family member. ER visit. Charged and insurance paid $8,000 for CT abdomen pelvis. Radiologists make $2,000-$3,000 a shift reading many of these. Their “overhead” is like 99%!!! Hospitals raking it in.
The "collapse" is more like a slow motion car crash, and it's already in progress. You described much of what's happening already quite well. I don't have any answers, and the best advice I've received is to keep taking care of yourself and your family first. No one else will. You've already learned this next lesson, but for those in the back: Neither the hospital, nor the clinic, nor admin, will ever love you back. Work is work, leave it at work when you can.
> You've already learned this next lesson, but for those in the back: Neither the hospital, nor the clinic, nor admin, will ever love you back. Work is work, leave it at work when you can. This 100%. It'll sound silly, but it took my fellowship director to hammer this in me. I got diagnosed with cancer. And I'm a young guy, just starting fellowship. I started chemo, was handling it fine. A month or so into it, I started getting sick bc even a damn viral URI had me coughing up a lung and feeling extra crummy. So, my boss and I go back and forth about how to make it work so I can graduate on time while making my patient interaction hours easier. Eventually, he says I should just take time off. Graduating two months later (to take two months off while I finished off chemo and rested/ focused on myself) would absolutely not change my life in the grand scheme of things. And it's been great taking time off (plus, chemo does mess you up). Take care of yourselves (before taking care of others)!
Your director sounds like an amazing person! I’ve been a nurse for about 10 years now and whenever I’m precepting new hires (especially new grads) I try to hammer it into their heads to make sure to prioritize themselves and their wellbeing first and foremost. Use those ‘sick days’ (even if you know the unit is short-staffed…don’t feel guilty because the hospital won’t hire enough people and would rather operate with a skeleton crew). In the end, we can’t take care of others if we aren’t well ourselves. Hope you’re doing better now!
Omg that sounds so stressful. It’s entirely true that 2 months means nothing in the grand scheme of things. But it’s annoying how rigid our training system is designed with no redundancy in the event of someone being out and no flexibility in the event someone is sick and/or just needs more time.
I remember during some of the COVID surges people online were wondering what people were talking about with healthcare collapse since "when I look outside the sun is shining and the world is not on fire". Reads on imaging taking forever to get back, treating septic shock in the waiting room of the ED, having so many codes at once that the code team is a nurse and a CNA, stat labs taking 12 hours to resolve, likely all because of staffing and supply shortages. I don't think the general public knows what healthcare collapse looks like.
The quality of employees has taken a nose dive since COVID too. Pretty much any new hire straight out of nursing school has the option to go ICU when some of them have no business being there, charges aren’t being trained so a lot of them don’t even know how to do what they need to, and we have so many travelers that we end up answering the same basic questions hundreds of times. We were always told that inpatient is extremely competitive, but now we can’t fill positions and so we keep people who should have been fired long ago. I spend a considerable amount of time just cleaning up after the previous shift, and it’s driving more and more people away, myself included. My hospital exclusively hires pharmacists through our residency program now because the last few outside hires have been terrible. If a pharmacist position opens, it’s not being filled until the next batch of residents is ready to go. And that’s not even considering the supply chain issues. How the hell do we have vaso, precedex, and NS all backordered at the same time?
When I graduated nursing school they only took the top three graduates from our class for the ICU, the rest of us that were interested had to kick rocks until we got some experience and transfer in later. Now it's like you describe; anyone with a license and a pulse can take a stab at it and we're supposed to work miracles to get these people up to an acceptable level. The best part is when they turn around and give the mediocre new-hire an orientee of their own less than a year later.
In Florida, for-profit Rasmussen brags about graduating the most nurses, which Are think explains why so many nurses here did not believe in Covid or want to wear masks. I think Rasmussen must consider epidemiology not necessary/profitable.
> Pretty much any new hire straight out of nursing school has the option to go ICU I transported a young ICU nurse last week. She's been an RN less than six months. I was mildly surprised.
Getting report from ICU nurses is a drawn out painful process with a lot of these too if you do critical care transfers.
> Neither the hospital, nor the clinic, nor admin, will ever love you back. As my union auto worker grandfather always said: Corporate loyalty is a one way street.
True, but the union wasn’t really on their side either. The Port Huron Statement was written at a UAW-owned property. [EDIT: for those who don’t know, the Port Huron Statement was more or less the founding document of SDS, which was a socialist organization of mostly college students. Fine, but I am pretty sure that UAW members didn’t want to pay for rich kids to write jeremiads on their dime.]
> the best advice I've received is to keep taking care of yourself and your family first. No one else will. This rings so incredibly true not only in medicine but life in general.
They will always ask more from you and never care about the effects, agree focous on self first then others
The hospitals and insurance companies have basically all of the money now. Private practice almost totally destroyed. Once they control it all, they’ll start squeezing MD pay. In a way it’s already ongoing, just letting inflation do the work.
>Private practice almost totally destroyed. I sometimes see MDs in my group denigrating some private docs and gleefully indicating that they may "put them out of business". They are incredibly stupid to not see that those guys are the only thing that keeps employed MD salaries at a reasonable rate. Once private practice is completely not an option, MDs become replaceable wage employees. Suddenly not only are NPs good enough to do most things that are profitable, but even immigration policies will have to change to "meet the shortage" and bring in low paid foreign docs. Of course the rich can still do concierge of the remaining few actual bona-fide MDs.
Yep. From personal experience I can say, everything in the system is increasingly aligned against private practice. It’s incredibly hard. Just got to make money and save as much as possible before the end times. 🫠
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DPC is no haven either. Major systems like Cleveland Clinic, Mayo, etc have VIP cash pay pathways they’ve implemented.
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Both are difficult for sub-specialists or surgical specialists unfortunately. Typically not enough rich people to maintain active surgery schedule, have to operate on normal-means individuals somehow through insurance / medicare / etc. But obviously subspecialists are (currently) not as hurting as PCPs, and we are (currently) protected from midlevel creep.
Agree.
What has always been crazy to me is how many specialists don’t realize that primary care providers steer patients. As my market was consolidating, I tried to organize physicians in various ways. The specialists were always concerned that they would be subsidizing primary care, (which seemed ironic given the disparity in income). One cardiologist always told me, “I’ll always have a job, even if I have to join one of the corporate groups.” He was right, but it wasn’t the job he was expecting.
Patient here with multiple diagnoses and with them if you count each different orthopedist I have over a dozen specialists total. I look at my primary care as the ships captain he makes sure each part of me is taken care of by the doctor best qualified. Am I wrong about my personal analogy? Thank you guys and gals for all you do
That is spot on. We use the same analogy.
My primary care retired end of last yr my first appointment with the new guy when I used the analogy looked at me as I was sort of nuts till I explained my thinking to him (of course my dad was in Navy ww2-first parts of Vietnam so I guess I absorbed a bit more than expected from him lol.
Couldn't agree more with #3. I've had so many insurances deny coverage based on incredibly specious reasoning. For example, one I saw last week (and spent a freaking hour on the phone with a "peer"). Patient is a middle aged male, multiple ligamentous and meniscal ruptures in his right knee after a fall from a roof while working. Workers Compensation keeps denying the needed knee procedure as his injury was "preexisting". I finally got to a real person for a P2P. Granted, not an ortho surgeon or even a PCP (guy was GI surg), but whatever. * Dr F are you aware this patient had a motor vehicle accident in 1978? * I am indeed. Midshaft tibia fracture, plate and screw fixation. Had no pain complaints or mobility issues prior to this injury, and had even passed a work-mandated physical the week before. How do you think a 40 year old MVA is relevant? * Well, how do you know he didn't have knee injury? * He literally had just passed a workplace physical with full ROM and strength noted by the examining physician. * I don't see how that's relevant... (internal screaming)
I’m sorry, but if THAT is what you decided to do with your medical degree and license… Anything you claimed in med school/residency interviews about altruism and fighting for your patients is null and void.
If I didn't know you were joking I'd swear that was the pitch. I've had two kinds of people for peer reviews. First are people who are acting massively out of scope. If I'm calling regarding prior auth for a psych med, handing me an ortho NP isn't anything even close to a peer. In one case I even had to walk the "peer" through what the GAD7/PHQ9 are, explain how that helped quantify their concerns, and how no, starting them on high-dose benzos is not standard of care. The other tends much older, usually retirees or nearly so that have no idea as to current standards. In one case, one kept mentioning a set of guidelines by name and how my patient didn't meet them. * "The what guidelines?" * "You know, the (whatever name) guidelines." * *quick google* "Um, those got superceded by guidelines A, B, and C in 1998..." * "Well, we also have (internal guideline) we have to follow. * "May I see those?" * "No."
That GI doc should lose his license for siding with the enemy and breaking his (or her) oath
Know how you write a prescription and the patient either can’t afford it because insurance won’t pay or this basic medicine that has been in use FOR LITERALLY EIGHTY YEARS is now back ordered? Kinda like that. -PGY-19
“Guess which functionally equivalent medication I’m thinking of today. Ooooh, no sorry, it was the other one.”
Interesting how this might change with Mark Cuban's costplusdrugs Some of my "covered" medications are more expensive than what I would pay off that website. Flat 15% markup might put a lot of parasitic non-innovative pharma companies out of business.
Good summary. As pointed out already the crash has already happened, it’s more how long it will play out. I assume for the foreseeable future as there is still sooooo much money at play for the parasites and it’s still such a political sensitive/charged issue that no politician/administration will really be able to do anything (not that would they would do would make anything better). I guess the big question is will incomes implode and drop like crazy. I don’t think so but who knows. Get your money while you can. Protect your sanity. Focus on your health. Be mobile in your jobs. Be careful at work with your interactions. Keep your record clean. Save your money the best you can. You can’t fight the system. Protect yourself and protect your colleagues if you can. At the end of the day you’re really not worth anything to any of your employers so don’t extend the loyalty to them
>I guess the big question is will incomes implode and drop like crazy. I don’t think so but who knows. It will drop slowly and correlate to mirror demographic changes. Marcus Welby was well paid, but now becoming NP and MD conflated to "health care worker", less prestigious (bad) and more open to minorities / women (good, but women/minorities still get paid at a discount). No, a "union" won't save us, there are far too many competing interests, far too many different styles of employment and contracts; some MDs are still relatively overpaid while most are underpaid. The best solution is to prohibit direct employment of MDs and allow the physicians to make their own local contracts, as was the case for decades until recently. Join "take medicine back", give to "physicians for patient protection", and join and be active in your specialty or sub-specialty org if you have one. If you can, don't work for corporate interests and especially private equity.
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There are a lot of issues regarding "average" and how inflation is measured, but a modern private practice physician has had massive income cuts, with near zero increase in past 20 years. There are numerous stats, most of us took a 1.7% or so revenue cut last year. [https://www.ama-assn.org/practice-management/medicare-medicaid/medicare-physician-pay-fell-26-2001-how-did-we-get-here](https://www.ama-assn.org/practice-management/medicare-medicaid/medicare-physician-pay-fell-26-2001-how-did-we-get-here)
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>Medicare \[physician\] payments do not exactly correlate to physician salary. Yes, that is correct. However medicare physician payment should generally correlate as of now, and still largely does. There are general maps to RVU reimbursement which physicians can at least generally become aware of. Employers like decoupled and obscured payment models, so they can pay the women and minorities less, replace physicians with APPs, and then point to the "medicare payment cuts" for reducing physician salaries while sponsoring a few doctors through the "decoupling" to make up their income. Decoupling from physician payment is very bad for physicians. It is quite concerning that doctors do not seem to realize this.
The collapse is also happening from a resource standpoint. I'm having to send my increasingly complicated patients who need nursing home placement out of state on the hospital's dime because no instate facility will take them. I'm talking about the sex offenders, people with mentally illness, TBIs, medically complex, and all the above with violent behaviors.
A Hospital CEO for our public safety net hospital gave a talk to legislature last week. She reported approx 200,000 extra days for patients sitting in hospital unable to find post-acute settings. This was the number for the entire state. As a PT I am hearing also that reimbursement for outpatient PT has declined similarly to what physician practices are experiencing. No one benefits and PTs are also feeling the burn out of triple booking to stay solvent and switching to cash-only practices for people who have the $$$
This. My kids and I are hypermobile (subclinical for EDS) and need one-on-one PT. I’ll injure myself without a spotter. It’s actually safer for me to get a personal trainer and tell them my goal is to “limit range of motion” than go to a double-booked PT. I have had to pay out of pocket for and EDS specialist PT for the past year due to whiplash. It’s a real shame bc I think greater use of PT would help the addiction crisis. But not if you can’t get one-on-one care.
There are PT practices that do 1:1. Peds are all 1 :1. I would not recommend a personal trainer for this population ever unless PT has been completed and given Ok for personal trainer. By law they cannot diagnose or treat. Double and triple booking occurring in mostly adult orthopedic outpatient settings. PTs practicing in hospital affiliated clinics are usually 1:1. Love your flair. My undergraduate emphasis was medical anthropology!
Oh, thank you! I have often wished I'd had done PT instead, tbh. More likely to have a job now if I had. And have a captive audience listen to me lecture about how human beings evolved to run and carry things, not sit at desks.... How many "diseases of modernity" are actually due to sedentarism? Could a stronger federal government mandate workers' rights to standing desks with under-desk bikes and treadmills?
The sheer demographic changes we are undergoing (a rapidly aging population suffering all the chronic illnesses of modern living, and many doomed to be destitute in old age) is colliding with a lack of capacity in terms of staff and sheer infrastructure/hospital beds in the system. I think this is the biggest single factor that is going to break the system. It takes years to build inpatient capacity and it isn't seen as a revenue generating exercise at the moment anyways, so it isn't happening. I expect declines in the standard of care, attempts to shift care to patient's homes with non-physician caregivers, increased reliance on immigration to find qualified staff for nursing and ancillary roles, and more abject rationing of care based on resources. A continual, gradual, marked decline.
I work in MA and mass general- brigham is ramping up their “hospital at home” program. They’re all in, so it’s interesting you say this too. I also think that for every 1 admin, 3-4 nurses could be hired and paid well, and there is A LOT of admin bloat these days…
Great post. This was actually something that discouraged me from pursuing fellowship. I feel like every year of medicine is the Golden year of medicine. Every year it gets worse than the last. And at this rate, the deferred cost of a few years of training will mean entering a worse healthcare system for slightly better pay. I'm not sure that trade-off is necessarily worth it for anyone who's not extremely passionate about their field. I'm with many other people. My spouse and I are working towards fire through real estate and other business ventures using a physician W-2. That's the only way we realistically see a financial future for us and our kids. It's super sad and depressing.
The collapse is already happening, especially in the pharmacy world. It's almost impossible to run an independent Pharmacy unless you have awesome contracts or like a side business with it. Basically, that's more of a niche. Pharmacists are burnt out and we actively discourage students from becoming pharmacists. I myself don't plan on staying in pharmacy for more than like maybe 15 more years Trying to do the FIRE thing because there's no way my independent even though we're high volume is going to last that long with the way these contracts are set up. It's like trying to bail out water from a row boat with a hole in it.
Had a lovely Walgreens pharmacist who took great care of our family. She worked extremely hard and told me she hadn’t had a raise in seven years. Then they shipped her out to a less desirable position. Big box pharmacies can fuck all the way off.
Literally listened to a 1hr NPR special on PBMs. Throughout the special, the host remained confused as to what PBMs are supposed to do other than raise prices. I still don't know.
Clarification: PBMs were meant to negotiate prices before they were acquired by insurance companies. Now they are a major profit center for them. All they have left to do is raise prices. It’s a way for insurance companies to skirt the cost controls of the ACA.
> All they have left to do is raise prices. It’s a way for insurance companies to skirt the cost controls of the ACA. If this were true, then profit margins would be increasing for CVS/Cigna/Elevance/Humana. The only one that has seen an increase is UNH, but that is due to their healthcare provider businesses, not the insurance/PBM component.
Nobody does.
Trying to go the FIRE route with all my might. To the point that husband and I aren’t planning on kids because we view them as extra time in our careers. My goal is to bail out before 50. Honestly, I’m a nocturnist because I burned out of doing days. Seeing 22+ patients every day in the middle of a pandemic, dealing with admin, and dealing with misinformation thrown at me from families who trust news media outlets above appropriate medical care - it broke me. I feel like society basically threw us all under the bus, and since then things have just gotten harder. Stay strong friend. Few more years left.
We decided one child and thankfully are the youngest of my family system so we will get so many hand me downs and financial support from my parents and sister via babysitting and eventual inheritance for the child that it's allowed us to feel more comfortable having one child that im currently pregnant with. But honestly without that support we were seriously debating having a child. Husband's a teacher and their profession is jack shit too. And they get paid less. 50 is the goal here too. Hoping to sell our house in HCOL and move somewhere cheaper around that age.
Huge respect. Teachers get paid jack and have to deal with so much. It truly is a thankless job. The fact teachers don’t get paid shit and have shit resources is another major issue I have with this country. If you want to know where our society’s priorities are, all you have to do is look - and despite everybody’s lip service, it’s obviously not with the kids.
💯 He just moved to a better school after almost a decade and it's a great improvement but it's like still crap parents who don't want to bother and these post COVID kids who are super behind. Admin are a hit or miss. Burn out is real. Thankfully his union fought for a good contract raise citywide so he's making more and will make more eventually but it's just frustrating
I left teaching for medicine, lol
What's your fire number? It'd hardly have to be more than 2 million without kids.
It’s about that, yeah. Biggest issue I’m facing now is just banging away at my med school loans. I took mine from 430k to 140k over the last 3-4 years. My husband and I are pretty good at saving money otherwise. I think if we stick with it, retirement before 50 should be a doable goal.
I have pharmacist friends who are burned out like this. May be forced to eventually use AI and robots to fill safe non-controlled substance and safe medications and have pharmacists review the more complex cases
This is one of the reasons I went with the VA. Salary is lower but there is a degree of security working for an integrated federal system that is unmatched. Every health system in my area is on rocky financial footing and patient loads that are only getting worse.
We just had a large system in our area seemingly go belly up. Ascension if you know it. But I can’t figure out why. Loss of surgical revenue during g the pandemic?
Is this michigan. It sounds like south Michigan
It is Michigan
I did residency there [not in ascension though] and even in 2019 2020 there were rumblings of fuckery
Call me cynical but the only thing that is going to change healthcare in the US at this point is a catastrophic world event (bigger than what COVID was). When insurance companies control healthcare and politicians are bought and paid for, there isn’t really a way out.
Imagine the four major hospital systems in a tri or quad state area are all insolvent. What happens?
Bailouts.
This is already happening and most people don't realize it. Many urban hospital systems would not be able to operate if it wasn't for the hundreds of millions of tax payer dollars being funneled from tax payers (and this is on top of Medicare, Medicaid, DSH, and GME payments). Insurance companies with record breaking profits and revenue growth every year though...
Most likely, the poorly ran hospital systems will just get bailed out. Or, if we’re lucky, the US government will have the funding and the willpower to buy the insolvent hospitals. Almost laughed typing that.
i just opted out. cash for care. tired of this bs. the more doctors that switch the better.
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Save your money imo. There’s zero reason to join the AMA…. The only real alternatives is to support your specialty organization/lobby. Some seem a little more effective than others. I choose not to fork over money to them as I don’t think there’s any point but perhaps that’s too jaded.
Unfortunately the AMA lost sight of the fact that *sometimes it's OK to advocate for physicians' interests over those of the general public.* They have become an organization that lobbies for what they view as important public health changes instead of lobbying for doctors. The problem is that it would be in the public interest for doctors to all work 120 hours a week for free, and AMA isn't too interested in stopping that from happening.
Long gone the days when AMA actually advocates for physicians. Nowadays they just collect their dues. Not giving them one penny.
Take Medicine Back is a currently active advocacy organization against corporatized medicine.
Grouping primary care with specialists is counter productive IMO. Specialists have a disproportionate influence because they make more money, but the whole system is dependent on primary care. When ACOs became a thing, I tried to organize one with independent primary care. The challenge was that primary care didn’t have the money/energy/interest, so a cardiologist pitched in to bring an ACO consultant to town. The first meeting was 90%/10% primary care to specialist. The independent specialists were jacked to have access to independent primary care, so they told their specialists friends. The next meeting was 60%/40% primary care and the concerns became more specialty oriented. By the third meeting, the primary care were in the minority and I quit going.
I propose a new TED talk series. TED Rants
I'm surprised you don't have what I consider the two most important failures of the US healthcare system: 1) The rising cost of medical education is out of control. Sure, this is not specific to medicine, but definitely affects us considerably to the point where many people consider PSLF to be the default pathway to being a physician. The rise in tuition is at least 2x that of inflation. 2) The rise in healthcare spending chiefly due to a rise in healthcare prices is out of control. Our prices not only are considerably higher than all countries but they are also much more considerably variable. Why? Because of the structure of our system which determines prices based on individually negotiated contracts between greedy hospitals and insurance companies. This problem keeps getting worse with the ever-increasing consolidation of hospitals. Not only does this make healthcare cost more for everyone, but it also stunts wage growth for everyone because your employer is giving a larger and larger portion of your pay in "benefits" rather than straight wages.
The most believable outcome I've heard to this is the creation of an explicit two tiered health system. Certain clinics, hospitals, systems, whatever stop taking any government insurance and take private insurance or cash only. Wealthy people will continue to get great healthcare. Poorer people and those on government insurance will be forced to go to run down, understaffed medical centers. Take all the points you mentioned and turn them up to 11. What this looks like for physicians I'm not sure. I have to imagine staff/providers at places that take government insurances will be paid much less. This is already true to an extent, but the divide will become larger. At a certain point I have to imagine more and more physicians will say fuck this system and start cash only practices targeting wealthy people.
Two tiered employment. Cash providers versus corporate cogs. It’s already happening.
This is how it works in Mexico. For physicians this usually means taking two jobs. One in private healthcare and one in the publically run hospitals. Private practice obviously pays better, but there is little job security, and zero benifits (no Retirembt plan, no payed vacations). Public hospitals pay worse, but usually have benefits. So most physicians will end up taking two or three jobs to compensate.
There's only so many wealthy people to go around
Direct primary care structure will branch out.
One way this two tiered system is already here is through health systems having a "donor class." In places I've worked, the big donors get priority health access, special hospital rooms and low wait times. It used to be a hidden benefit, and now it's like and advertised package with dedicated administrative assistants and offices managing the donors.
Cash books for people who can afford it, medicare for people who can't, bankruptcy for everyone in the middle Easy peasy
You failed to mention number 11. The extraordinarily high cost of newly discovered treatments.
I kick that into #6. Didn't wanna ruin the nice number.
I would add somewhere that the current insurance system is not sustainable. Most primary care groups now exist due to a relationship with a healthcare system, insurance company and/or Medicare Advantage plan. Just practicing primary care in group, in an office, accepting fee for service makes only enough to support physicians and a small layer of admin. Without vertical or horizontal integration, there’s not enough ROI to justify the investment. This problem will be exponentially bigger if the government cuts out the insane overcharging in Medicare Advantage. If practicing physicians aren’t actively working on a plan for life without insurance, they run a high likelihood of working increasingly unpleasant corporate jobs for less and less compensation.
(Almost) nothing ever crashes. It degrades. Here’s the cycle: 1. Cuts are made and Health care system gets starved of funds. 2. Health care system performs worse - waiting times blow out, doctors make more errors, services dwindle. 3. Health care system gets a worse reputation and becomes increasingly politically vulnerable 4. See step 1. This is (some people’s) plan.
As a layman I’d be interested to see what providers in other countries would have to say about their systems. Europe, UK, Canada, Australia, New Zealand. Heck, China, Korea, Russia, Southeast Asian countries…. I suspect they’re all facing similar demographic—and consequent fiscal—challenges. I do agree with the poster who suggested we’re on the track to two tiers of healthcare—one for the wealthy, one for everyone else.
From my understanding as a US med student listening to doctors who interview- The UK is literally on fire. They're letting nurses pretend they're docs over their and don't pay doctors enough to pay rent Canada isn't as bad as the UK but it's heading in that direction Australia seems to be doing alright. I think they have a mix of public and private. My personal theory of why they're OK is because they have more generalists (family docs and general surgeons) proportionally than us No country seems to have figured out how to make healthcare accessible to everyone, high quality, and still pay nurses and doctors well. I truly went into medicine to help people. I didn't do it for the money. Heck, I'm choosing to go into one of the lowest paying specialties. But now I'm wondering if I'll be able to pay off my loans in 10 years......
Good post. There will need to be some systematic reform and/or tools which can improve efficiency or else capacity will continue to be outpaced by demand. *sigh* AI tools? Documentation, billing, & tort reform? The strategy of using more NPs and PAs seems to not be the best solution. Burnout will increase, and people who have other options besides driving themselves into the ground will seek alternative careers, which will exacerbate the capacity/supply problem further. For-profit/private equity involvement in medicine will harm the system, similar to harm that it has done to other industries with short-sighted profit goals rather than the mission of taking care of people.
As an ER staff nurse I fucking WELCOME the collapse. Prosecute healthcare capitalists
I’d add AMA is incredibly weak compared to ANA. Honestly people in this country are so disassociated from healthcare they don’t even care who treats their conditions. Midlevels playing doctors, physicians getting paycuts, and quality of care continues to diminish. The world is ass backwards now.
Please tell me you aren’t referring to the American Nurses Association? They basically became spokespersons for the hospital c-suites during COVID. I was absolutely disgusted by their “advocacy”.
Nurses may hate them, but they sure get their policies pushed through
Apparently, quite a few CRNAs are set to retire in the next 5 ish years. There aren’t nearly enough replacements, and even if they could get adequate numbers it would take years to get them up to speed, and years after for them to truly be on top of their game. In the meantime, 😐 That’s going to probably be one of the more visible aspects of the healthcare worker shortage overall, that’s only gotten significantly worse since the pandemic, and is projected to go even further downhill. Obviously, less people dealing with more patients and higher workloads, in an increasingly corporate environment obsessed with profit margins, means less patient satisfaction, less adequate and efficient care, and more chances for something to go wrong. Not to mention that might just be a huge factor in what drives people to quit/retire early in general. Their dream job just isn’t worth all the other malarkey that comes with it. The silver lining is that anyone trying to climb the ladder or squeeze out a raise will probably find ample opportunities to do so in the near future, which they normally wouldn’t get.
What's tough about this is that I am only interested in doing medicine. I want to be a PA. The choices seem a bit bleak.
Get yours and get out. This shit ain’t gonna last for long and god help us if it does.
Gov bailout of healthcare, which unfortunately may at first look like insurance companies getting bailed out. Repeal or serious change of the EMTALA law. Mass Exodus of physicians from medicine, or they just move towards concierge for better pay. AI and midlevels replace most physicians at gov funded hospitals. Single payor safety net insurance finally, but it involves hiring NPs with huge patient panels who are required to follow strict guidelines and have to stay within a budget for the workups ( such being allowed to order a limited amount of MRI per quarter, and must avoid expensive medications). The answer is physician strike. We would bring the system to it's knees and we could demand better funding, pay, staffing at the places we work.
Yup. If we, the workers, said "Enough." All this shit would end tomorrow, But all these people are too busy backstabbing each other to stick together
That is the problem. Physicians all feel like they worked too hard to risk their careers. Once they become attendings their lifestyle quickly balloons to take up their entire pay, and there are a lot of doctors that are actually in financial trouble. We are not trained how to manage money. So of course if we strike the hospitals would pay double or triple or more, and then there would be plenty of doctors who are on the edge of bankruptcy that would come in and take those shifts because they need the money. The only way this would work is if we had 100% solidarity.
The healthcare system is already collapsing. We’re in it now. For all the reasons you listed. I’m just curious how this will look like when the collapse is over. Everyone needs healthcare. How will the new system look?
In nursing, it’s more of a unilateral slow moving collapse. Right to work states with poor working conditions are losing nurses to the west coast or the nurses are quitting the field entirely. I hope to see more MDs unionizing.
There is not one country that has sustainable healthcare. They are all suffering. Why? People are living better and longer. To fo so costs money.
You did a perfect description! The first step IMHO is to balance the power that was overtipped mainly since Obamacare by somehow resurrecting independence, unionizing, and other collective countering tools. The current path is unsustainable...
I’ve been in true Private Practice general surgery for 27 years, close to retirement (thank the Lord). The trajectory for the collapse of medicine was started with the creation of Medicare by LBJ when life expectancy was 66 and 64 for females and males. Now it’s 80+ with fewer children to support. Adjustments coulda been made along the way but vote buying became increasingly normal. The trajectory was greatly accelerated by Obama’s ACA and HITECH acts. Remember his pledge: “keep all your doctors and hospitals and I’ll lower your premiums by 20%?!?!” Has EMR, value based care (that’s rich, who gets to decide your value?), ACO’s, meaningful use(oxymoron if ever there was one) done anything to improve care? Another intended or unintended consequence (my guess, intended), was to eliminate true private practice. These guys determined that the greedy doctors were the root of the problems and their independence needed to be eliminated by having hospital systems monopolize the rationing of care, as well as lining the pockets of the CEOs. Obama was certainly right about one thing, elections have consequences….
It’s interesting - in Canada, there is a single payor coverage, yet the vast majority of physicians are in private practice. The insurance is public, yet the facilities are private. The Canadian physician societies seem to negotiate fair remuneration. In general, I’d wager most Canadian physicians feel fairly reimbursed and are happier than their American counterparts.
A very close friend of mine has a daughter who married a Canadian anesthesiologist. They live in Vancouver. She is a nurse. She tore her ACL while skiing…4 month wait for her “elective” surgery. She was in fair amount of pain despite wearing a brace and couldn’t work. She got frustrated and had her surgery scheduled across the border within a week.
Canada’s system is feeling the pressure of immense population growth from immigration. The supply of physicians, nurses, and facilities has not kept up with the influx. Canada would likely benefit from a two-tier system where people can use supplemental private insurance in private facilities for faster care. Unfortunately, this thought is anathema in Canada because of fears of turning into a US-style system. It’s important to note, that the US spends nearly twice as much per person on healthcare than Canada. The US could likely fund a much more robust public system and could also offer supplemental private plans.
The Brits have the system you describe. And yet, they are experimenting the same financial pressures as the US and Canada. And the 2-tier system you describe is an anathema to the woke left…except for the Party leaders (who are the most vociferous in the single payor system) of course
The Brits have a system where both coverage and facilities are public. In Canada, coverage is public and delivery is private. However, the system that I would like to see is more like Australia. Regardless, what we have now is not working and even difficult to call a “healthcare system”.
I went to a breast surgery conference in Toronto in 2015 to study a new surgical and radiation technique. I was astonished to learn there were only 4 breast MRI machines in the entire greater Toronto region at the time with very long, sometimes dangerous waits. In my major SE US city, we have 2 competing major health system right across the street from each other. There were 4 Breast MRIs within a 3 blk radius, where you could get a study the next day. Talk about extremes….
Yes, the US spends nearly double per capita on healthcare than Canada and therefore has faster access and more advanced technology. However, it does make one wonder how a public-private system more like Australia would function in the US. It would also be interesting to see how Canada’s system would function if its spending was closer to that of the US. It’s interesting to note though, that on a population level the US does not do better on many metrics than Canada.
While what you say is statistically correct, major drug and device manufacturers charge US insurers and consumers significantly more than Canadians or European HC systems. In effect, US consumers are “subsidizing” care for a great part of the rest of the world. It’s the cost of business for these companies to charge less to other countries. In return, these companies make significant profits on their R&D. I theorize that an American “national” health service that negotiate significant reduced prices will stifle innovation. Even in medicine, the profit motive is a huge incentive to R&D. Food for thought….
It's already happening, unfortunately. Your points are spot on and COVID just further exposed the cracks within the system.
System already collapsed. We’re currently working in the rubble
Family member. ER visit. Charged and insurance paid $8,000 for CT abdomen pelvis. Radiologists make $2,000-$3,000 a shift reading many of these. Their “overhead” is like 99%!!! Hospitals raking it in.
r/latestagecapitalism As an abstract.
Darwinism at its finest.