The PPACA Thread Part III - Let's have a healthy debate!

[WisconsinWildcard]

Re: The PPACA Thread Part III - Let's have a healthy debate!

I wouldn't think that it is. My point is somehow it seems the Boston metro area has figured out how to get people seen on a timely basis. Why that is I'll defer to the experts as well as if certain areas of the country are better at this than others. I could see a connection between how densely populated an area is and how a patient could be seen more quickly.

I was talking with my colleague today who trained at Tufts and she was able to identify a few areas that wait times to see specialist in Boston were above average. But that is not the main point and it will turn into a he said she said ****ing match if we go further . A significant portion of the doctor shortage is due to distribution of physicians, instead of just a pure shortage. If you are being recruited, you will actually note that rural jobs or off the trail states actually compensate better than the big city positions. Many physicians just do not want to practice in Idaho. If you are a specialist, by necessity you likely trained in an academic setting in a large city and it tends to be the place you would like to continue to practice.

 

[WisconsinWildcard]

Re: The PPACA Thread Part III - Let's have a healthy debate!

If you can't be bothered to drive 6 hours for a specialist, its not serious.

I can honestly not disagree with this comment more. This is incredibly privileged and out of touch, and I will just leave it at that.

Hovey, just to put it in perspective...Mayo's US (i.e., worldwide) ranking this year:

Cancer #3
Cardiology & Heart Surgery #2
Diabetes & Endocrinology #1
Ear, Nose & Throat #2
Gastroenterology & GI Surgery #1
Geriatrics #1
Gynecology #1
Nephrology #1
Neurology & Neurosurgery #1
Orthopedics #2
Psychiatry #8
Pulmonology #1
Rehabilitation #6
Rheumatology #4
Urology #1

I get that you are proud of your Mayo. They are a great health care system. But you should look at the rankings with significant skepticism. Their methodology is fundamentally flawed. I could go into it further but to be brief, it rewards big names like Mayo and CCF, demerits places who work in difficult populations (if your patients are sicker, have more co-morbidities, you will have worse outcomes and it does not do a good job with this), and focuses on quaternary care which in reality, 99% of people and conditions will not never require.

Conversations between physicians never go like "we should refer this difficult patient to Mayo, as they are number 1." The conversation goes like "this is a difficult patient. Dr. XXXX is really good with these cases we should refer to him or her." It does not matter where they are, it matters who they are. The only time I have heard a physician bring up rankings is usually joking (yes even from those in a top 5 ranked program). Also it is very disease specific. Cancer rankings are particularly odd since the disease is so variable, there are clinical studies everywhere for different conditions, and it is big business so it is difficult to be far away from a place that can offer standard of care (which is honestly the goal). There is an odd elitism with these rankings and it results in patients feeling they are getting inferior care if they are not at a top ten hospital which is not the case.

 

[St. Clown]

Re: The PPACA Thread Part III - Let's have a healthy debate!

If you can't be bothered to drive 6 hours for a specialist, its not serious.

It's amazing how quick you are to show yourself to be a snob, likely without even realizing it.

 

[busterman62]

Re: The PPACA Thread Part III - Let's have a healthy debate!

I can honestly not disagree with this comment more. This is incredibly privileged and out of touch, and I will just leave it at that.



I get that you are proud of your Mayo. They are a great health care system. But you should look at the rankings with significant skepticism. Their methodology is fundamentally flawed. I could go into it further but to be brief, it rewards big names like Mayo and CCF, demerits places who work in difficult populations (if your patients are sicker, have more co-morbidities, you will have worse outcomes and it does not do a good job with this), and focuses on quaternary care which in reality, 99% of people and conditions will not never require.

Conversations between physicians never go like "we should refer this difficult patient to Mayo, as they are number 1." The conversation goes like "this is a difficult patient. Dr. XXXX is really good with these cases we should refer to him or her." It does not matter where they are, it matters who they are. The only time I have heard a physician bring up rankings is usually joking (yes even from those in a top 5 ranked program). Also it is very disease specific. Cancer rankings are particularly odd since the disease is so variable, there are clinical studies everywhere for different conditions, and it is big business so it is difficult to be far away from a place that can offer standard of care (which is honestly the goal). There is an odd elitism with these rankings and it results in patients feeling they are getting inferior care if they are not at a top ten hospital which is not the case.

[SARCASM] Thank God CMS's new star system is accurate [/SARCASM]

 

[5mn_Major]

Re: The PPACA Thread Part III - Let's have a healthy debate!

If you can't be bothered to drive 6 hours for a specialist, its not serious.

It's amazing how quick you are to show yourself to be a snob, likely without even realizing it.

Not sure I get your point. I can get the best car for me - a Japanese or German rather than American. I'm not a snob. I can get the best travel destination for me - in Florida not the upper Midwest. I'm not a snob. But if I get what I feel is the best health care for me six hours away vs. one an hour away...I'm a snob?

I get that you are proud of your Mayo. They are a great health care system. But you should look at the rankings with significant skepticism. Their methodology is fundamentally flawed. I could go into it further but to be brief, it rewards big names like Mayo and CCF, demerits places who work in difficult populations (if your patients are sicker, have more co-morbidities, you will have worse outcomes and it does not do a good job with this), and focuses on quaternary care which in reality, 99% of people and conditions will not never require.

Conversations between physicians never go like "we should refer this difficult patient to Mayo, as they are number 1." The conversation goes like "this is a difficult patient. Dr. XXXX is really good with these cases we should refer to him or her." It does not matter where they are, it matters who they are. The only time I have heard a physician bring up rankings is usually joking (yes even from those in a top 5 ranked program). Also it is very disease specific. Cancer rankings are particularly odd since the disease is so variable, there are clinical studies everywhere for different conditions, and it is big business so it is difficult to be far away from a place that can offer standard of care (which is honestly the goal). There is an odd elitism with these rankings and it results in patients feeling they are getting inferior care if they are not at a top ten hospital which is not the case.

Inner city hospitals get difficult patients...and these 'top rated' hospitals get some of the toughest referrals. Is the same? Who knows, but the best is not the worst...and vice versa. And to your second point, I agree. Go where the top doctors are.

Its quite simple. Trying to evaluate any product or service is full of data points. How do you know you're buying a reliable product? You evaluate statistics and get advice from those who are knowledgeable. Alternatively, you can ignore all forms of data and indicators all together. I'll take the best thinking for what appears to be the best health care.

Medical error is the third leading cause of death. http://www.bmj.com/content/353/bmj.i2139. Three people close to me. Two required a transplant of the same important organ. One went to Mayo, the other went elsewhere. The Mayo patient avoided the transplant and is healthy for all practical purposes. The other didn't survive. A third I know was misdiagnosed 3 times for terminal cancer at other institutions (they did not have terminal cancer). I appreciate your point of view, but I won't be convinced to change my serious health care decisions to be based primarily on my immediate proximity unless I must.

 

[Rover]

Re: The PPACA Thread Part III - Let's have a healthy debate!

I was talking with my colleague today who trained at Tufts and she was able to identify a few areas that wait times to see specialist in Boston were above average. But that is not the main point and it will turn into a he said she said ****ing match if we go further . A significant portion of the doctor shortage is due to distribution of physicians, instead of just a pure shortage. If you are being recruited, you will actually note that rural jobs or off the trail states actually compensate better than the big city positions. Many physicians just do not want to practice in Idaho. If you are a specialist, by necessity you likely trained in an academic setting in a large city and it tends to be the place you would like to continue to practice.

Which is why I said originally that you people need to move to civilization.

Look, people living in rural settings have it harder in general when it comes to services, jobs, etc etc. I get that. IMHO that's outside the scope of the ACA, which was designed to 1) increase coverage, and 2) slow cost increases. Oddly enough the free market, which conservatives pledge complete allegiance to, is letting them down in these rural areas.

 

[St. Clown]

Re: The PPACA Thread Part III - Let's have a healthy debate!

Rochester is also at lease five hours from those in Fargo, add on another 60-90 minutes of drive time to those in Grand Forks. Is that realistically attainable for everyone one in the Midwest? No, it is not.

If you can't be bothered to drive 6 hours for a specialist, its not serious.

Not sure I get your point. I can get the best car for me - a Japanese or German rather than American. I'm not a snob. I can get the best travel destination for me - in Florida not the upper Midwest. I'm not a snob. But if I get what I feel is the best health care for me six hours away vs. one an hour away...I'm a snob?

Yes, you're a snob. Good for you that you can have the ability to go anywhere you deem fit for treatment or can get the $70K car and take off a day of work when needed, but you're completely ignore people's resources available to them - not limited to money as the only resource - and say that if they don't make the same choices as you, then you're not taking it seriously. Some people can't take a six-hour ride to visit a doctor, either they don't have access to a vehicle, their condition may prevent them from driving altogether, or they can't miss time away from work - farmers in NoDak have their very sense of being tied very closely to those farms and the abandon them in the middle of September might as well be like demanding you to give up your religion. A six-hour ride to the doctor is at least thirteen hours of commitment in one day, more likely sixteen to seventeen hours once you factor in meal times, waiting for the physicians, prep time in getting ready for a long-distance visit to a doctor, pure exhaustion from the stress of it all, and other factors. Chances are for a visit to a place like Mayo, people are not making that trip alone.

Adding the money factor into it, chances are better than not that a clinic six hours away from where you live is not covered as part of your insurance plan. That makes things very expensive for the Average Joe on the street, including a great many of those who live in places like North Minneapolis.

But of course, none of that matters. If it were serious, they'd make the trip to Mayo.

Also, all those inferior doctors my mother visited (three of them independently) who were not working at Mayo in Rochester diagnosed her with Alzheimer's back in 2004. We decided to make the trip down to Mayo, which required of her multiple follow up visits to see a panel of doctors, which in turn required time from her family that we happily gave, though not everyone has such resources available to them. Mayo diagnosed her as simply being too stressed out and that was leading to her memory issues. Odd thing is that when she was in the process of passing away over the next nine years, absolutely everything she experienced met every exact and gruesome detail as provided by the resources I read for Alzheimer's patients. The vaunted panel of Mayo doctors got it wrong. There's my anecdote compared to yours. Mayo is not infallible.

 

[dxmnkd316]

Re: The PPACA Thread Part III - Let's have a healthy debate!

Yes, you're a snob. Good for you that you can have the ability to go anywhere you deem fit for treatment or can get the $70K car and take off a day of work when needed, but you're completely ignore people's resources available to them - not limited to money as the only resource - and say that if they don't make the same choices as you, then you're not taking it seriously. Some people can't take a six-hour ride to visit a doctor, either they don't have access to a vehicle, their condition may prevent them from driving altogether, or they can't miss time away from work - farmers in NoDak have their very sense of being tied very closely to those farms and the abandon them in the middle of September might as well be like demanding you to give up your religion. A six-hour ride to the doctor is at least thirteen hours of commitment in one day, more likely sixteen to seventeen hours once you factor in meal times, waiting for the physicians, prep time in getting ready for a long-distance visit to a doctor, pure exhaustion from the stress of it all, and other factors. Chances are for a visit to a place like Mayo, people are not making that trip alone.

Adding the money factor into it, chances are better than not that a clinic six hours away from where you live is not covered as part of your insurance plan. That makes things very expensive for the Average Joe on the street, including a great many of those who live in places like North Minneapolis.

But of course, none of that matters. If it were serious, they'd make the trip to Mayo.

Also, all those inferior doctors my mother visited (three of them independently) who were not working at Mayo in Rochester diagnosed her with Alzheimer's back in 2004. We decided to make the trip down to Mayo, which required of her multiple follow up visits to see a panel of doctors, which in turn required time from her family that we happily gave, though not everyone has such resources available to them. Mayo diagnosed her as simply being too stressed out and that was leading to her memory issues. Odd thing is that when she was in the process of passing away over the next nine years, absolutely everything she experienced met every exact and gruesome detail as provided by the resources I read for Alzheimer's patients. The vaunted panel of Mayo doctors got it wrong. There's my anecdote compared to yours. Mayo is not infallible.

If there weren't people watching, I'd stand up in my cube and applaud this post.

 

[Kepler]

Re: The PPACA Thread Part III - Let's have a healthy debate!

But the point here is that the health care delivery system can't change where the doctors are. Large, wealthy cities are going to have better health care under any system of health care delivery. That's one of the (IMO, few) advantages there is to living in or near a big city. Sometimes a non-urban area lucks out because they have a university research hospital, but not often.

The complaint that Obamacare hasn't solved the wait time for rural patients is like saying it hasn't solved the higher potential for skin cancer in areas with more sun. That's not in scope.

 

[Rover]

Re: The PPACA Thread Part III - Let's have a healthy debate!

But the point here is that the health care delivery system can't change where the doctors are. Large, wealthy cities are going to have better health care under any system of health care delivery. That's one of the (IMO, few) advantages there is to living in or near a big city. Sometimes a non-urban area lucks out because they have a university research hospital, but not often.

The complaint that Obamacare hasn't solved the wait time for rural patients is like saying it hasn't solved the higher potential for skin cancer in areas with more sun. That's not in scope.

Exactly. People complaining about the ACA tend to complain about problems that have existed for eons and that the law wasn't designed to address. I'll say again, its almost always conservatives complaining about the ACA, so why are they so upset that the free market isn't delivering enough doctors in low population areas? Isn't your problem with Adam Smith, not Barack Obama?

PS - Give me urban/suburban vs rural any day of the week and twice on Sunday. I grew up on a boring @ ss place, and let me tell you, I'd rather be shot to death in Detroit than bored to death in Arizona. Life's too short to live somewhere where nothing ever happens.

 

[St. Clown]

Re: The PPACA Thread Part III - Let's have a healthy debate!

But the point here is that the health care delivery system can't change where the doctors are. Large, wealthy cities are going to have better health care under any system of health care delivery. That's one of the (IMO, few) advantages there is to living in or near a big city. Sometimes a non-urban area lucks out because they have a university research hospital, but not often.

The complaint that Obamacare hasn't solved the wait time for rural patients is like saying it hasn't solved the higher potential for skin cancer in areas with more sun. That's not in scope.

If we were going to design and implement a law with the intent of getting more patients into clinics and hospitals, then we should have taken into consideration the need for more medical staff to handle these same patients. Someone should have designed the incentives needed to find a way to lure doctors to these various backwoods locations.

 

[ScoobyDoo]

Re: The PPACA Thread Part III - Let's have a healthy debate!

If we were going to design and implement a law with the intent of getting more patients into clinics and hospitals, then we should have taken into consideration the need for more medical staff to handle these same patients. Someone should have designed the incentives needed to find a way to lure doctors to these various backwoods locations.

I agree 100%. AND, also designed into the system should have been more research money, not less. Specifically targeting ways to cut costs in the testing area which are way to expensive. The demand for tests keeps going up but an MRI's cost never go down. Congress has been stealing money from the research kitty for years now. Time to stop.

 

[Kepler]

Re: The PPACA Thread Part III - Let's have a healthy debate!

PS - Give me urban/suburban vs rural any day of the week and twice on Sunday. I grew up on a boring @ ss place, and let me tell you, I'd rather be shot to death in Detroit than bored to death in Arizona. Life's too short to live somewhere where nothing ever happens.

I don't agree. Living in the West changed my entire perspective on what the good life is. Population density is inversely proportional to quality of life. I'd rather be bored to death in Arizona than amused to death in Manhattan.

 

[Handyman]

Re: The PPACA Thread Part III - Let's have a healthy debate!

But the point here is that the health care delivery system can't change where the doctors are. Large, wealthy cities are going to have better health care under any system of health care delivery. That's one of the (IMO, few) advantages there is to living in or near a big city. Sometimes a non-urban area lucks out because they have a university research hospital, but not often.

The complaint that Obamacare hasn't solved the wait time for rural patients is like saying it hasn't solved the higher potential for skin cancer in areas with more sun. That's not in scope.

But isnt that argument that health care should be more local and less on the Fed? If a federal plan (especially a pretty weak wristed one like ObamaCare) only works in the big cities then it really isnt as useful as you think it is. Not everyone is going to live in the Big City...

Scooby and St. Clown nailed it.

 

[unofan]

I don't agree. Living in the West changed my entire perspective on what the good life is. Population density is inversely proportional to quality of life. I'd rather be bored to death in Arizona than amused to death in Manhattan.

I lived in Hanover for 5.5 years, and have some vague memories of growing up in Steamboat Springs until I was four.

Nope. Give me a metro area of at least a half million any day. There's a reason people continue to flock to cities around the globe.

I would never move back to NYC after having been there for 6 months , but all else being equal, I'd move to the Chicago area or twin cities in a heart beat.

 

[unofan]

But isnt that argument that health care should be more local and less on the Fed? If a federal plan (especially a pretty weak wristed one like ObamaCare) only works in the big cities then it really isnt as useful as you think it is. Not everyone is going to live in the Big City...

Scooby and St. Clown nailed it.

The population in this country is roughly 80% urban these days (counting suburbs and exurbs as part of a greater metropolitan area). You can only subsidize the remaining 20% so much. And it doesn't help that those 20% often vote against the things that would help them more than others.

 

[Kepler]

Re: The PPACA Thread Part III - Let's have a healthy debate!

But isnt that argument that health care should be more local and less on the Fed? If a federal plan (especially a pretty weak wristed one like ObamaCare) only works in the big cities then it really isnt as useful as you think it is. Not everyone is going to live in the Big City...

Scooby and St. Clown nailed it.

No, no they really didn't. You are saying, "domes on stadiums do nothing about traffic jams, so maybe they're not as useful as you think they are."

One clause has literally NOTHING to do with the other.

 

[Kepler]

Re: The PPACA Thread Part III - Let's have a healthy debate!

The population in this country is roughly 80% urban these days (counting suburbs and exurbs as part of a greater metropolitan area). You can only subsidize the remaining 20% so much. And it doesn't help that those 20% often vote against the things that would help them more than others.

We heavily subsidize rural voters, because both parties find that to be extremely useful symbolically. The list of districts which receive far more (i.e., from 10x to 1000x) in tax dollars than they contribute is dominated by rural districts. Famously, 97 of the poorest 100 districts in the country are Republican. They are overwhelmingly rural, and they receive federal benefits up the wazoo.

 

[Kepler]

Re: The PPACA Thread Part III - Let's have a healthy debate!

I lived in Hanover for 5.5 years, and have some vague memories of growing up in Steamboat Springs until I was four.

Nope. Give me a metro area of at least a half million any day. There's a reason people continue to flock to cities around the globe.

I would never move back to NYC after having been there for 6 months , but all else being equal, I'd move to the Chicago area or twin cities in a heart beat.

My ideal is to live 30 miles from a city of 300,000; west of 105° W.

People flock to cities for jobs, because the 20th century reduced the number of farmers we need from 95% to 5% of the population, and thank god since other than mining farming has to be the worst job on the planet for an even semi-sentient being.

 

[Rover]

Re: The PPACA Thread Part III - Let's have a healthy debate!

My ideal is to live 30 miles from a city of 300,000; west of 105° W.

People flock to cities for jobs, because the 20th century reduced the number of farmers we need from 95% to 5% of the population, and thank god since other than mining farming has to be the worst job on the planet for an even semi-sentient being.

Kep, people are flocking to cities not just for jobs, but for entertainment. City living is trendy now. Not saying that will always be the case, but right now people want to be where the action is, not looking out over the prairie where the deer and the antelopes play. The country is a good place to visit on the weekend. Live there? Nah.

Regarding health care in rural areas, look life's full of tradeoffs. Yes its generally cheaper to live in a rural area, but there's some conveniences you'll have to give up. Easy access to multiple health care providers is most likely one of them, along with indoor plumbing and a good hockey team.