6 ms·

The hospitals are poorly run. Please hate your hospitals management more. Or if you are a good manager, convince some friends to run a hospital. Imagine 10 app

The hospitals are poorly run. Please hate your hospitals management more. Or if you are a good manager, convince some friends to run a hospital. Imagine 10 appointments a day, 30 mins each. You have to write /everything/ down the patient tells you. You often have to go over the 30mins because some patients need it. You need to follow up to order extra tests, you need to occasionally google something. You skip lunch often. You need to find time to reply to messages from previous patients. Nurses will mess up something or a patient will show up late. Want to see patients past 5? The nurses have left and you can't legally 'bill' or code the appointment without the nurses. day is over and you review tomorrow's patients. You read through their histories. Now you check the messages. There's between 5-45 a day. You see a lot of patients. Then you're told that your department isn't bringing in enough money. They want you to see 11 patients a day. The reason? They didn't bill people correctly. For the past year. A lot of doctors quit.

pseudocomposer 3y ago
It seems like we just need more doctors, no? The AMA is notorious for trying to limit the number of new doctors. They do that more than much of anything to do with public health.
- lotsofpulp 3y ago
  Supposedly, AMA reversed course in 2019: https://www.ama-assn.org/press-center/press-releases/ama-fund-graduate-medical-education-address-physician-shortages https://www.ama-assn.org/press-center/press-releases/ama-fun... https://www.openhealthpolicy.com/p/medical-residency-slots-congress https://www.openhealthpolicy.com/p/medical-residency-slots-c... But don't know how much is talk versus walk. It is not clear to me why only the US Federal Congress can fund residencies. Surely, with how much doctors can earn, a private underwriter would be willing to finance a residency. https://www.washingtonian.com/2020/04/13/were-short-on-healthcare-workers-why-doesnt-the-u-s-just-make-more-doctors/ https://www.washingtonian.com/2020/04/13/were-short-on-healt...
  - nradov 3y ago
    It's not just talk. In recent years the AMA has actively lobbied Congress to increase funding for residency programs (graduate medical education). Anyone can fund residencies. If a wealthy donor has enough money to spare, a teaching hospital would probably be willing to create an endowed residency slot in their name. And there is already some private funding, although it is a tiny fraction of Medicare funding. Commercial payers (medical insurers) also indirectly subsidize residencies by reimbursing teaching hospitals at higher rates than other facilities for the same procedures. None of the other major healthcare industry players have a direct incentive to fund residencies. https://www.chcf.org/wp-content/uploads/2018/08/GuideGraduateMedicalEducationFunding.pdf https://www.chcf.org/wp-content/uploads/2018/08/GuideGraduat...
- screye 3y ago
  > trying to That's an understatement. It is blatant and deliberate.
  - danlugo92 3y ago
    Is it greed? Is it all doctos tacitly agreeing to this so they can get bigger paychecks?
    - whiterknight 3y ago
      Yes. They sign up for big salary at hospital where their schedule is managed for them.
    - givemeethekeys 3y ago
      The individual doctors don't have much choice when they're heavily indebted by the time they become doctors. We (the AMA?) regulate where a doctor gets their education in order to become a doctor. This gives schools a lot of power. It also gives hospitals a lot of power when those doctors work insane shifts during their rotations.
      - nradov 3y ago
        The AMA is only a private professional association. They have some political influence but no regulatory authority. Medical schools have to be accredited so that's one limiting factor. But the real bottleneck today is more lack of slots in graduate medical education (residency) programs. Every year there are some students who graduate with an MD but can't practice medicine because they don't get matched to a residency program. To expand the supply we have to start there. https://www.ama-assn.org/education/gme-funding/save-graduate-medical-education https://www.ama-assn.org/education/gme-funding/save-graduate...
        givemeethekeys 3y ago
        Maybe they should be able to gain experience abroad towards their accreditation. Win win win. They get accredited. The country receiving them gets well-educated help. We end up with more doctors.
- whiterknight 3y ago
  The problem is doctors are expensive so the management is economizing their time.
  - tylerrobinson 3y ago
    You’re being downvoted because that’s baked into the parent comment; the suggested solution is to increase the supply of doctors.
    - whiterknight 3y ago
      The parent comment doesn’t state it explicitly, and suggests it’s the managements fault. One of the problems is that regulations require MD oversight but not necesssrily performing all operations. That’s a good thing but forces them into a role where they hover for a few minutes then get rushed to the next supervision activity. So there are lots of dials to play with in addition to supply.
  - dillydogg 3y ago
    In my experience in the clinic, the attendings are spending an incredible amount of their time doing busywork required by management instead of actually caring for patients.
    - whiterknight 3y ago
      Interesting. If you had to weight it towards legal compliance or productivity surveillance which would you say?
      - dillydogg 3y ago
        Maybe letting them see patients? I feel like this is a false dichotomy. I guess legal compliance of I had to choose, so it wouldn't lead to insane numbers of patients per hour
        whiterknight 3y ago
- AtlasBarfed 3y ago
  The AMA is one of the four pigs at the trough of US healthcare: 1) Insurance companies - extract profit from the usual insurance model applied to healthcare. 2) Drug/Device companies - extract maximum profit from patent monopolies, FDA regulatory capture, and marketing. 3) Malpractice lawyers - use regressive law precedent to maximize individual payout and lawyer billing to the detriment of everyone else 4) AMA/Providers - restrict supply, and maximize billing for services Really, none of these pigs have the interests of overall public health in mind: - Insurance companies are incentivized to maximize the cost of insurance and deny coverage as much as possible, like any insurance company vertical. Obviously this results in denial of care. However, an insurance company is motivated to reduce provider costs and possibly to incentivize preventative care. Insurance companies are also vertically integrating into owning provider facilities to solidify local monopolies (so people HAVE to use their insurance if they live in an area) and to be able to impose cost cuts to actual providers. - Drug/Device companies are incentivized to maximize the profits from 20 years of provided patent monopolies, often exploiting desperate people looking for relief from maladies, but the cost is usually beyond the ability of individuals to afford. Lawyers are incentivized to bill/get percentages of settlements and maximize awards of "damages" regardless of the overall impact to health services costs and the implicit denial of care that involves. However, these orgs, while generally not doing the core science of new treatment modalities (universities do that), they do help usher treatments through safety review. - Trial lawyers are incentivized to maximize their patient damages and billing, which obviously is transferred to higher costs for all. Lawyers are one of the few hammers to get insurance companies to properly pay out, keep hospitals from devolving into managerial corruption, and keep Drug/Device companies from fudging the numbers. - And the AMA/Providers are incentivized to maximize the billing for their services, overbill for often superfluous services, resist any intermediate level profession (Nurse Practitioners, etc) from devaluing their law-enforced professional monopoly, and incentivized to not address general health of patients but rather bill with expensive specialist care rather than help patients maintain wellness that averts serious illness. In my experience no provider ever cared about how much their services cost the patient, until it became apparent the patient could no longer pay. Then their economic awareness of the cost of care become VERY APPARENT. The AMA is criminally complicit in restricting supply of doctors, which it very well knows raises the cost of medical services and of course denies care to people on the aggregate. Each of the four pigs simply points to other pigs as someone to blame and lobbies with maximum force to prevent any threat to their gravy train. To address US healthcare costs will generally require all four pigs: a public insurance option (at a minimum). Reduce patent length or invalidate patents, and with cases like unpatented production that has been monopolized (epipen, insulin) enforce antitrust. Fix prices if necessary. Obviously trial lawyers awards should be capped. Finally, nurse practitioners and AI expert systems used to decrease costs, and supply of doctors increased vastly. Overall, government needs to address the total lack of preventative care.
lokar 3y ago
And to get to this we spend far more (as a percentage of GDP) then other western nations.
wighty 3y ago
> The nurses have left and you can't legally 'bill' or code the appointment without the nurses. What? I've never heard this requirement and I cannot think of why it would be the case (I'm a PCP). The rest of your comment is pretty much the issue as PCP though. I have at least 30 minutes a day of "out of visit" requests (reviewing documents from outside hospital/consults, labs, imaging, other results, extra nurse patient triages) in addition to anywhere from 30 minutes to 2 hours of completing my notes each night. The payment methods for primary care do not work.
- maxerickson 3y ago
  I think it's pretty stupid that basic appointments are billed on complexity and not time. Well, and lots of other things too. Getting a radiologist to do a definitive diagnosis using imaging doesn't actually make the ER doctors job harder (rather, it de-risks the interaction for them). It's also ridiculous that I have to promise to pay any bills that my insurance won't cover. If some care can't be justified as medically necessary, there should be a specific contract for that when it comes up, not a blanket rider prior to accessing treatment. Forcing the two sophisticated entities to have a workable agreement where they can't dump costs off on the individual patient would at least improve perceptions of care.
  - nradov 3y ago
    The No Surprises Act included some protections against balance billing. It's still a problem but somewhat less than before. https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills https://www.cms.gov/newsroom/fact-sheets/no-surprises-unders...
a_gnostic 3y ago
Why do they bill $700 for a bag of salt water they paid $1 for? (1) 1. https://www.advisory.com/daily-briefing/2013/08/27/the-secret-of-salines-cost-why-a-1-bag-can-cost-700 https://www.advisory.com/daily-briefing/2013/08/27/the-secre...
- Rury 3y ago
  A major part of business of former employer of mine, involved simply buying parts from another business, doing things to try and hide who the OEM was, and having salesmen resell it for a large markup without doing anything else to the parts. A major reason it did this, was because it subsidized the other side of the business which often lost money in the short term, but resulted in growing this profitable side of the business. If things were priced correctly, the money losing side would have charged more its services, and this profitable side cheaper. However, if they did just that, the demand may have not of been there to sustain or grow the business like it had. I honestly hate this sort of stuff though. When I pay my toll on the highway, I expect it to pay for maintaining the road I used, not for unrelated things. Anyhow, may be a similar kind of thing going on here, or you know... just flat out profiteering.
  - lotsofpulp 3y ago
    >When I pay my toll on the highway, I expect it to pay for maintaining the road I used, not for unrelated things This is a great example. You expect to pay for the "maintenance of the road", but what about the ongoing opportunity cost of the road and all the externalities of the road? What about all the roads that do not have tolls on them? The toll road does not exist in a vacuum, and life is not so simple so as to be able to sequester all costs into separate line items. In fact, one of the main uses for tolls is not for the maintenance of the toll, it is for managing congestion of the road, since the road has a carrying capacity. After a certain number of vehicles, the road becomes less and less useful, so a variable rate toll can ensure a limited number of vehicles operate on the road at peak congestion. It is simply not feasible to tie revenue to expenses 1 to 1, and specific taxes (like tolls) legislated to do that for government expenses hamstrings leaders because it removes flexibility needed to move resources around (which obviously could be used for bad, but also good, as you demonstrated your business's example).
dillydogg 3y ago
In my outpatient family medicine clerkship, I saw over 25 patients a day. 20 minute appointments from 8 AM until 5 PM. It was a whirlwind of activity from beginning to end. I don't think in 4 months I saw my preceptor get a 20 minute lunch break. It's crazy. Each room you go in, subjective, objective, assessment, plan, boom, next room. Hope you got all your orders in before that next patient without getting too far behind! I don't think people get how much their doctors are doing behind the scenes. And after each appointment they need to document everything in the chart. If you aren't charting in the room, you will be there for hours after your last patient catching up. But if you do chart in the room, your patients get mad at you because you are on the computer the whole visit. Then you have to prechart at the end of the day on all of your patients tomorrow and get ready to do it all again.
luckman212 3y ago
Oh boo fuckin hoo. TLDR- it's hard to operate a properly functioning healthcare practice when everything is controlled and mandated by the insurance companies. Who demand that patients take no more than 7 actual minutes of "doctor time" and must be whisked out the door with lots of prescriptions for expensive medications that guarantee they (a) will not be cured and (b) will continue to provide a steady revenue stream to big pharma which helps to subsidize the whole upside down dystopian health pyramid that is the US healthcare system.

pseudocomposer 3y ago

It seems like we just need more doctors, no? The AMA is notorious for trying to limit the number of new doctors. They do that more than much of anything to do with public health.

lotsofpulp 3y ago
Supposedly, AMA reversed course in 2019: https://www.ama-assn.org/press-center/press-releases/ama-fund-graduate-medical-education-address-physician-shortages https://www.ama-assn.org/press-center/press-releases/ama-fun... https://www.openhealthpolicy.com/p/medical-residency-slots-congress https://www.openhealthpolicy.com/p/medical-residency-slots-c... But don't know how much is talk versus walk. It is not clear to me why only the US Federal Congress can fund residencies. Surely, with how much doctors can earn, a private underwriter would be willing to finance a residency. https://www.washingtonian.com/2020/04/13/were-short-on-healthcare-workers-why-doesnt-the-u-s-just-make-more-doctors/ https://www.washingtonian.com/2020/04/13/were-short-on-healt...
- nradov 3y ago
  It's not just talk. In recent years the AMA has actively lobbied Congress to increase funding for residency programs (graduate medical education). Anyone can fund residencies. If a wealthy donor has enough money to spare, a teaching hospital would probably be willing to create an endowed residency slot in their name. And there is already some private funding, although it is a tiny fraction of Medicare funding. Commercial payers (medical insurers) also indirectly subsidize residencies by reimbursing teaching hospitals at higher rates than other facilities for the same procedures. None of the other major healthcare industry players have a direct incentive to fund residencies. https://www.chcf.org/wp-content/uploads/2018/08/GuideGraduateMedicalEducationFunding.pdf https://www.chcf.org/wp-content/uploads/2018/08/GuideGraduat...
screye 3y ago
> trying to That's an understatement. It is blatant and deliberate.
- danlugo92 3y ago
  Is it greed? Is it all doctos tacitly agreeing to this so they can get bigger paychecks?
  - whiterknight 3y ago
    Yes. They sign up for big salary at hospital where their schedule is managed for them.
  - givemeethekeys 3y ago
    The individual doctors don't have much choice when they're heavily indebted by the time they become doctors. We (the AMA?) regulate where a doctor gets their education in order to become a doctor. This gives schools a lot of power. It also gives hospitals a lot of power when those doctors work insane shifts during their rotations.
    - nradov 3y ago
      The AMA is only a private professional association. They have some political influence but no regulatory authority. Medical schools have to be accredited so that's one limiting factor. But the real bottleneck today is more lack of slots in graduate medical education (residency) programs. Every year there are some students who graduate with an MD but can't practice medicine because they don't get matched to a residency program. To expand the supply we have to start there. https://www.ama-assn.org/education/gme-funding/save-graduate-medical-education https://www.ama-assn.org/education/gme-funding/save-graduate...
      - givemeethekeys 3y ago
        Maybe they should be able to gain experience abroad towards their accreditation. Win win win. They get accredited. The country receiving them gets well-educated help. We end up with more doctors.
whiterknight 3y ago
The problem is doctors are expensive so the management is economizing their time.
- tylerrobinson 3y ago
  You’re being downvoted because that’s baked into the parent comment; the suggested solution is to increase the supply of doctors.
  - whiterknight 3y ago
    The parent comment doesn’t state it explicitly, and suggests it’s the managements fault. One of the problems is that regulations require MD oversight but not necesssrily performing all operations. That’s a good thing but forces them into a role where they hover for a few minutes then get rushed to the next supervision activity. So there are lots of dials to play with in addition to supply.
- dillydogg 3y ago
  In my experience in the clinic, the attendings are spending an incredible amount of their time doing busywork required by management instead of actually caring for patients.
  - whiterknight 3y ago
    Interesting. If you had to weight it towards legal compliance or productivity surveillance which would you say?
    - dillydogg 3y ago
      Maybe letting them see patients? I feel like this is a false dichotomy. I guess legal compliance of I had to choose, so it wouldn't lead to insane numbers of patients per hour
      - whiterknight 3y ago
AtlasBarfed 3y ago
The AMA is one of the four pigs at the trough of US healthcare: 1) Insurance companies - extract profit from the usual insurance model applied to healthcare. 2) Drug/Device companies - extract maximum profit from patent monopolies, FDA regulatory capture, and marketing. 3) Malpractice lawyers - use regressive law precedent to maximize individual payout and lawyer billing to the detriment of everyone else 4) AMA/Providers - restrict supply, and maximize billing for services Really, none of these pigs have the interests of overall public health in mind: - Insurance companies are incentivized to maximize the cost of insurance and deny coverage as much as possible, like any insurance company vertical. Obviously this results in denial of care. However, an insurance company is motivated to reduce provider costs and possibly to incentivize preventative care. Insurance companies are also vertically integrating into owning provider facilities to solidify local monopolies (so people HAVE to use their insurance if they live in an area) and to be able to impose cost cuts to actual providers. - Drug/Device companies are incentivized to maximize the profits from 20 years of provided patent monopolies, often exploiting desperate people looking for relief from maladies, but the cost is usually beyond the ability of individuals to afford. Lawyers are incentivized to bill/get percentages of settlements and maximize awards of "damages" regardless of the overall impact to health services costs and the implicit denial of care that involves. However, these orgs, while generally not doing the core science of new treatment modalities (universities do that), they do help usher treatments through safety review. - Trial lawyers are incentivized to maximize their patient damages and billing, which obviously is transferred to higher costs for all. Lawyers are one of the few hammers to get insurance companies to properly pay out, keep hospitals from devolving into managerial corruption, and keep Drug/Device companies from fudging the numbers. - And the AMA/Providers are incentivized to maximize the billing for their services, overbill for often superfluous services, resist any intermediate level profession (Nurse Practitioners, etc) from devaluing their law-enforced professional monopoly, and incentivized to not address general health of patients but rather bill with expensive specialist care rather than help patients maintain wellness that averts serious illness. In my experience no provider ever cared about how much their services cost the patient, until it became apparent the patient could no longer pay. Then their economic awareness of the cost of care become VERY APPARENT. The AMA is criminally complicit in restricting supply of doctors, which it very well knows raises the cost of medical services and of course denies care to people on the aggregate. Each of the four pigs simply points to other pigs as someone to blame and lobbies with maximum force to prevent any threat to their gravy train. To address US healthcare costs will generally require all four pigs: a public insurance option (at a minimum). Reduce patent length or invalidate patents, and with cases like unpatented production that has been monopolized (epipen, insulin) enforce antitrust. Fix prices if necessary. Obviously trial lawyers awards should be capped. Finally, nurse practitioners and AI expert systems used to decrease costs, and supply of doctors increased vastly. Overall, government needs to address the total lack of preventative care.

lokar 3y ago

And to get to this we spend far more (as a percentage of GDP) then other western nations.

wighty 3y ago

> The nurses have left and you can't legally 'bill' or code the appointment without the nurses. What? I've never heard this requirement and I cannot think of why it would be the case (I'm a PCP). The rest of your comment is pretty much the issue as PCP though. I have at least 30 minutes a day of "out of visit" requests (reviewing documents from outside hospital/consults, labs, imaging, other results, extra nurse patient triages) in addition to anywhere from 30 minutes to 2 hours of completing my notes each night. The payment methods for primary care do not work.

maxerickson 3y ago
I think it's pretty stupid that basic appointments are billed on complexity and not time. Well, and lots of other things too. Getting a radiologist to do a definitive diagnosis using imaging doesn't actually make the ER doctors job harder (rather, it de-risks the interaction for them). It's also ridiculous that I have to promise to pay any bills that my insurance won't cover. If some care can't be justified as medically necessary, there should be a specific contract for that when it comes up, not a blanket rider prior to accessing treatment. Forcing the two sophisticated entities to have a workable agreement where they can't dump costs off on the individual patient would at least improve perceptions of care.
- nradov 3y ago
  The No Surprises Act included some protections against balance billing. It's still a problem but somewhat less than before. https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills https://www.cms.gov/newsroom/fact-sheets/no-surprises-unders...

a_gnostic 3y ago

Why do they bill $700 for a bag of salt water they paid $1 for? (1) 1. https://www.advisory.com/daily-briefing/2013/08/27/the-secret-of-salines-cost-why-a-1-bag-can-cost-700 https://www.advisory.com/daily-briefing/2013/08/27/the-secre...

Rury 3y ago
A major part of business of former employer of mine, involved simply buying parts from another business, doing things to try and hide who the OEM was, and having salesmen resell it for a large markup without doing anything else to the parts. A major reason it did this, was because it subsidized the other side of the business which often lost money in the short term, but resulted in growing this profitable side of the business. If things were priced correctly, the money losing side would have charged more its services, and this profitable side cheaper. However, if they did just that, the demand may have not of been there to sustain or grow the business like it had. I honestly hate this sort of stuff though. When I pay my toll on the highway, I expect it to pay for maintaining the road I used, not for unrelated things. Anyhow, may be a similar kind of thing going on here, or you know... just flat out profiteering.
- lotsofpulp 3y ago
  >When I pay my toll on the highway, I expect it to pay for maintaining the road I used, not for unrelated things This is a great example. You expect to pay for the "maintenance of the road", but what about the ongoing opportunity cost of the road and all the externalities of the road? What about all the roads that do not have tolls on them? The toll road does not exist in a vacuum, and life is not so simple so as to be able to sequester all costs into separate line items. In fact, one of the main uses for tolls is not for the maintenance of the toll, it is for managing congestion of the road, since the road has a carrying capacity. After a certain number of vehicles, the road becomes less and less useful, so a variable rate toll can ensure a limited number of vehicles operate on the road at peak congestion. It is simply not feasible to tie revenue to expenses 1 to 1, and specific taxes (like tolls) legislated to do that for government expenses hamstrings leaders because it removes flexibility needed to move resources around (which obviously could be used for bad, but also good, as you demonstrated your business's example).

dillydogg 3y ago

In my outpatient family medicine clerkship, I saw over 25 patients a day. 20 minute appointments from 8 AM until 5 PM. It was a whirlwind of activity from beginning to end. I don't think in 4 months I saw my preceptor get a 20 minute lunch break. It's crazy. Each room you go in, subjective, objective, assessment, plan, boom, next room. Hope you got all your orders in before that next patient without getting too far behind! I don't think people get how much their doctors are doing behind the scenes. And after each appointment they need to document everything in the chart. If you aren't charting in the room, you will be there for hours after your last patient catching up. But if you do chart in the room, your patients get mad at you because you are on the computer the whole visit. Then you have to prechart at the end of the day on all of your patients tomorrow and get ready to do it all again.

luckman212 3y ago

Oh boo fuckin hoo. TLDR- it's hard to operate a properly functioning healthcare practice when everything is controlled and mandated by the insurance companies. Who demand that patients take no more than 7 actual minutes of "doctor time" and must be whisked out the door with lots of prescriptions for expensive medications that guarantee they (a) will not be cured and (b) will continue to provide a steady revenue stream to big pharma which helps to subsidize the whole upside down dystopian health pyramid that is the US healthcare system.