dagblog - Comments for "Bait & Switch: how care, not insurance, leaves southern blacks behind"

but we have to admit there is

artappraiser — Sat, 01 Jul 2017 12:08:14 +0000

but we have to admit there is still going to be a "how to get to treatment" problem, I was just thinking that after thinking about what would be a good example of common things that happen. Good example came to me: what happens after that prostate cancer or breast cancer screening comes back positive? You've got biopsies, then complex treatment choices, then maybe many visits to where chemo or radiation is administered as outpatients or short stays. Because they need to be close by complex treatment if something goes wrong. How do you do this rurally?

Both are so complex, that many are overtreated or mistreated because they don't get access to the top specialists who really know their stuff. I.E., women lose entire breasts when they don't need to, men become impotent or incontinent when they didn't need to. Where the virtual would help: whenpeople die when a virulent type is missed in the process of treatment, I would think a conference of the general oncologist with a top expert could catch that.

I mentioned housecalls as

PeraclesPlease — Sat, 01 Jul 2017 12:06:56 +0000

In reply to but we have to admit there is

I mentioned housecalls as being more justifiable if easier groundwork done, and potentially more portable diagnostics and treatment devices (self-serve mail order?), but ues, many afflictions and problems require near-by service on an ongoing lengthy basis - nolo contendere.

I think single payer can be

PeraclesPlease — Sat, 01 Jul 2017 11:43:00 +0000

In reply to On pumping trillions in..

I think single payer can be useful, but it's not a solution/benefit unto itself - it would help simplify/solve problem X, Y and/or Z, as you note. It's not like world peace - it's not a self-obvious truth.

I have a similar experience with a a programmer friend leading IT for a somewhat similar org. I'm not sure it's all so altruistic, but it can be justified, and doesn't appear to be inherently overtly evil. I.e. perhaps a half or 3/4 a loaf as we get older and less ambitious and the market for samaritanism dries up?

Funny, I've been thunking

PeraclesPlease — Sat, 01 Jul 2017 11:39:00 +0000

In reply to very good point about the

Funny, I've been thunking about these remote delivery platforms for the disabled (plus education), but hadn't glommed on to the need for a more general platform for general use.

To some extent we need more trained Digital Health Librarians able to triage patients and information and appropriate facilities. When a family member gets first symptoms of dementia or ALS or autism or a paricular serious hormone deficiency or first tiredness stage of cancer, you don't even have the affliction named and diagnosed. When someine loses their eyesight or a limb, there's an array of known needs and options to prwsent and wade through. Sure, each can do that themselves wading through WebMD, but that's a less intensive, directed with outcomes approach. If much of the prelim groundwork is handled, even hiusecalls then become cost effective as last mile portion of the assistance, not soup-to-nuts.

very good point about the

artappraiser — Sat, 01 Jul 2017 11:28:01 +0000

In reply to Thanks for these. Though

very good point about the geography problem! Everyone trying to make an honest argument should admit this, that we can not be like Europe, we are not the same. Yes, getting to decent care is going to be a major problem for rural of the future. Until we really have like some kind of system set up where treatment is virtual via video or whatever. And to do that, generalist docs/P.A.'s/N.P.'s that are willing to work rural areas need to be trained to work as a team virtually. They need to be specifically trained to be able to basically be specialist's assistants, to know what to look for. It's not the way most are trained now. They are trained to try to keep patients well and away from expensive specialists because that costs money.

Doing that now, though, is a kind of public health approach, cookie cutter. I.E., tell everyone to eat vegetables and cut down on fats, when that may not be what the individual person needs. Or they may need anti-fungal, not anti-biotics, when having an infection, and anti-biotics make them worse, etc. Complex medicine these days is more capable of treating the individual and is capable of doing it well with a team (as well as the opposite, over treating to detriment of patient). But the G.P., unless an extremely talented intuitive diagnostician working with a very knowledgeable patient, cannot do this anymore. Get what I am saying? The right kind of virtual care has the potential of being enormously successful, or a terrible failure...depends upon how providers are being trained. I do sense some of the younger guys/gals at some of the top schools are finally better prepared. But there are far from enough of those, as anyone who knows who has read about the visas for foreign doctors, we aren't producing enough of them in general.

On pumping trillions in..

artappraiser — Sat, 01 Jul 2017 11:09:50 +0000

In reply to I know of one company,

On pumping trillions in..

and the "automation" of info. to run all this is in its infancy. I personally know someone who is an extremely programmer/systems admin. person who just switched industries and chose this company to work for

http://www.cedar.com/

I checked it out a little because he's an acquaintance and I'm interested in what he's up to, and the truth is right now this company, they seem to be focusing on getting the whole co-pay thingie down, seems it screws up a lot and people are, er, not paying their bills after the work on the broken limb or whatever is done if you know what I mean. So the provider is screwed. So their current p.r. about helping physician and patient experience is not, er, accurate. But let's give them the benefit of the doubt and hope later done the line, they care about patient quality issues too.( Why--I would tend to think this acquaintance, since he could probably get a job anywhere, would chose along the lines of google's "don't be evil", he's that type of guy.)

My point: in the midst of all this software being developed, and companies and start ups competing to be the eventual one everyone uses, It would be sooo opportune right now to have single payer or even just a few payers instead of so many.

It just would be so much more efficient, and even for "Wall Street", they would know where we are going and who can profit and who cannot. Because there will be tons of people spinning wheels and lots of cos. failing until things are more organized and "set".

Thanks for these. Though

PeraclesPlease — Sat, 01 Jul 2017 09:29:34 +0000

In reply to Not on the rural care problem

Thanks for these. Though again I don't see "Single Payer" as addressing the issue of widespread access to needed healthcare per se. These doctors get paid from 1 place and aren't happy. These rural folks might have insurance but no clinic. We're always solving from the insurance companies' perspective or what?

One thing that makes America's proplem hard is we're so damn big geographically. 2/3 of the EU's population in what, 2 1/2 times the area? And little mass transit, which affects the aged and poor most, especially with illnesses.

Not on the rural care problem

artappraiser — Sat, 01 Jul 2017 09:10:36 +0000

In reply to Bait & Switch: how care, not insurance, leaves southern blacks behind

Not on the rural care problem at all, just the opposite, but I am plopping it here because I think it might be another canary in coal mine about how our health care system is about to explode. Turns out the "going postal" shooting at the Bronx Lebanon Hospital was by an M.D.:

Doctor Opens Fire at Bronx Hospital, Killing Woman and Wounding 6 Others

By Sarah Maslin @ NYTimes.com

Apparently, his dispute with the hospital was about accusations of sexual harrassment against him and he felt treated unfairly. So it is not really proof of what I am going to address next, but it served to raise the whole topic for me.

I mentioned there are "unconvenient truths" about our health care system upthread. In particular, I think there is a lot of anger brewing. Before Trump and the new Congress was inaugurated, in my own interactions with the health care system, and in a lot of the things I read, I sensed a lot of dissatisfaction by providers, that the system was being stretched to the breaking point under Obamacare. Providers know patients like it, they very much like that more people are covered for preventive care, and that the whole pre-existing thing was solved, they would not like to see those things done away with, but they were still were very much dissatisfied with the whole situation! They desperately wanted to see improvement, especially as the boomers age and access many more services, not go backwards.

I especially heard and read a lot about the insurance companies squeezing them and playing other games, having to cut costs, not having enough staff to handle everything (hospitals and docs and nurses all), the drug companies and investors with their huge profit motives. Then there is a serious staffing problem and cost cutting in most hospitals, especially that nurses are overloaded.

In NYC, Manhattan specifically, it is common to see specialty docs opting out totally, not accepting any insurance at all, and just going to out-of-pocket patients. They will give you a claim form for you to file for your insurance to try to get money back from them, but they will not do the insurance thing anymore. In my own personal experience, not all of these docs are money grubbing assholes, but very fine caring doctors who are just fed up with it all. They still very much like helping people regardless of income, but just "mad as hell and can't take it anymore" having to deal with lots of insurance companies and, aging themselves, want to practice and help whoever they can rather that quitting totally.

Another alternative I see happening over the same problem is huge doctor conglomerates, like Advantage Care Physicians (36 office locations, 29 medical specialties, 400 primary care and specialist physicians) where they have basically gone over to a salaried system just so someone else handles all the paperwork and negotiate with the insurance companies, and they can just practice medicine. Unfortunately for patients, though, while the docs are happy to have all the crap handled by their bosses, these big medical bureaucracies are for profit, and they also do the squeeze thing. And they can be the worst kind of nightmare bureaucracies, where you can get into Kafka like experiences if something like a prescription goes wrong because of a software glitch or human error typing in the wrong code. You cannot reach a human being with medical knowledge, the doctors are protected from such phone calls. They got rules and a system to make money, and will not tolerate anything else.

I once had a small type of problem like this and when I finally saw my doctor, I complained to him that the phone system and the email system was a huge runaround and no one but him could have solved it but I was not allowed to reach him, but just deal with idiots that didn't understand. This was his solution: if anything like this happens again, just stop by in person and have them call me out and I will fix it! So ironic. We have phones and email but in person is best. Unfortunately, it's not like the big clinic is right down the block, you're talking half a day lost.

MY POINT ABOUT ALL OF THIS: like I told Obey on another recent thread, I THINK SINGLE PAYER IS COMING SOONER THAN A LOT OF PEOPLE THINK. When you see conservatives say this too,some warn that it is coming if what they consider a good repeal isn't enacted, that is why, I think: they get the situation more than their colleagues, they get that there is still need for radical change. We all know plenty of individual doctors are Republicans on other issues, they talk to such providers that are their constituents, they know they are still unhappy with the system. Their solution is unrealistic, like market forces and health savings accounts, but they get that the system is at a breaking point, that both providers and patients will eventually demand single payer if things don't change soon.

I know of one company,

PeraclesPlease — Fri, 30 Jun 2017 21:32:31 +0000

In reply to We don't even talk about

I know of one company, Accolade, doing some sort of massive health care info facilitation, though I think they stay one step removed from actual health delivery, for liability & costs & what not. Could imagine that scenario improving 50 times, along with telemedicine, better home delivery, etc.

The way senior facilities are run is rather extortionary and rather criminal neglect, except no one will sue because then the patients just get thrown out of the facilities quicker. Don't Republicans have parents? Apparently not, or they don't mind messy complicated long drawn out & painful roads to a humiliating death that tends to drag down the whole family with it. Or maybe I just missed the facilities that are 10x overpriced - maybe it's all golden there. I imagine care for the mentally disabled is worse.

Greatest nation on earth pumping trillions in....

Recent New Yorker article

artappraiser — Fri, 30 Jun 2017 20:55:44 +0000

In reply to Bait & Switch: how care, not insurance, leaves southern blacks behind

Recent New Yorker article about similar southern belt problems, though not about the Afro-American issue exclusively, about the rural poor and how health care in general in these areas is disappearing. (Comes to mind people get all upset about no abortions being available, but the fact is all kinds of health care is not available, no providers):

A Doctor’s View of Obamacare and Trumpcare from Rural Georgia

By Charles Bethea

June 28, 2017

Nineteen years ago, after medical school at Columbia University; a stint at Montefiore Medical Center, in the Bronx; and a period running homeless shelters in Times Square; Karen Kinsell moved to Fort Gaines, a tiny town in southwest Georgia, on the Alabama line. Fort Gaines is in Clay County, which is consistently ranked among the poorest of the hundred and fifty-nine counties in the state. It currently ranks third-to-last in “health outcomes,” according to the Robert Wood Johnson Foundation, up from dead last. Clay County’s only hospital closed its doors in 1983, long before Kinsell, who is now in her sixties, arrived and became its only doctor. “It’s a bad place to live,” Kinsell said recently by phone, between seeing patients, “which is why I moved here. I was looking for a place that needed me.”

Kinsell runs Clay County Medical Center, a facility with four exam rooms built out of a former Tastee-Freez. It’s a private practice, but she is a full-time volunteer. There is a receptionist and two other full-time staff members; they see “around thirty to thirty-five patients a day,” Kinsell said. Monty Veazey, the president of the Georgia Alliance of Community Hospitals, told me that “Kinsellcare” is the only health care that’s had a meaningful and positive effect here. “She’s going bankrupt treating everyone that comes in,” he said. “Most have no money, no Internet access, no other basic care. Many don’t have insurance. How much longer can she do that? I don’t know. But she’s their only hope.”

On Tuesday, shortly before Senator Mitch McConnell announced a delay in the vote for the Senate Republicans’ health-care reform bill, Kinsell spoke by phone about the effects of Obamacare, the prospect of Trumpcare, and the plight of sick people in southwest Georgia. Her account has been edited and condensed.

“My patients are sixty per cent black and forty per cent white. Forty per cent are completely uninsured, and we just ask them for ten dollars to cover the visit. If they can’t pay, then it’s free. We do that because this is one of the poorest places in Georgia, with some of the sickest people, and we’re adjoined by counties that are just as bad.

“We’ve had two rural hospitals in the wider area close in the last seven years. And the quality of the remaining really rural hospitals is pretty awful [.....]