Times are tough at the medical university and hospital. To preserve jobs in a brutal economic climate, one of South Carolina’s largest economic engines is slashing costs by instituting a hiring freeze, cutting overtime and using less paper and electricity. The Medical University of South Carolina and the Medical Hospital Authority employ about 11,000 people. At the hospital, underfunded Medicaid services are on the chopping block, and the workforce is being adjusted through attrition.
This is truly regrettable. My uncle was treated at MUSC shortly before he died back in 1996, and my father-in-law was treated there for a serious disease not quite two years ago. In both cases, I was very impressed with MUSC staff.
I’m afraid that we health care providers have reached the point that medicaid and, I’m afraid to say, medicare too, are simply no longer viable concerns for us to accept. Forget what you used to think about doctors’ salaries. There are internal medicine docs struggling to stay afloat. They are moonlighting, putting their families to work in the office, and selling vitamins on the side. And we of all specialties are severely limiting the m’caid and m’care patients we accept. They –you — and me someday — are too complex, and often too demanding and litigious, to make it worthwhile to be paid 12 cents on the dollar. Sorry, but we’ve been pushed down long enough. Yes, emergencies are a different story altogether. Advice: if you’ve got m’caid or ‘care, do not lose the relationships you currently have with health care providers! It will be difficult to replace them.
Agree, hippocamper.
In my own field we can still make a few cents on Medicare- and at the volume of MC we treat it’s still a marginally viable/ minimally profitable option- but if the huge cut had not been stopped by Congress this Summer all providers would be underwater on Medicare. Some of the local specialties have dropped the MC HMOs already because they lose money on them. Almost all of the primary care docs restrict their volume of new MC patients.
Everyone has been losing on Medicaid patients for a decade or more. These strains are what will eventually cause the system to “crash”
The real tragedy here is that needy people do not get the services they so desperately need.
So what, physicians on this blog, is the answer? How would you reform the system to make it viable?
I believe that fixing our system ultimately involves some form of rationing of care, especially at the extremes of age, and immunity from retribution when we do ration. Costs would come down, premiums would follow, and insurance would become more affordable. Other measures include making health insurance marketable nationwide, like life insurance currently is, instead of confined to fifty small, highly regulated markets.
#6 Agreed. We already have rationing. We ration by hassle factor, and by absence of services for selected populations.
My patients on Medicaid (I’m the only provider who sees them) can’t get vagal nerve stimulators for intractable seizures because the only surgeon in the state who used to put them in has just stopped taking Medicaid.
I get a continuous stream of patients on Medicare who have just “lost their doc” (as internists leave practice and become hospitalists or urgent care docs.
One could solve part of the problem by simply expecting patients to take more responsibility for themselves, and giving them the tools. If a patient is stable on 3 meds, why should he/she have to keep going to a doc to get a prescription? If non-addictive medications were available without a prescription, then I think folks would learn to manage their asthma, hypertension, diabetes, thyroid disease, seizures, migraines, choleserol etc. There are algoriths, and guidelines. Folks, after all are expected to assess their mortgages, and do their own taxes without government subsidized assistance, I don’t see medicine as being a whole lot harder than that.
Those who have trouble managing their medications or who have complex problems that don’t get better, can go to docs or other providers. There the issues driving costs are regulations and litigation.
I would have a three tier system.
Tier 1: any provider gets to play – pharmacists, nurses, med techs, docs, dentists etc. They can charge whatever they like, but patients pay cash on the barrel, as with chiropractitioners and massage therapists. Lawsuits are forbidden, and there is no regulation. Thus a clever med tech could probably charge 10-20 dollars/hour helping somebody straighten out his meds.
Tier two: Certified professionals – Doctors or Physician Assistants or Nurse Practitioners. These would be certified, and they would be forced to keep records, but lawsuits would have to go through arbitration only. Again, cash on the barrel, though insurance may reimburse later. I anticipate that folks would be able to charge about 50/hour.
Tier Three: The full panoply of specialists etc. Since this would also cover hospitals this would be complex care, high risk, need for extensive records and tests, and this will need insurance coverage. In my opinion insurance coverage should be reserve for catastrophic (read hospital based) care only. It would probably be impossible to extinguish litigation from this system, so rationing will have to come in to reduce costs.
As to rationing, it is inevitable. After all, everybody is going to die eventually. The cost of saving a 90 year old with a heart attack and pneumonia is a 20 x that of saving a 40 year old with heart attack and pneumonia. Eventually the body wears out. In a situation where 50% of costs are spent on those in the last two years of life, and where most people live close to 80, if we had automatic DNR/no operations/comfort care only orders for everybody over the age of 90 or with metastatic cancer this would probably save medicare. If one added “no elective surgery” for those over 85 or those who are completely disabled, it might be possible to have universal health care. This, after all is how Europe affords her universal health care. None of the folks in my hospital’s ICU (all of whom are over 78) would be alive in Belgium. In England, you can’t get dialysis if you are over 50. Other countries ration and there is government immunity for this. Eventually it will need to come here or the system will simply fail due to shortages with absence of available hospitals and providers. The latter situation is what is already beginning to happen. Folks on medicaid who need specialty care can no longer find it for any money. Folks on medicare can no longer find a primary care provider. Kids who need specialty care need to travel 300 miles or more to get care. We are already rationing. We are just rationing irrationally.