As EMS providers, we don’t know enough about the health care system. I am always amazed at some of my veteran colleagues that know nothing about the business of healthcare in which they’re integrally apart. Partly, I think it’s because of our disconnect with other health care providers. If we all worked in a hospital with other providers, we would not be falling behind in education, professional advancement, money, etc, relative to other health care professions. We are after all, the ******* stepchild of both health care and other emergency public servants. I think we would be better off and be able to grow professionally if we were at least versed in the health care system. Not well versed, just versed. So, I think we should promote more health care system education in ems classes, as well as, take the time to learn more ourselves. To that end, I would like to hear your opinions. I have typed up with a very rough overview of the health care system and I think this info should be taught in every emt-b class to give them a basic understanding. I don’t have the time to write up something really nice, but below is a down and dirty idea of what we are dealing with. It is presented in no particular order, just a bunch of facts that show how our health care system is constructed. I don’t have the time to cite all this, but any fact could be quickly verified using google. If I left out anything major or if you disagree with anything, I’d love to hear about it. I won’t be getting into any political arguments, but if a fact is wrong, cite a source.
Our healthcare system is all about money. This fact makes our health care system unique amongst all other developed nations when compared to “socialized” health care in European countries and Canada. We have 47 million people or 15% of population uninsured. This doesn’t include the under insured people who have Medicaid, etc. Two trillion is spent on health care which equals 15% of our GDP. Many experts say the biggest threat to our system is the uninsured population. The average individual per family health care insurance cost is 12 thousand dollars. In other words, it’s very hard to afford insurance on minimum wage.
In this country, only three types of people are guaranteed to be seen (could be bad quality care, but at least they’re seen): 1) life threatening problem or active labor 2) active duty military 3) incarcerated prisoners. World Health lists the US at 1st place for amount of money spent and 30 something for service and health. There are huge disparities in cost. (example, a medication might cost $300 in one place and $15 in another store in the same city--advice: always check target and walmart first).
Our two major entitlement programs are Social Security and Medicare. Bottom line here, baby boomers are going to drain the system dry unless something is changed. Different types of hospitals include: 1) not for profit hospitals which invest money into hospital instead of stock. 2) for profit hospitals that distribute money to shareholders and are obligated to make as much as possible. 3) Safety net hospitals, which are subsidized by the state. 4) VA, which is a completely socialized healthcare system from start to finish, or vertically integrated. 5) Specialty hospitals. For the most part, adults >50 are using the system and spending/costing a lot of money. Kids cost the system relatively little. 20% of the people are using 80% of the system (something us ems people know well). In the US, we have a marriage made in hell because people like having useless procedures done to them, doctors like doing these procedures, and insurance companies like paying for it.
History of insurance companies is as follows: 1930s-employees paid for healthcare. 40s-employers started offering health care benefit to entice employees. 50s- medical business started booming but poor and elderly weren’t insured. These holes were closed by Johnson with Medicaid and medicare. Health care insurance is like a bet, you bet you will get sick, and the insurance company bets you will be healthy. Whoever wins the bet gets the better end of the deal. 50s and 60s-insurance paid for everything, which led to no incentive to be worked up at the hospital efficiently. Insurance was never meant to pay for routine procedures, and when this started happening, the business model broke. Jap cars became cheaper secondary to public paying large amounts to insure its employees and government began to realize it was paying too much. 80s- saw backlash and welfare reform. Medicaid/care started only paying certain amounts for certain procedures and stopped allowing doctors to charge more than the Medicaid/care set price. 90s- we now see outpatient centers popping up and shorter hospitals stays. If they know they can only get a certain amount of $, they’re going to get you out of there as soon as possible. Managed care plans put more power in the payers hands and less to the doctors.
Some problems: 1) it’s a bad business model from day one, henry ford couldn’t make money on this model. There is a constant tension between healthcare as a commodity and social service. Cost, Quality, and Access are three main areas of contention. Whenever you move to one, you move away from the other three. Medicare-D, in a nutshell, gave a bunch of cranky rich old voters free drugs, it costs a hell of a lot, and has a clause that guarantees huge profits to drug companies. It also allowed some poorer old people free drugs.
Doctors want easy, schedulable, predictable patients. Thus, many refuse to be on call for emergencies. If you go to the hospital and need a hand surgeon or psychiatrist or neurosurgeon, good luck on getting one some areas. Hospitals can’t force these people to be on call because if they piss them off, they will go to another hospital. And it is the neurosurgeons, etc that make all the profit, not the money toilet known as the ED. This results in pts being shunted to different hospitals, which is good for ems transport companies, but bad for pts.
More specialty practices and freestanding surgery centers mean that doctors are able to draw profitable rich people out of general hospitals. This means the general non-profit safety net hospitals must turn to the government for more and more for money. And these general hospitals must be funded because they act as safety nets to collect all the poor who would not be allowed through the front door of the private practices. Some worrisome trends: Doctors training in such specialties as L&D now giving botox injections (easy job, more money). Keep in mind, we pay for all residency training through medicare, so we have a right to be upset about this trend.
Nurse practitioners are now starting to take self paying pts from hospitals and doctors practices and giving them much cheaper general care. The quality of the care is the same, and it is cheaper for the pt, but the hospitals that are dependent on paying customers to keep the money pit ED running, are losing more and more $. Another troubling trend is that doctors are seeing less pts for more money. The doctors go from 1500 pts and making $150K/year after overhead (paying army of people to file insurance papers) to business models that have 600pts that pay $100/month/person for better care that ends up netting the docs $600K/year. This is good for people that can afford 100/month, and bad for everyone else.
The drug companies meanwhile are spending god-awful amounts of money on advertising causing inflation. In fact, the two biggest causes of inflation are drug companies and medical imaging. Malpractice has shown no evidence of increasing quality of care and isn’t a big contributor to inflation. Malpractice isn’t negligible, but it isn’t nearly what they make it out to be. The system is set up to allow doctors to misbehave and get away with it. Most of the time when doctors are hauled in front of state medical licensing boards, it is because of addiction or sexual misconduct. It is not because of negligence usually. Lastly, medical tourism is gaining in popularity because people are receiving comparable care at a reduced price in other countries or “offshore.” It has gotten to the point where Johns Hopkins and Harvard are going into partnerships and allowing the use of their name on hospitals in India. They are like worldwide fast food chains, but medical instead.
Many ED doctors are lucky to get back 30 cents for every dollar they bill. The system has to evaluate poor patients for a serious condition, and usually by the time that’s over, the doctor just writes the bum a prescription. When ED docs actually have someone sick, many times their patients in the ED has to wait for a bed upstairs to open up because those beds are usually full of paying customers that reserved the bed a week ago. Also, ED docs are having a harder time getting experts in other fields to come down to the ED and examine their pt. With all this craziness, it’s no wonder they can be pricks to us sometimes.
Our healthcare system is all about money. This fact makes our health care system unique amongst all other developed nations when compared to “socialized” health care in European countries and Canada. We have 47 million people or 15% of population uninsured. This doesn’t include the under insured people who have Medicaid, etc. Two trillion is spent on health care which equals 15% of our GDP. Many experts say the biggest threat to our system is the uninsured population. The average individual per family health care insurance cost is 12 thousand dollars. In other words, it’s very hard to afford insurance on minimum wage.
In this country, only three types of people are guaranteed to be seen (could be bad quality care, but at least they’re seen): 1) life threatening problem or active labor 2) active duty military 3) incarcerated prisoners. World Health lists the US at 1st place for amount of money spent and 30 something for service and health. There are huge disparities in cost. (example, a medication might cost $300 in one place and $15 in another store in the same city--advice: always check target and walmart first).
Our two major entitlement programs are Social Security and Medicare. Bottom line here, baby boomers are going to drain the system dry unless something is changed. Different types of hospitals include: 1) not for profit hospitals which invest money into hospital instead of stock. 2) for profit hospitals that distribute money to shareholders and are obligated to make as much as possible. 3) Safety net hospitals, which are subsidized by the state. 4) VA, which is a completely socialized healthcare system from start to finish, or vertically integrated. 5) Specialty hospitals. For the most part, adults >50 are using the system and spending/costing a lot of money. Kids cost the system relatively little. 20% of the people are using 80% of the system (something us ems people know well). In the US, we have a marriage made in hell because people like having useless procedures done to them, doctors like doing these procedures, and insurance companies like paying for it.
History of insurance companies is as follows: 1930s-employees paid for healthcare. 40s-employers started offering health care benefit to entice employees. 50s- medical business started booming but poor and elderly weren’t insured. These holes were closed by Johnson with Medicaid and medicare. Health care insurance is like a bet, you bet you will get sick, and the insurance company bets you will be healthy. Whoever wins the bet gets the better end of the deal. 50s and 60s-insurance paid for everything, which led to no incentive to be worked up at the hospital efficiently. Insurance was never meant to pay for routine procedures, and when this started happening, the business model broke. Jap cars became cheaper secondary to public paying large amounts to insure its employees and government began to realize it was paying too much. 80s- saw backlash and welfare reform. Medicaid/care started only paying certain amounts for certain procedures and stopped allowing doctors to charge more than the Medicaid/care set price. 90s- we now see outpatient centers popping up and shorter hospitals stays. If they know they can only get a certain amount of $, they’re going to get you out of there as soon as possible. Managed care plans put more power in the payers hands and less to the doctors.
Some problems: 1) it’s a bad business model from day one, henry ford couldn’t make money on this model. There is a constant tension between healthcare as a commodity and social service. Cost, Quality, and Access are three main areas of contention. Whenever you move to one, you move away from the other three. Medicare-D, in a nutshell, gave a bunch of cranky rich old voters free drugs, it costs a hell of a lot, and has a clause that guarantees huge profits to drug companies. It also allowed some poorer old people free drugs.
Doctors want easy, schedulable, predictable patients. Thus, many refuse to be on call for emergencies. If you go to the hospital and need a hand surgeon or psychiatrist or neurosurgeon, good luck on getting one some areas. Hospitals can’t force these people to be on call because if they piss them off, they will go to another hospital. And it is the neurosurgeons, etc that make all the profit, not the money toilet known as the ED. This results in pts being shunted to different hospitals, which is good for ems transport companies, but bad for pts.
More specialty practices and freestanding surgery centers mean that doctors are able to draw profitable rich people out of general hospitals. This means the general non-profit safety net hospitals must turn to the government for more and more for money. And these general hospitals must be funded because they act as safety nets to collect all the poor who would not be allowed through the front door of the private practices. Some worrisome trends: Doctors training in such specialties as L&D now giving botox injections (easy job, more money). Keep in mind, we pay for all residency training through medicare, so we have a right to be upset about this trend.
Nurse practitioners are now starting to take self paying pts from hospitals and doctors practices and giving them much cheaper general care. The quality of the care is the same, and it is cheaper for the pt, but the hospitals that are dependent on paying customers to keep the money pit ED running, are losing more and more $. Another troubling trend is that doctors are seeing less pts for more money. The doctors go from 1500 pts and making $150K/year after overhead (paying army of people to file insurance papers) to business models that have 600pts that pay $100/month/person for better care that ends up netting the docs $600K/year. This is good for people that can afford 100/month, and bad for everyone else.
The drug companies meanwhile are spending god-awful amounts of money on advertising causing inflation. In fact, the two biggest causes of inflation are drug companies and medical imaging. Malpractice has shown no evidence of increasing quality of care and isn’t a big contributor to inflation. Malpractice isn’t negligible, but it isn’t nearly what they make it out to be. The system is set up to allow doctors to misbehave and get away with it. Most of the time when doctors are hauled in front of state medical licensing boards, it is because of addiction or sexual misconduct. It is not because of negligence usually. Lastly, medical tourism is gaining in popularity because people are receiving comparable care at a reduced price in other countries or “offshore.” It has gotten to the point where Johns Hopkins and Harvard are going into partnerships and allowing the use of their name on hospitals in India. They are like worldwide fast food chains, but medical instead.
Many ED doctors are lucky to get back 30 cents for every dollar they bill. The system has to evaluate poor patients for a serious condition, and usually by the time that’s over, the doctor just writes the bum a prescription. When ED docs actually have someone sick, many times their patients in the ED has to wait for a bed upstairs to open up because those beds are usually full of paying customers that reserved the bed a week ago. Also, ED docs are having a harder time getting experts in other fields to come down to the ED and examine their pt. With all this craziness, it’s no wonder they can be pricks to us sometimes.
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