Originally Posted by The Rani

Not trying to be a mind-reader here, but I don't think that Justin was talking about specialists.
What might happen if we get socialized medicine is an extension of what is happening now, with physician assistants and nurse practitioners moving into the roles of primary care physicians in locations (mostly rural) where there are shortages. They are paid much less than physicians, and aren't as highly trained, but they're better than nothing, I suppose.

These days, I'm not sure why anyone would want to be a GP. Low pay and at the bottom rung of doctorworld because you can't generate the same revenue as a specialist. I was speaking to one cardiologist a few monhs ago who was complaining about essentially having to financially carry the GPs in his practice. They are almost cost centers. You simply can't bill them out at the good rates.

There's more money in being a nurse anesthetist than a GP. And if you are a PA you can do all kinds of things with much less schooling.

If I were in med school and the only thing open to me was GP (or internal medicine), I'd probably cut my losses and find something else to do.

Originally Posted by The Rani

And that actually scares the shit outta me. I've seen the results of kids medicated by nurse practitioners. It's not pretty.
I am sure that docs go into general practice, or at least they used to, because they enjoyed the direct patient contact. Over the last 20 years or so, you are right, it has not been worth the hassle, which is why we now see the niche being filled by nurses/PAs.

I like the neurosurgeons who let their PAs practice neurosurgery.

There are lots of funny PA stories floating around doctorworld.

Originally Posted by The Rani

The Hippocratic Oath has nothing to do with politics, which was entirely my point.
Thanks for the assist.

I wasn't asking a political question.

Maybe a little background is in order.
Whne I was growing up in the early '70's every now and then I would hear about problem pregnancies where they took the abby to save the mother. Clearly this priority started somewhere.

Originally Posted by The Rani

A lot of times patients with bipolar disorder don't WANT to take their meds, because they like the highs and the lows. WINNING!

Sometimes they buy everyone in the bar a drink.

Sometimes they fly to Scotland on a whim.

Sometimes they make out with women down the street in full view of the public and really, really irritate their wives.

I wonder how many go to Vegas.

Originally Posted by JonLaw

I like the neurosurgeons who let their PAs practice neurosurgery.

There are lots of funny PA stories floating around doctorworld.

Every PA has to be supervised by a qualified physician. There are a lot of funny stories out there about lawyers too.

Originally Posted by Deb C

Every PA has to be supervised by a qualified physician. There are a lot of funny stories out there about lawyers too.

Some law firms are very strange places to work. This has more to do with the fact that they are run by lawyers than anything else.

Originally Posted by The Rani

And that actually scares the shit outta me. I've seen the results of kids medicated by nurse practitioners. It's not pretty.
I am sure that docs go into general practice, or at least they used to, because they enjoyed the direct patient contact. Over the last 20 years or so, you are right, it has not been worth the hassle, which is why we now see the niche being filled by nurses/PAs.

At least now children can be diagnosed with bipolar disorder. That opens up an exciting new world in psychiatry. My brother-in-law psychiatrist (recenlty out of med school) hates the bipolar diagnosis. He practices in a rural area and is convinced that GPs diagnose it because the person is angry and poorly educated, but respond well to Xanax. Apparently many angry people respond well to Xanax. Just like they respond well to beer.

I'm anxiously awaiting the DSM-V.

I hope they include Post-Traumatic Embitterment Disorder.

Originally Posted by Brian Beecher

I say negative to this one, even though CEO's and others at the top collection millions while many are starving are not among my favorite people. But I don't believe that they actually don't do anything.

I didn't say they did nothing. I said the exact opposite, that they do too much and frequently end up doing more harm than if they had done nothing.

Studies on rewards have shown that increasing the size of the reward increases the effort expended by the person being rewarded. For work that is repetitive rewards work very well, this is the concept behind piece work compensation and commissions. However for work that involves analysis and good judgment, excessive rewards tend to reduce performance. The reason is because the higher reward motivates the worker to do something as opposed to not doing anything and thinking about the problem some more. You could say, with more on the line the probability of "choking" goes up.

CEOs, as the highest compensated workers, are under enormous pressure to do achieve results or at least be engaged in a process that plausibly may lead to success. In a large corporation their is very little CEO can do directly to materially affect the work products of the business. He can have the most direct effect by reorganizing the corporate management structure, often through M&A activities. So CEOs tend to do a lot of these activities. M&A's fail to achieve their stated objective about 75% of the time. In hindsight most M&A's should not have been done, the CEO would have better served the company had he done nothing instead and took the time to more deeply think about the business problems and opportunities his company faces.

But the enormous compensation the typical CEO receives demands a very high level of action, not sitting on your butt and thinking. The shareholders are impatient, the board is impatient. And CEO's are by nature confident people of action, who are used to success in their careers, having reached the very pinnacle of performance, so they too are primed for action, rather than judicious management. And their companies suffer for it.

Originally Posted by JonLaw

At least now children can be diagnosed with bipolar disorder. That opens up an exciting new world in psychiatry. My brother-in-law psychiatrist (recenlty out of med school) hates the bipolar diagnosis. He practices in a rural area and is convinced that GPs diagnose it because the person is angry and poorly educated, but respond well to Xanax. Apparently many angry people respond well to Xanax. Just like they respond well to beer.

I'm anxiously awaiting the DSM-V.

I hope they include Post-Traumatic Embitterment Disorder.

I agree with you on the Bipolar thing. I was diagnosed with Cyclothymia (basically mild Bipolar) just because I have mood swings. Really, really moronic.

On the bright side, the DSM-V is eliminating the spurious distinction between "Asperger's Syndrome" and "Autistic Disorder" that has annoyed this person on the spectrum for a while. Of course some people on the Aspie message board I post at are furious that they're cherished self-label is being taken away and are fearful of the label "autistic" because people associate it with low-functioning and non-verbal folks. *rolls eyes*

Originally Posted by Mikebert

But the enormous compensation the typical CEO receives demands a very high level of action, not sitting on your butt and thinking. The shareholders are impatient, the board is impatient. And CEO's are by nature confident people of action, who are used to success in their careers, having reached the very pinnacle of performance, so they too are primed for action, rather than judicious management. And their companies suffer for it.

So the problem is inhernet within the very social organization of corporations.

Didn't the German Army figure out this problem? Make the really intelligent people who are disinclined to action the senior staff of the army?

Originally Posted by The Rani

Because doctors treat patients, not disorders.

That's what they all say all right. However, when I was working at a hospital in western Pennsylvania some years ago, we became interested in the variability of staff physicians in treating commonplace ailments. When we pulled the data, we discovered that our Internists varied from 2 days to 7 days of hospitalization to stabilize and discharge congestive heart failure patients. Furthermore, when we drilled into the data, we discovered that the poorest outcomes were with the docs that had the longest hospital stays.

As you probably know, treating CHF is not rocket science, but some of our guys made it into that.

Originally Posted by TnT

That's what they all say all right. However, when I was working at a hospital in western Pennsylvania some years ago, we became interested in the variability of staff physicians in treating commonplace ailments. When we pulled the data, we discovered that our Internists varied from 2 days to 7 days of hospitalization to stabilize and discharge congestive heart failure patients. Furthermore, when we drilled into the data, we discovered that the poorest outcomes were with the docs that had the longest hospital stays.

As you probably know, treating CHF is not rocket science, but some of our guys made it into that.

I'm curious why the outcomes of longer stays were not as good. Did you also study the variables to what might be the reasons for poorer results? Just a hypothetical question, were any of these longer stays a result of patients who were extremely sick?

I only ask because we had a situation at a local hospital that was said to have had longer stays compared to some other hospitals. This hospital with the longer stays was serving many more chronic illnesses because of the location and population. The hospitals that faired better with shorter stays were located out here in the suburbs with healthier populations. So in this particular case, it was skewed data that gave the inner city hospital lower marks on lengths of stay.

As a side note: many insurance corporations are demanding shorter stays because it cuts into their profits. My 85 year old mother had a major operation where they took out most of her colon. The insurance carrier wanted her out of the hospital in three days. The surgeons and and doctors fought to keep her longer. They allowed one extra day.

Every patient is not a cookie cutter case. We need to treat patients as individuals, taking into consideration a person's age, severity of illness, and ability to recover. Not as some set formula dictated by the insurance industry.

Originally Posted by Deb C

As a side note: many insurance corporations are demanding shorter stays because it cuts into their profits....

We need to treat patients as individuals, taking into consideration a person's age, severity of illness, and ability to recover. Not as some set formula dictated by the insurance industry.

Psychiatric hospital stays are completely controlled by insurance company requirements and have virtually nothing to do with the patient. "Danger to self or danger to others" is the only thing that matters. Take someone in, "stabilize" them, and get them out. Homelessness is the outcome for the non-violent. For many, the criminal justice system is the care of last resort.

Whatever you think is wrong with medical care, its twice as bad in mental health.

James50

Originally Posted by James50

Psychiatric hospital stays are completely controlled by insurance company requirements and have virtually nothing to do with the patient. "Danger to self or danger to others" is the only thing that matters. Take someone in, "stabilize" them, and get them out. Prison is the mental health care of last resort.

Whatever you think is wrong with medical care, its twice as bad in mental health.

James50

You have that right! Even after we thought we had Mental Health Parity, there are still loopholes.

Originally Posted by James50

Take someone in, "stabilize" them, and get them out. Homelessness is the outcome for the non-violent. For many, the criminal justice system is the care of last resort.

Again, you get on SSI and SSDI. Then you have Medicaid/Medicare. There are programs in place for the material needs.

Although, I do find it amusing that everyone comes out of a psychiatric hospital with a GAF of 60.

Originally Posted by The Rani

And if you get a psychiatrist who treats every patient with Major Depression the same, according to a cookbook formula, you are truly fucked.

There's nothing like the psychiatrist med-check system. Just try random drugs until something happens that seems positive.

It's actually pretty profitable if you can fit in 6 patients an hour and bill $55 per visit.

You can turn mental health into a profit generating machine!

Originally Posted by JonLaw

Again, you get on SSI and SSDI. Then you have Medicaid/Medicare. There are programs in place for the material needs.

Although, I do find it amusing that everyone comes out of a psychiatric hospital with a GAF of 60.

Applying and being approved for disability is a very complex issue, as you must know. And if your a mentally ill homeless person, it gets even more complex. Don't you need a bank account to prove eligiblity and an address to send the check to?

Even under the best case conditions, as I understand it, are usually not approved at the first request. Therefore, a lawyer is then needed? If the person doesn't have money, how do you get paid?

I have read recently where the application system is overwhelmed right now and the process of getting approval is becoming longer. Once your approved, isn't there a two year wait for assistance with health care?

Medicaid is a simpler system, but still need a bank account and and a place to send the checks. Is that correct?

We were promised transparency but we get closed doors.

We really need to face the facts that our political system is broken. It appears that short films, public TV and documentaries, brought to us by brave directors, give us more truth than the corporate bought media.

I do hope we on both sides of the aisle awaken to how we are manipulated by political marketing and rhetoric before it's too late.

Obama’s Deal | FRONTLINE | PBS
www.pbs.org

A sobering look at the push to reform health care, revealing the realities of American politics, the power of special interest groups and the role of money in policy making...

Originally Posted by Deb C

We were promised transparency but we get closed doors.

We really need to face the facts that our political system is broken. It appears that short films, public TV and documentaries, brought to us by brave directors, give us more truth than the corporate bought media.

I do hope we on both sides of the aisle awaken to how we are manipulated by political marketing and rhetoric before it's too late.

Obama’s Deal | FRONTLINE | PBS
www.pbs.org

A sobering look at the push to reform health care, revealing the realities of American politics, the power of special interest groups and the role of money in policy making...

This is the direct link: http://www.pbs.org/wgbh/pages/frontline/obamasdeal/

Originally Posted by The Rani

6 patients per hour?! I don't know any psychiatrists who prescribe meds that way, except as part of medication groups for the chronically mentally ill. Those are mostly patients who have been stable on the same meds for many many years, so in those cases it's appropriate.

That's the only way to get insurance compensation above $300 per hour. I got that info from my brother in law. Mabye it's 5 per hour. In any event, it was an insurance billing issue. He's on a state contract, but he was talking about the private practice machine approach and what he would hate about being forced to practice medicne that way.

You have to wait 29 months to get Medicaid. Benefits begin accuring immediately after onset of disability for SSI, 5 months later for regular disability.

And you often get denied first due to the rubber stamp issue The Rani mentioned. Lawyers get paid by the government on approved contingency fee contracts (up to the fee cap of $6,000). It's all regulated.

One homeless mentally retarded schizophrenic got about 5 years of back SSI benefits recently on a case with which I am familiar. It mostly takes time and persistence. If the case takes long enough, the back benefits hit six figures, but that is unusual.

There's no auto-pay system in mental health disability. You have to actually fight them. They've been giving "you will get better in 12 months" denials for schizophrenia lately.

Charlie Hall (a well-known SSA attorney) has a Social Security blog at socsecnews.blogspot.com.

Originally Posted by The Rani

Holy smokes. Isn't there a checkbox for "length of disability" on the application form that the M.D. has to fill out?

If by "M.D." you mean the rubber stamp, then yes, they have to agree that such a condition will not remain severe for 12 months.

If by "M.D." you mean the actual treating physician, then, no, they don't have to fill out anything. They just have their staff send the medical records to the Social Security Administration.

In some cases, the claimant is alleging schizophrenia, when it's really schizoaffective, so there's some of that as well.

Originally Posted by JonLaw

No, I'm pretty sure that in the bizarro U.S. Healthcare System, increasing the supply of specialist doctors would increase the cash flow to the specialist doctors as a whole.

I know it's counter-intuitive.

I decided not to get prostate antigen tests anymore after reading a big study on the subject in the New England Journal of Medicine. I also read several hundred comments, most of them from doctors. The hatred of general practitioners for specialists was beyond belief. Just amazing.

Originally Posted by The Rani

I'm sure the lawyer can provide details, but here's how the system works in socialist Texas:




As an aside, I talked to someone once about a possible job doing disability evals for psych patients. The woman made it very clear, though she was careful about the way she phrased it, that they only wanted docs working for them who would go along with the agency's determination of whether or not they were "disabled." In other words, they wanted a rubber stamp from someone with "M.D." after their name. A lot of docs are willing to do that. I'm not one of them.

You are actually an M.D.? I didn't realize that.

Originally Posted by The Rani

6 patients per hour?! I don't know any psychiatrists who prescribe meds that way, except as part of medication groups for the chronically mentally ill. Those are mostly patients who have been stable on the same meds for many many years, so in those cases it's appropriate.
Unfortunately, I've heard anecdotally that many family practice docs do it that way. Hardly anyone shows up in a shrink's office anymore without having tried at least 3 different meds prior to referral.

In fact the NY Times recently had a big feature about a psychiatrist who did just that. He talked about how he used to know his patients' intimate details and now he couldn't even remember their names. He did at least six patients an hour, maybe more, just writing scrips. The feature said this was a growing trend.

This is written by Wendell Potter, former insurance executive. I very much agree with Potter's thoughts.

Pay Much Attention to the Insurers Behind Paul Ryan's Curtain

Democrats who think Paul Ryan and his Republican colleagues have foolishly wrapped their arms around the third rail of American politics by proposing to hand the Medicare program to private insurers will themselves look foolish if they take for granted that the public will always be on their side.

Rep. Ryan's budget proposal would radically reshape both the Medicare and Medicaid programs. It would turn Medicaid into a block grant, which would give states more discretion over benefits and eligibility. And it would radically redesign Medicare, changing it from what is essentially a government-run, single-payer health plan to one in which people would choose coverage from competing private insurance firms, many of them for-profit.

Poll numbers would seem to give the Democrats the edge in what will undoubtedly be a ferocious debate over the coming months and during the 2012 campaigns. An NBC/Wall Street Journal poll conducted February 27-28 showed that 76 percent of Americans considered cuts to Medicare unacceptable. The public is almost as resistant to cutting Medicaid, at least for now: 67 percent of Americans said they found cutting that program unacceptable as well.

According to a story in Politico this week, Democrats "with close ties to the White House" think Ryan has handed them a gift that will keep on giving. They believe the Ryan blueprint will enable them to portray Republicans as both irresponsible and heartless, hellbent on unraveling the social safety net that has protected millions of Americans for decades. That message will be the centerpiece of the Democrats' advertising and fundraising efforts, unnamed party strategists told Politico.

More: http://www.huffingtonpost.com/wendel..._b_846003.html