Health Care

The Doctor Shortage revisited.

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33 - Lister

I have previously written posts about a coming doctor shortage.

They assume that primary care will be delivered by nurse practitioners and physician assistants. They are probably correct as we see with the new Wal Mart primary care clinics.

The company has opened five primary care locations in South Carolina and Texas, and plans to open a sixth clinic in Palestine, Tex., on Friday and another six by the end of the year. The clinics, it says, can offer a broader range of services, like chronic disease management, than the 100 or so acute care clinics leased by hospital operators at Walmarts across the country. Unlike CVS or Walgreens, which also offer some similar services, or Costco, which offers eye care, Walmart is marketing itself as a primary medical provider.

This is all well and good. What happens when a patient comes in with a serious condition ?

The health policy “experts” have been concerned to train “lesser licensed practitioners” and have pretty much ignored primary care MDs except to burden them with clumsy electronic medical record systems that take up time and make life miserable.

I repeatedly ask medical students if they would choose a career in primary care if it would completely erase their student loan debt. A few hands go up, but not many. In fact, for a while now, the federal government has dedicated millions of dollars to repaying loans for students who choose primary care. Yet residency match numbers show that the percentage of students choosing primary care is not increasing. Though loan forgiveness is a step in the right direction, medical students realize that by choosing a more lucrative specialty, they can pay off their loans just fine.

I proposed years ago, a health reform that resembled that of France where medical school is free. It could be arranged that service in primary care, low income clinics would give credit against student loans. Nothing happened. Except physician income has declined. And tuition has increased.

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A Tale of H1B Workers in Dallas‏

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This H1B American worker replacement program for multi-national megacorporations is getting real. It isn’t limited to the IT industry workers and Disney actors training their own H1B visa replacements any more. It is now hitting the American health care industry in the skilled medical technician level, many of whom are college educated American citizen minorities, at least here in Dallas.

I just saw the local CVS pharmacy I use replace several college educated, Black Female, Hispanic female and Hispanic male Pharmacists, with Indian H1B workers last week.

The reason this sticks out in my wife went to pick up a changed 30-to-90 day prescription of mine for which the CVS Pharmacy has insufficient meds. A typical case of Indian “IT help desk hell” occurred with two people with incomplete knowledge of the issues of my meds, with the H1B worker trying to get 90 days of prescription price from my wife for 30 days of meds. No transaction happened.

I can only wonder what a seventy something retired senior trying to get his or her meds are dealing with this corporate H1B visa imposed communication problem?

And I also wonder about all those minority med-techs I see replaced here in Dallas are dealing with this?

The same way white male 40-to-50 something White male electrical engineers have in Silicon Valley for the last 15 years? The corporate versus middle class politics of this are poisonous in this Presidential season.

Consider the implications for the Black vote for Trump in Nov 2016. Trump’s Florida polls show him with _40_%_ of the below $25,000 a year black males over his plan to close the Mexican border with a wall. If Trump gets the same 1-in-5 vote that Richard Nixon got in 1972 with Obama’s 2008 and 2012 turn out percentages, he will take at least 45 states in the electoral college.

This is the electoral power of a real “closed borders” Presidential candidate.

And the corporate K-Street political contributor class behind both political parties still doesn’t see it coming.

New Era Drugs and Death

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One of the most fascinating shows that I watch is called “Drugs, Inc.” on National Geographic, which describes the “business” of drugs from its creation (chemicals) or growth (agriculture), through transportation (to America or Europe) and then to distribution (street level), along with interviews with drug abusers and their families.  I did a blog post about this show here if you are interested.

Unlike television shows with a “narrative arc” of redemption, the business of Drugs, Inc. shows users as ever-insatiable and ever-addicted to the various drugs that are investigated by the show.  Drug dealers are meeting demand that exists and is never questioned; the only risks to the dealer are competition from other cartels / distributors or the police.  The fact that demand will always be there assuming the quality of the product is solid is taken as a given.

When they interview addicts their lives are not glamorous and often are morose and filled with regrets.  The addicts may take an hour to find a place on their body to inject the drug, they steal from their own families, and they live brutal and dangerous lives in order to acquire the cash to make the next fix.  The traditional high school movies that tried to scare you off drugs have nothing on this systematic and pragmatic approach to just watching the destroyed lives of drug users as they live to support their next fix.

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More evidence that Obamacare is just expanded Medicaid.

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I have been saying that Obama care is just Medicaid for all. As time goes by, here is more and more evidence that this is the case.

The latest evidence is in The Wall Street Journal and behind a pay wall but I will quote some of it.

But a new paper from the Heritage Foundation, however, suggests that nearly all of the increase came from adding nearly nine million people to the Medicaid rolls.

In other words, ObamaCare expanded coverage in 2014 to the extent that it gave people free or nearly free insurance. That goal could have been accomplished without the Affordable Care Act. To justify its existence, ObamaCare must make affordable private insurance available to a broad cross-section of uninsured Americans who are ineligible for Medicaid.

But with fewer people buying insurance through the exchanges, the economics aren’t holding up. Ten of the 23 innovative health-insurance plans known as co-ops—established with $2.4 billion in ObamaCare loans—will be out of business by the end of 2015 because of weak balance sheets.

And while rates vary widely by state, the cost for private insurance through the exchanges is also increasing dramatically. An analysis by consulting firm Avalere Health released on Friday shows that some of the most popular insurance plans in the ObamaCare exchanges will experience double-digit premium hikes in 2016.

My earlier objections to Obamacare were that it promises too much and pays too little.

As it turns out, Medicaid patients can’t get appointments with physicians.

“America has severe primary care physician shortages, and many physicians will not accept Medicaid patients because Medicaid pays so inadequately,” said Michael Gerardi, MD, FAAP, FACEP, president of the ACEP.

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Medicine: The Public-Health Model is Wrong

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This Theodore Dalrymple post is a variation on a conventional argument whose unstated main premise is that medical cost decisions should be evaluated from a public-health perspective.

The annual medical is a kind of ceremonial or ritual which, according to its critics, is without rational foundation despite the fact that so many patients, and perhaps a majority of doctors, believe in it. This proves that superstition is not dead: but perhaps that is no fatal criticism of the annual medical after all, because superstition will never be dead. If it does not attach to one thing, it will attach to another.
 
[. . .]
 
In fact, most medicals are bureaucratic procedures rather than exercises in getting-to-know-you (as The King and I put it). The doctor asks a few questions, ticks some boxes on a computer screen, performs a perfunctory physical examination equivalent to examining a cubic inch of haystack to find a pin, and does a few selected blood tests, the interpretation of whose abnormal results (if any) will be far from straightforward. In fact, what has been done and measured in annual medicals over the years has changed, without any change in their ineffectiveness.

Ineffective for whom?

The answer depends on who is paying the bill. If it’s third parties such as govts or insurance companies then the conventional argument has merit: maximizing system utility is an important goal. However, if patients control their own medical spending then the main goals should be whatever the individual customers want them to be.

Dalrymple’s analyses are usually much better than this one. Perhaps his frame blindness in this case is a function of his background with the NHS.