Healthcare post COVID-19

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BH+
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Re: Healthcare post COVID-19

Post by BH+ »

I am surprised that mid-levels are not utilized more in medicine. A lot of visits are follow-ups and prescriptions. Beyond original diagnostic workup, establishing a treatment plan and performing procedure, most of what an MD does can be replicated by mid-levels with appropriate software/checklist support.
nydoc
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Re: Healthcare post COVID-19

Post by nydoc »

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jayk238
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Re: Healthcare post COVID-19

Post by jayk238 »

BH+ wrote: Wed May 20, 2020 1:54 pm I am surprised that mid-levels are not utilized more in medicine. A lot of visits are follow-ups and prescriptions. Beyond original diagnostic workup, establishing a treatment plan and performing procedure, most of what an MD does can be replicated by mid-levels with appropriate software/checklist support.
I disagree. The hardest part is determining in each patient what is and isnt hard. Often times by the time you've figured out its easy - you've already seen the patient.

The real issue isnt that they aren't used enough, its that they are over used. When we have midlevels seeing patients for anything but the simplest cases that the vast majority of laypeople will recognize as easy- it makes it more likely important conditions are missed. But how would we know? If the issue is that 70% of a symptom leads to an easy diagnosis but 30% of the time it represents soemthign more serious how does anyone make that distinction other than a physician? Thats really the problem. Most people odnt fall in the 30% obviously- so they feel that its easy care. But its not. Or worse yet, its the PCP who goes around referring everyoen out. I cant tell you the # of patients I have who saw other providers who referred them out for IDDM II, CKD 3a, MGUS, NASH R0 and were being poorly managed because none of hte specialists talk to one another or never get the full picture.

Underutilization is not teh problem. Its overutilization because doctors long ago devalued the cognitive effort needed for good comprehensive care. - it makes a lot more money for everyone- the local multispecialty group, the specialist, the hospital system to get as many touches on teh patient as possible. Having a few doctors manage the pt brings less revenue than having a lot more doctors and visits. Thats teh sad truth.
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VictoriaF
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Re: Healthcare post COVID-19

Post by VictoriaF »

I look at healthcare post-COVID-19 from the perspective of health (rather than disease):
- In the past three or four years, I have been reading books and blogs, listening to podcasts, and searching for specific health-related information. I am trying to exercise personalized healthcare, meaning that I do research, identify potential issues and their prevention, and then find healthcare providers who would assist me with either getting preventative treatments I want or convincingly talking me out of them.
- I am healthy. I am gladly paying for the maximum insurance I can get and for certain additional expenses not covered by my insurance. I want to stay healthy, because I have internalized the idea that health has the greatest value. Beyond money. Even beyond time.

Relevance to COVID-19:
- If telephone- or web-based medicine persists and is covered by insurance, it will be easier for me to consult with non-local healthcare providers.
- Several companies send out test-at-home kits that eliminate visits to labs. As far as I know, these tests are not covered by insurance. COVID-19 may legitimize at-home self-testing.
- A couple of Bogleheads I know personally are using a thorough personalized approach to their health. The vast majority of people don't. My hope is that COVID-19 will wake up more people to the importance of their health. COVID-19 shows not just respiratory symptoms but also the implications of diabetes, cardio-vascular problems, excess weight, lower immunity, and other factors. It provides a vivid reason for the importance of health.

Victoria
WINNER of the 2015 Boglehead Contest. | Every joke has a bit of a joke. ... The rest is the truth. (Marat F)
Glockenspiel
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Re: Healthcare post COVID-19

Post by Glockenspiel »

When over 20 million people in the United States lose their health insurance during a pandemic, you know something is wrong with tying health insurance to jobs. Telemedicine will become more mainstream. I think many industries have been forced to advance 10 years into the future by the pandemic.
ddurrett896
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Re: Healthcare post COVID-19

Post by ddurrett896 »

Glockenspiel wrote: Thu May 21, 2020 12:28 pm When over 20 million people in the United States lose their health insurance during a pandemic, you know something is wrong with tying health insurance to jobs. Telemedicine will become more mainstream. I think many industries have been forced to advance 10 years into the future by the pandemic.
You should be able to sign up for health insurance at healthcare.gov, even mid year as loosing a job is a qualifying life event.
EnjoyIt
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Re: Healthcare post COVID-19

Post by EnjoyIt »

VictoriaF wrote: Thu May 21, 2020 12:15 pm I look at healthcare post-COVID-19 from the perspective of health (rather than disease):
- In the past three or four years, I have been reading books and blogs, listening to podcasts, and searching for specific health-related information. I am trying to exercise personalized healthcare, meaning that I do research, identify potential issues and their prevention, and then find healthcare providers who would assist me with either getting preventative treatments I want or convincingly talking me out of them.
- I am healthy. I am gladly paying for the maximum insurance I can get and for certain additional expenses not covered by my insurance. I want to stay healthy, because I have internalized the idea that health has the greatest value. Beyond money. Even beyond time.

Relevance to COVID-19:
- If telephone- or web-based medicine persists and is covered by insurance, it will be easier for me to consult with non-local healthcare providers.
- Several companies send out test-at-home kits that eliminate visits to labs. As far as I know, these tests are not covered by insurance. COVID-19 may legitimize at-home self-testing.
- A couple of Bogleheads I know personally are using a thorough personalized approach to their health. The vast majority of people don't. My hope is that COVID-19 will wake up more people to the importance of their health. COVID-19 shows not just respiratory symptoms but also the implications of diabetes, cardio-vascular problems, excess weight, lower immunity, and other factors. It provides a vivid reason for the importance of health.

Victoria
First and most important. Kudos for making the choice in taking control of your health. Patients who take an active interest in their own health tend to have higher compliance with physician recommendations and generally would have better results. I love it when patients ask questions and want to understand more of what's going on. Unfortunately most people that I see just don't care. They want the pill that will make it all better. They want the easy route. They want surgery to make their stomach smaller so that they are forced to eat less. I doubt that COVID has changed how most people think.

On the other extreme, I dislike those patients who think they know what is wrong with them because they consulted Dr. Google think they have some rare disease and demand unnecessary testing. when clinically there is no way they have what concerns them, there is no rational discussion that they will accept.

I am not trying to be political and stating a fact. Government via CMS decides the winners and losers for healthcare professions. What CMS does, insurance companies follow. Today fast and quick procedures that you can do multiple times pay the most while good intellectual medical care pays the least. Fixing a cut on someone's forearm with glue pays more than managing one's blood pressure. As someone above described doing punch biopsies and burning off warts pays more than taking care of the patient as a whole and preventing disease. The medical world is incentivized to do the wrong things and then we wonder what is going wrong and why does it cost so much? COVID has changed nothing other than elluminate a smidgeon of the flaws.
A time to EVALUATE your jitters: | https://www.bogleheads.org/forum/viewtopic.php?f=10&t=79939&start=400#p5275418
clip651
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Re: Healthcare post COVID-19

Post by clip651 »

ddurrett896 wrote: Thu May 21, 2020 1:37 pm
Glockenspiel wrote: Thu May 21, 2020 12:28 pm When over 20 million people in the United States lose their health insurance during a pandemic, you know something is wrong with tying health insurance to jobs. Telemedicine will become more mainstream. I think many industries have been forced to advance 10 years into the future by the pandemic.
You should be able to sign up for health insurance at healthcare.gov, even mid year as loosing a job is a qualifying life event.
Only if they have at least the right amount of (projected) income for the year. And only if they can afford the premiums now that they have no job ...
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JAZZISCOOL
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Re: Healthcare post COVID-19

Post by JAZZISCOOL »

VictoriaF wrote: Thu May 21, 2020 12:15 pm I look at healthcare post-COVID-19 from the perspective of health (rather than disease):
- In the past three or four years, I have been reading books and blogs, listening to podcasts, and searching for specific health-related information. I am trying to exercise personalized healthcare, meaning that I do research, identify potential issues and their prevention, and then find healthcare providers who would assist me with either getting preventative treatments I want or convincingly talking me out of them.
- I am healthy. I am gladly paying for the maximum insurance I can get and for certain additional expenses not covered by my insurance. I want to stay healthy, because I have internalized the idea that health has the greatest value. Beyond money. Even beyond time.

Relevance to COVID-19:
- If telephone- or web-based medicine persists and is covered by insurance, it will be easier for me to consult with non-local healthcare providers.
- Several companies send out test-at-home kits that eliminate visits to labs. As far as I know, these tests are not covered by insurance. COVID-19 may legitimize at-home self-testing.
- A couple of Bogleheads I know personally are using a thorough personalized approach to their health. The vast majority of people don't. My hope is that COVID-19 will wake up more people to the importance of their health. COVID-19 shows not just respiratory symptoms but also the implications of diabetes, cardio-vascular problems, excess weight, lower immunity, and other factors. It provides a vivid reason for the importance of health.

Victoria
+1
I like this post. It should empower us to do the things we can for our own health, educate ourselves and hopefully improve our quality of life (during and post-COVID-19). :happy
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JAZZISCOOL
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Re: Healthcare post COVID-19

Post by JAZZISCOOL »

potatopancake wrote: Sun May 17, 2020 5:26 am Total agreement with the above post. The existence of dermatology certified NPs is proof that the system is changing unfavorably for physicians. Dermatology is the most competitive non-surgical field for medical students. It is a four year residency program and the majority (~66%) took an additional year in medical school to complete research to become better candidates. Together, this is a nine year training program which is far from guaranteed, with match rates in the 60 - 70 % range. Now, I see a PA dermatologist who completed school in two years and was trained, on the job, for three months by a supervising physician. The healthcare system has changed and medical education has not.
My dermatologist's practice has about 5 MD's, no PA's or NP's that I am aware of. I prefer to see MD's for derm. A friend of mine had a rare Merkel Cell diagnosis a little over 5 years ago (different practice) and the additional training makes me feel more confident in overall care. YMMV.
Blue456
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Re: Healthcare post COVID-19

Post by Blue456 »

eagleeyes wrote: Wed May 20, 2020 1:47 pm I think NP/PA can thrive in a limited scope of practice. They certainly have a role in medicine. But they come with limitations.

I personally would not allow a mid level to examine me or my family members. Just wouldn’t happen.

In dermatology, Most NPs/PAs would likely have higher biopsy rates, higher follow up rates, and inescapably higher cancer miss rates, stacked up against the MD. If people are willing to accept this, and go with a mid level, that is completely fine.

Experience matters. While many are probably quite good, the underlying fund of knowledge that one acquires as a physician as well as the ability to think through a differential diagnosis is not applicable to most mid levels.

(Above statement will come across as disrespectful, so my apologies in advance)

There are lots of boards that do lots of certifications. The rigorousness of those boards has been called into question with NP school mills.

Physician extenders can be helpful in decreasing wait times, but what’s the point if you have to go back and see a doctor the second time, because you weren’t diagnosed correctly the first time? Or worse, your melanoma was misdiagnosed as a benign mole?
Yeah but it is cheaper for insurance company to pay NPs and that's the problem. From business perceptive it is better to pay nurse practitioner $50 per patient than physician $150 per patient. And once there is enough nurse practitioners around you can only guess what new doctor coming into town will be offered.
Pawpatrol
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Re: Healthcare post COVID-19

Post by Pawpatrol »

The rise of video/phone appts will continue and this is a step forward (optimist) or a step backward (realist). As someone who worked in a system that used telemedicine when others wouldn’t due to fee for service billing constraints, I welcome the change. Covid should accelerate the change from fee for service models to capitation models of insurance.

The problem is that with the loss of small practices and solo practitioners, the adminIstrators (non-physicians) control everything and will push video/phone appts to such a degree because it will be cheaper. Since patients will appreciate the increased convenience it will go unnoticed and care will suffer.

Similar to bogleheads investing philosophy, sometimes our best work as doctors is when when we reassure patients but do nothing, despite at times being experienced poorly for it. As i tell the med students, “those challenging encounters are why we are we paid well”. Unfortunately, in our current fee for service model, there are multiple levels of disincentives to do nothing: concern over patient satisfaction surveys, reduced billing, rarely will be thanked for your work. This is a contributor to how we ended up with an opiate epidemic.
redfan11
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Re: Healthcare post COVID-19

Post by redfan11 »

My takeaways from the COVID pandemic:
1) Telemedicine is here to stay. Once the current baby boomer generation phases out over the next few decades or so, health care will primarily be run with televisits because I feel younger people will choose convenience over face to face interactions since that is more natural to them. Text-medicine /tik-Tok medicine ain’t far away
2) technology to perform basic auscultation of the heart and lungs via accesses attached to the phone tablet will flourish and reduce the need for actual physical evals
3) home based labs/infusions will go up
4) home busies May make a comeback
5) Private practices will continue to dwindle
6) NPs and PAs will put downward pressure on physician salaries. This is a controversial topic. When physicians began training NPs and PAs it was to assist them, to perform alternate functions not with the idea of replacing physicians. But replace physicians they are. I am a physician so I do have a dog in the fight and my views are obviously biased. But this will be another effect of the pandemic.

There are several parallels between Boeing and the commodification of medicine. Prior to the Boeing- McDonnell Douglas merger, Boeing was an engineering company innovating and changing aviation and run by engineers. McDonell Douglas bought in their admisntrative approach to aircraft manufacturing and design and their focus was the bottom line. How much EBIDTA? Not how innovative our products are or are they safest flying machines. How do we reuse old ideas and rebadge them to make more money.
In medicine I see similar parallels. Physicians have handed over administrative duties to business admins because they feel being employed is easier and safer, and it is. But, the loser is the patient. Eventually all this cost cutting will impact patient care. There are several 737 Max crashes happening everyday, on a smaller scale in medicine. I maybe making a naive comparison due to my lack of formal education in this field and I apologize if I’m offending anyone, that isn’t my intention.
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firebirdparts
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Re: Healthcare post COVID-19

Post by firebirdparts »

My perspective is that my wife is a health nut and I eat what she tells me to. We're not on any prescriptions. You can think of us as the "opt out" crowd. I don't think Covid has any effect at all, except maybe for an individual considering a personal career in health care. They might decide it's too scary for them to be on the "front lines". I just don't think it's that big of an event. Without Covid, I think all the things in redfan's list would happen anyway.
A fool and your money are soon partners
EnjoyIt
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Re: Healthcare post COVID-19

Post by EnjoyIt »

redfan11 wrote: Sun May 31, 2020 3:42 pm My takeaways from the COVID pandemic:

6) NPs and PAs will put downward pressure on physician salaries. This is a controversial topic. When physicians began training NPs and PAs it was to assist them, to perform alternate functions not with the idea of replacing physicians. But replace physicians they are. I am a physician so I do have a dog in the fight and my views are obviously biased. But this will be another effect of the pandemic.
I just want to talk about point 6 above. Let's look in the OR where we have AA (anesthesia assistants) and CRNA (certified registered nurse anesthetists). At one point in time you have a doctor who did the anesthesia. Now it is a care team in most busy hospitals. The anesthesiologist will manage 4 AAs and/or CRNA and therefor you need 1 doctor and 4 anesthetists for every 4 operating rooms as opposed to 4 doctors. In the past and still in some hospitals when the anesthesiologists owned their own practice this was a huge wage increase to the physicians. Now the docs are paid a little more and the corporation they work for makes the extra profit.

I see similar going on in Emergency Medicine where a doc will supervise 1 or 2 NPs(nurse practitioners) or PAs (physician assistants.) The doc is now responsible for many more patients and takes on the risk and liability of those extra patients but splits the profits with the corporation and the NP/PAs.

I see it even worse in other aspects of medicine. The documentation and regulatory burdens have become so cumbersome that a physician is physically unable to manage the same volume load as before and must hire an PA/NP to assist them just to keep up.

And then I see the worst of it where NPs practice medicine with no physician supervision which scares the crap out of me. Don't get me wrong, there are some very bright and talented NPs as there are some baboon physicians. I will admit that much of medicine is very protocol driven and frankly a robot can handle following those protocols. But a good physician is one that realizes that this particular case is different and requires a different direction to manage. This is why doctors are paid the "big" bucks. I have worked with and currently work with some amazing NPs/PAs but even those bright one miss things and need help every so often.

For the corporations this is a cost benefit analysis. They much much less for a NP/PA and they will miss things from time to time which will cost some money but probably the end results it is cost affective to have the NP/PA. For the actual patient that gets harmed is this a cost they are willing to pay.

What I foresee is a very grim future in medicine I see regulatory and documentation demands keep increasing thereby driving up cost while at the same time corporations will demand increasing efficiency. The end result is that our patients will suffer.
A time to EVALUATE your jitters: | https://www.bogleheads.org/forum/viewtopic.php?f=10&t=79939&start=400#p5275418
arsenalfan
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Re: Healthcare post COVID-19

Post by arsenalfan »

Curious to see the outcome of the ambulatory surgery center model.
I'm 90% all ASC anesthesia, and we went to 50% work (no electives, just urgent ortho injuries like fractures/tears).
But now, our cups runneth over as everyone wants their total joints done at an ASC and not at a covid-ridden hospital.
If there is a second wave of covid, so long as testing is ramped up and available, I suspect the ASCs will be open full time through another wave, and be the preferred place to have outpatient surgery.
rich126
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Re: Healthcare post COVID-19

Post by rich126 »

I agree with some others regarding the positives of video/teledoc type appointments. I've had one using Facetime (other option was Zoom) and another using some other system.

From a patient perspective:

1. No wasted time commuting to/from the office
2. No wasted time sitting in a waiting room (more important with the virus but a huge PITA at anytime)
3. Skipping routine checks being done (i.e., BP, weight, etc.) for non sickness issues.

Obviously there are tons of situations where it cannot be done but in other cases it is a nice time saver. And even in the one case where I still had to stop by for blood work, it was a time saver since I didn't have to wait to see the doctor. Just went in at a slow time to get my blood drawn and was out quickly.

My PCP is an older doctor (60s appears to be in excellent shape) with a private practice (rare nowadays). Interestingly they generally did not wear masks. There wasn't any handshaking (obviously) and I saw him sanitize stuff even things like the pen he was using. And they used gloves (pretty normal).

I've only gone once to an emergency room in my life and fortunately it wasn't anything major but I don't know why (insurance issues aside) anyone would want to go there. Not a place I care to spend time unless I am in significant distress. I think it was a good 8+ hours to basically get one test. At that time urgent care centers weren't too common, now I would go there first in many cases.

I wonder if some in the field may get burned out, frustrated with this experience and may consider other fields.
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