Comment by lloyd-christmas | Hacker News Reader

Comment by lloyd-christmas | Hacker News Reader

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lloyd-christmas

> Isn't the fix to just stop taking more patients than you can handle comfortably and enjoyably?

And then the hospital starts making less money (losing money), research funding dries up, and we start using mercury to treat syphilis again. I'm only half-kidding. I say hospital because all the laws that have changed in healthcare have driven most doctors out of private practice into hospital positions. since 2004, hospital-employed doctors have gone from 11% to over 60%[1]. One major reason being that with the wave of medical reform, the overhead of running a practice has skyrocketed. "Comfortable and enjoyable" are rarely applicable when you only start paying off your $1m schooling debt at 30.

> I'm surprised that they don't feel more in-control of the situation

I'm not sure what else to say other than "They aren't". These are laws, not administrative suggestions. Hospitals expect/need the same output regardless of the laws the government changes.

> this assumption that constant note taking makes someone feel like they're not being treated as human isn't completely convincing either...

I have a life-long condition. I don't care when my doctor is typing because I've had it my whole life, it's nothing more than maintenance, and I'll see them again in 6 months. Imagine being told you have 6 months to live from someone half-sitting behind a computer.

>Also, why not just take micro breaks during billable time to do notes?

My father doesn't eat lunch, using that time to catch up on notes. For as long as I remember, has left for work at 5am and gotten home at 8pm. He spends his Saturdays and Sundays working. And again, hospital employees don't get to choose how many hours they bill.

[1] http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/P...

> And then the hospital starts making less money (losing money), research funding dries up, and we start using mercury to treat syphilis again. I'm only half-kidding. I say hospital because all the laws that have changed in healthcare have driven most doctors out of private practice into hospital positions. since 2004, hospital-employed doctors have gone from 11% to over 60%[1]. One major reason being that with the wave of medical reform, the overhead of running a practice has skyrocketed. "Comfortable and enjoyable" are rarely applicable when you only start paying off your $1m schooling debt at 30.

Sorry, I meant suggest taking less patients, in addition to charging enough to match what you were making before. Not just doctors/hospitals making less money across the board. This will encourage more people to be doctors/open hospitals in the long run to fill the demand (then bringing down the price again, until we're at a nice equilibrium), which will bring down prices, and ensure that doctors take as many patients as is comfortable.

> I'm not sure what else to say other than "They aren't". These are laws, not administrative suggestions. Hospitals expect/need the same output regardless of the laws the government changes.

Is there no doctor's lobby? If the law is wrong/naive, there are measures you can take to make sure it's changed.

> I have a life-long condition. I don't care when my doctor is typing because I've had it my whole life, it's nothing more than maintenance, and I'll see them again in 6 months. Imagine being told you have 6 months to live from someone half-sitting behind a computer.

Yes, that would be a very insensitive way to convey such information, but that's also not the routine case, right? Also, I noted that it seems serviceable for the doctor to cut up the time (in a world where they could set their own billable hours, which could exist).

> My father doesn't eat lunch, using that time to catch up on notes. For as long as I remember, has left for work at 5am and gotten home at 8pm. He spends his Saturdays and Sundays working. And again, hospital employees don't get to choose how many hours they bill.

I didn't call into question how much current doctors work to catch up on notes -- from what the article said, and your personal experience that is a crazy amount of paperwork. If hospital employees don't get to choose the amount they bill, then maybe someone should change the hospitals? Or come up with some other structure for serving patients.

My main point condensed: The amount of paperwork doctors are buried under is insane, that much is clear. Doctors are some powerless group of victims -- surely there are some actions they can take to alleviate the problems, especially if what's best for patients is what the care about.

I did not know about these problems so reading this article was informational for me, but I found it lacking in the "what we're going to do about it" department.

> Sorry, I meant suggest taking less patients, in addition to charging enough to match what you were making before.

How? They can't negotiate with public insurers (Medicare and Medicaid), who together control over 40% of the payer market.

They can't charge self-paying (uninsured) patients any more, because those patients can't really afford it so they don't actually pay.

And they already overcharge private insurers (to account for the below-cost reimbursement rates of public insurers), so there really isn't room to charge them any more.

> Is there no doctor's lobby?

Not really. The last 40 years have been a massive power shift from doctors to hospitals, and from hospitals to insurance companies. The ACA was probably the single biggest sign of that, but it was as much a symptom as it was a cause.

Contrary to popular belief, doctors have less power today than they did 20 or 40 years ago, and they have very little leverage with which to secure any additional power. Almost all the industry power rests in the hands of the insurers. (And the private insurers are themselves beholden to Medicare).

The entire narrative is around expanding coverage and reducing costs, which invariably means paying doctors less, not more, for the same work.

> Almost all the industry power rests in the hands of the insurers. (And the private insurers are themselves beholden to Medicare).

Don't forget Big Pharma who pay for all of their research and sponsor their conferences. Speaking out against them means your research funding disappears. Doctors have a lot of industries surrounding them that are pulling strings. It's arguably the most regulated industry in the world. If you puff your chest out in any direction, it's the Alamo.

The entire narrative is around expanding coverage and reducing costs, which invariably means paying doctors less, not more, for the same work.

Or creating new technology. I wonder just how much spending has been headed off by pneumonia vaccines. Not that a single treatment like that will make a noticeable dent in demand, but at least it usually comes with a good improvement in outcomes.

Thanks for the information/sharing the challenges that are present.

Forgive my naive thought - but what if doctors just stop... negotiating with public insurers? is there some legislation I don't know about that prevents that?

> what if doctors just stop... negotiating with public insurers? is there some legislation I don't know about that prevents that?

Doctors aren't negotiating at all with public insurers. Medicare doesn't negotiate, for any meaningful definition of 'negotiate'. They set the rates they are willing to pay, and you can either accept it or.... accept it. As a provider, it's very, very difficult to refuse to treat Medicare/Medicaid patients in practice, for all sorts of legal reasons.

(Also, it's usually the hospital that's in this position now, not doctors. Private practice is a dying breed; most doctors in the US are now salaried.)

OK got it - so there is some law that prevents/makes it prohibitively expensive for hospitals to not serve medicare/medicaid patients?

Not specifically law, but the number of patients on Medicare. You're essentially eliminating at least 15% of potential patients(and growing as the population ages) That doesn't even factor in the age of patients. Only 15% of that 15% are under the age of 65. That leaves you with 40m+ people on medicare who are over 65. Who tends to go to the doctor more frequently, a 25 year old or a 70 year old? Dependent upon specialty, you could have 90% of your patients on medicare. If I dropped 90% of my clients, I don't think "comfortable" would be an accurate description of my workload.

It's a tough position to be in. Many doctors ARE dropping medicare due to the large amount of paperwork, costs of auditing, deep price discounts, etc. This means that the doctors who DO accept medicare end up getting swamped with patients which increases the patient wait times. So, as a medicare recipient, you either end up paying more out of pocket to see the doctors who dropped medicare or you wait longer to see your doctor. As a doctor, you either lose your patients or gain an unmanageable amount of patients along with drastically more paperwork. Lose-lose.

All that being said, it's clearly a lot easier to criticize than contribute meaningful suggestions. The only thing I could suggest is to put much more effort into preventative medicine. Preventing disease is drastically cheaper than managing symptoms. While it comes up a lot, it doesn't seem to be a focal point.

> Sorry, I meant suggest taking less patients, in addition to charging enough to match what you were making before. You forgot that doctors that accept medicare don't have any say in what they get paid for a service. The government decides. They (or the hospital/practice) also have to negotiate with insurance companies for payment amounts. Have you ever seen in the news where an insurance company stops allowing its customers to go to a certain hospital system because the hospital wanted to negotiate higher payments form the insurer?

*Doctors are NOT some powerless group of victims

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