Hurry up and wait
Curmudgeon here, checking in.
My hamstring pull is slowly improving, but because it was almost healed about ten days ago when I re-injured it, I decided to ask for some physical therapy to see if it could be helped along to heal completely without another setback.
First, although technically self-referral to a physical therapist is possible, I couldn’t find one who didn’t require a referral from a doctor. Fine – except that meant a delay while I waited for a doctor appointment. And it also meant more expense for insurance.
Then I was fortunate enough to get a quick PT appointment, but only because of a cancellation. I saw the physical therapist today. She was friendly and generally knowledgeable, although a bit stumped. My orthopedic history is byzantine, and although I first went to that office in the early 1990s and have gone quite a few times since, they no longer have my old records and so they haven’t a clue about that history except the summary version I tell them.
And then for followup appointments she could see me in six weeks, which is absurd for an injury. That’s the way it is these days, and it’s by no means the longest wait. They said there are always cancellations and so I guess it will all work out.
But just try to get an appointment with a neurologist these days – six months is considered a short wait. And good luck if you have to cancel an appointment with your regular PCP and reschedule in a timely fashion – long waits there, too.
It’s ordinarily much easier to see a nurse practitioner or physician’s assistant. Even then the waits can be long, and sometimes – not always by any means – the care is substandard.
What’s this all about? Is there just a higher ratio of patients to medical people? What’s going on? Why is it so much worse than it used to be? It’s not my imagination, is it?
Doctors following old folks to Florida? Not sure how the rest of Florida is, but it seems that the Gainesville/Ocala Florida area does pretty good with Doctors being available.
Karmi:
That makes sense. Here, it’s different. In fact, it’s very difficult to get a PCP here if you don’t already have one or if you want to change. Most are not taking new patients.
There is no short answer, but a shortage of doctors, relative to demand, is a big factor. Private practices have been gobbled up by hospitals and medical health organizations. These providers put rules on doctors concerning the number of patients they must see every day (a lot) which leads to some burnout, early retirements, and career changes; further reducing the number of practitioners. Many want to blame the insurance companies but this state of affairs is, imo, the predicted result of the creation and deployment of Obamacare.
I’m in the Phoenix VA system. Each region is led differently. Phoenix had a bad reputation for outrageous delays and for lying about them, but I’ve had good care.
The VA has many PAs, and some nurse practitioners, and a large number of clinical pharmacists. These pharma types don’t count pills, but handle things like the stop smoking program, supervising blood thinner meds, and other stuff that needs some clinical knowledge.
If delays cross some threshold–it might be six weeks–one can opt for community care. Now it can take a week or two for that office to pick up the file, but then they send it out to private groups who volunteer to do it for Medicare rates. I wound up with one of the top surgeons in the valley for my hernia, plus one of his colleagues (it was not a typical hernia repair).
I saw a PA for my torn rotator cuff Monday. He said given my arthritis, there was no point in surgically repairing the muscle. Physical therapy will be tried, and if that doesn’t work, replace the joint. No surprise; they’ve been talking about replacement if the cortisone shots stopped working, but they do.
I have figured out how to see my PCP on short notice. Visit the branch clinic for an Xray, and stop by his group’s desk and update them on how I’m doing. The magic words “short of breath” causes them to react immediately, and no amount of “look, just wanted to update you” will prevent a workup.
They are surprisingly modern in care. One can get acupuncture, if your clinic can find someone to do it. We’re doing tai chi in the recreational therapy sessions. And I had ten sessions with a sleep psychologist–not many of those yet–who revamped my sleep habits to great positive effect.
Not the same as a sleep medicine MD, I have one of those also. She’s making me do the full sleep study workup again. I had no idea I move my legs constantly while sleeping, but my ex says, oh yes, you do.
Another reason may be related to Blue states ‘n Red states (??).
When I lived closer to Ocala Florida – I had many Indian (India) Doctors…great Doctors, IMHO.
Am closer to Gainesville Florida now, and lots of female Doctors…have one German female PC Doctor, and Dermatologist is a female__I’ve had numerous Mohs surgeries, from days in South Florida scuba diving, fishing, water skiing, and some illegal stuff__rarely used tanning oils except occasionally baby oil (?!?) that sorta acted like a magnifying glass…probably.
Not sure of the Doctor situation in other areas of FL tho…
@steve walsh:this state of affairs is, imo, the predicted result of the creation and deployment of Obamacare.
It’s more than one thing. Obamacare probably didn’t help; it didn’t create health care providers out of thin air, it just sent more dollars chasing them. Repealing Obamacare would not fix the underlying issues or meaningfully improve them.
The number one issue is the increase in the number of older people relative to younger people. Older people are sicker, and the sickest 5% are where 50% of the health care spending goes.
Once kids are about 3-4 years old they cost almost nothing in health care: owies and booboos and chicken pox for the most part. Women of child-bearing age cost the health care system something because some of them get pregnant, but men up until their fifties cost the health care system very little unless involved in drugs or crime. (This is easy to see if you can look up any state’s Medicaid managed care premium structure.)
Right now in America, for every person of retirement age, there are three of working age and one child. In 1970, for every person of retirement age, there were 6 of working age and four children. Those 6 people retired, some of them died, those four kids replaced them as workers, and have only one or two coming up to replace them in turn when they retire.
The other issues are more connected with the economics of health care: everybody is spending other people’s money on other people, which is a recipe for low quality and high prices. Health care is highly regulated and competition is largely prevented. In many states it is illegal to build a competing hospital: you have to prove that your new hospital will take no business away from the existing one.
The pharmacy benefits managers sit in a vortex of payments between different levels: retail, wholesale, manufacturing..
tl; dr health care in America is a vibrant coral reef of CF-ery that grew up over time, has many entrenched interests in favor of not changing anything, and the government is heavily involved in it, both by setting its rules and paying for a lot of it, but even where the government isn’t involved no one is paying for what they take: they are using other people’s money and spending it on other people. And those people on average are getting older and sicker every year with fewer people working to provide for them.
It can’t go on, and it won’t. Health care sucked up 9% of GDP in 1980, 12% in 1990, 13% in 2000, 17% in 2010, and is about 18% now.
Even if every working person became a health care provider and we spent 100% of GDP on it, we’d still in a few years have more old people than working people, and not enough children to replace the working people as they age into old people.
Judging from the comments in the other thread about cataracts, most of us commenting here won’t live to see the thing collapse, but my kids will be adults when it happens.
Niketas Choniates
Forty years ago, my father died of lung cancer, spending his last 6 weeks in a hospital. The hospital bill was $40,000, of which my mother had to pay only $400. That wouldn’t happen today.
I suspect that physician/dentist availability is correlated to urban/rural. Last year my cousin in rural Oklahoma told me that two months was standard wait for a physician or dental appointment.
I live in a big city. I waited a week for appointments with a dentist and a podiatrist. My podiatrist was less than a mile away, so I walked there. Four days later, I went to another office to get my boot, which was also within walking distance.
Our population has almost doubled since 1960,but I doubt the number of medical students has kept pace. Update: I was wrong. First year medical students: 8,759 in 1965-66; 21,383 in 2015-16.
https://www.aamc.org/media/8661/download
Re: Hamstring injury….
Ok. I’m not a professional medical person. But, as an armature athlete, I’ve had many quad strains over the years in my youth, (and middle age). It is a nagging injury requiring cessation of hard physical leg-centric activity (sprinting). You can use heat, ice, wrapping it up for a few weeks. That’s what you can do unsupervised. Eventually some gentle stretching.
But here’s the bottom line. You can do all of that and start to feel better (maybe 6 weeks later). Eventually you are back to full strength! (maybe 2 months after the injury)…. And then it happens again, out of the blue. You fly out to the leftfielder, and you are doing a casual run down to first base and now you are grabbing your hamstring again. It is frustrating. This is the case, even for professional athletes.
For us mere mortals – ice, heat, compression and be aware of what you are doing. The doorbell rings – oh, I’m going to jump out of the chair and see who’s there and….. back to square one.
I think we are all curious what a PT pro would recommend. I’m not sure there’s a treatment. Hoping for the best for you.
Ciao JB
@Gringo:Forty years ago, my father died of lung cancer, spending his last 6 weeks in a hospital. The hospital bill was $40,000, of which my mother had to pay only $400. That wouldn’t happen today.
For one, the treatments would have been very different. For two, he’d have been less likely to have been a lifelong smoker (or exposed to nasty chemicals at work) had he been born 40 years later. For three, $40K in 1984 is $120K today.
But one of the things you might not realize about health care is that the bill and how much you pay are only distantly related to what anything actually costs.
I don’t know the details of your dad’s insurance, so let’s take me. My employer pays for most of my insurance. The hospital writes down its billed charges, which is a completely imaginary number, and charges my insurance a totally different number, its contracted rate for that thing. My insurance pays for some of it and then I pay for some of it.
But my hospital is getting paid 3 times as much from my insurance as it bills to Medicare (and 4 times what it gets from Medicaid) for the very same thing. So I and my employer and my insurance company are subsidizing people I don’t even know who they are. If another insurance company is getting a better rate we’re all subsidizing them too.
In addition, I and my employer are paying payroll taxes to pay some of the Medicare bills of people I don’t know, and I am also paying Federal income taxes and state taxes to pay the Medicaid bills of people I don’t know. If it’s a public hospital some of my taxes are going to it too in a revenue stream that has nothing to do with my treatment.
What my treatment actually costs the hospital is completely opaque: if there’s equipment involved its spread across many patients, and who and how many professionals are involved is completely up to them, I get a bill every time someone I don’t recognize stick their head in or talks to anyone about me.
Do you see the problem? There are so many third parties, doing something for someone and getting paid by someone else, involved in every transaction. Don’t get me started on prescription drugs….
Neo, for several years now Physical Therapists with Doctoral degrees can practice without a Physician’s referral. In many cases it might be worth the effort to locate one. Most recently credentialed PTs will have a Doctorate (DPT).
My daughter has said that every PT that she now hires for her staff of dozens has a DPT. In fact, she returned and obtained her own in order to maintain status, and incidentally to maintain her qualification as adjunct faculty in the changing environment.
@Oldflyer:Physical Therapists with Doctoral degrees can practice without a Physician’s referral.
If her insurance covers it without the referral…
It’s bad everywhere I hear. For over a year now I have been trying to get a GYN to even accept me as a patient. If I had any idea it would get this bad, I would have kept seeing my old ones even though after menopause I really didn’t have any particular need to.
What’s the opposite of raining on the parade?
Scattering sunshine maybe — just wanted to show the problem is not universal.
We are fortunate to live 5 minutes from a hospital and associated physician’s offices, which is the new suburban campus a Denver hospital built 13 years ago when their old building became physically impossible to work in (after 119 year the continuous add-ons were a rabbit warren and they couldn’t retrofit for up-to-date equipment).
We were able to get PCPs almost immediately, never have any trouble getting appointments within a week or so. I just had to change neurosurgeons after two years when he moved his office practice; I called the middle of January and was in to see the new guy last Monday. No problem getting lab or imaging appointments either.
As for PTs, I have had a couple of incidents over the last 14 years that required therapy; there is a franchise that has a location about 2 blocks from the hospital. The people are great, and as a bonus my doc teaches Pilates classes as well (my next turn is tomorrow; we have to rotate who gets slots because she is so popular).
And our optometrists and dentists are great also, although the latter is my third one in succession: our first guy retired, “sold” his patients to another DDS in the same building, and when he retired a new guy bought the complete practice, including office and staff.
As an example, on one visit a couple of years ago, he noticed one of my crowns was not seated right and was causing a problem: he replaced it at his own expense.
So far, our insurance has never balked at paying for whatever we have had done, but we aren’t high-end treatment sinkholes yet, thank goodness.
I’ve seen our bills for occasional hospitalizations (my gall-bladder removal and AesopSpouse’s stroke), and those for all four of our parents before they passed away, and Niketas Choniates is almost certainly correct about the merry-go-round of who gets charged what.
What NC doesn’t mention, but I’ve read about more than once over the years, is how much hospitals shell out to treat gang members and criminals shot up by other crooks or the police. It’s a LOT. And now we’re funding health care for illegals, including incipient terrorists, and anchor-baby-moms.
I’m not saying we shouldn’t — people are deserving of care, whoever they are — but it is very expensive, and it is a privilege not a right. It’s an act of charity by Americans who voted for the politicians who voted for the laws that entitle all people to medical care.
However, as with many other “generosity” laws, I don’t think the Congress really envisaged what would happen when the number of “entitlees” went through the roof.
That’s one reason we call them bleeding heart liberals, but lot of well-meaning conservatives don’t think things through either, and no one looks for more sustainable solutions than just throwing money at the problem.
The Cloward-Piven crew is happy with the situation, however.
PS to Niketas Choniates: I’m reading a book by Robert Graves called “Count Belisarius” which is about a Byzantine general who played a major part in the history of the Eastern Roman Empire, around AD 500-565.
It has been really interesting. Graves does his homework, and I like his rather dry wit, which makes his otherwise interminable history of court intrigues and battles easy to get through. Most people are more familiar with his writings on Emperor Claudius, which were made into TV specials. Free downloads are available on the internet.
I thought that might be a book you would enjoy, although it’s set half a millennium before the time of your avatar.
My Dad always used to say, “It’s not health insurance it’s sickness insurance” and a lot of your health is lifestyle driven. Most doctors are just practicing symptom management with pharmaceuticals. Whatever you can do to stay healthy, do it.
Thanks, @Gringo for numbers on Med students. We still need more. Most Republican states should be opening up new Med school every two years or so until there are enough doctors. $amount spent on healthcare per doctor should be going down, and wait times should be going down.
#doctors per person over 65 might also be very relevant.
My son the doctor much prefers the state run Slovak system over what he reads about the US system, but wait times here (in SVK) are getting longer, tho my own experience has been ok—thanks to my wife being a doctor and getting preferential treatment, from doctor friends.
My very active 77 year old wife has torn both of her hamstrings a number of times. The best therapy seems to be simply rest and no stressful activity involving its use. Good luck with the healing process.
Just a recommendation from a 72 yr old who still refs kids soccer and has had several related injuries: PT does help, but I’ve found at my age the injury never fully heals. As such, I always wrap the area before activity with a layer of elastic bandage followed by a layer of self adhesive wrap. My left knee is a prime example. Second, make sure to warm up those muscles for at least a half hour starting very gently and slowly increasing. Up in New England on cold days it may take longer. Here in FL on the warm days I can cut down the time.
And just try obtaining an answer directly from your physician what a specific procedure will cost you.
The doctor will not know.
But do not fret; you will receive in the mail a week or so later, a statement from your insurance company (easily decipherable with your Enigma de-Coding machine) that “explains” why they will not pay a good percentage of the doctor’s fee.
Ever wonder why we all get junk mail from your local supermarket advertising all sorts of items on sale, but you never get one from any local hospital or doctor?
Ever wonder why there are a bunch of admin folks in the lobby of a doctors office that are not nurses or doctors?
Ever wonder how many medical insurance codes there are?
The fact is that our government has allowed (encouraged?) the medical profession and insurance companies to fix prices.
The problem is… It is not a single problem. But every time some clown in Washington wants to “fix” things, they think in terms of “A problem,” — one single “problem” — and never that cascade of issues following that. Most of the problems are PLURAL — and interrelated. And not simple fixes. With some legislation written by an aid with no knowledge of business of medicine, insurance, etc.
Some of the problems include:
1) Medical school is crazy expensive. It is really hard to pay off those debts unless you go into a really lucrative speciality. (and why is medical school crazy expensive? Another cascade of issues….)
2) Working in rural areas is not “fun” — we have demonized rural America as some place no one with any sense wants to live, combine that with the killing off of industry and “mom and pop” businesses in “flyover country” and the concomitant explosion of drug use: Rural America seems to be dying on the vine… Doctors graduating from medical school get “stuck” working in rural areas, and leave as soon as they are able. (Where I grew up, once a very cute town, now has nothing. Industry was off shored. Walmart and Family Dollar General kills off retail.)
3) Malpractice Insurance is crazy expensive. (Why? Litigation is insane. More below.)
4) All insurance is crazy expensive — whether it is health insurance, general liability insurance, etc. (Which also helps to contribute to the killing off of rural America.)
5) Underwriting the costs of other countries’ pharmaceuticals. A lot of other countries set maximum prices for a lot of drugs, but the cost ( R&D, manufacturing, insurance) of producing that drug costs more than that. Does the country setting the price pay the difference? Nope. Other people who buy those drugs, mostly Americans, do.
6) Private Equity take over of some hospitals and health care systems. Private equity is not our friend. Private equity is not about doing good works. Private equity is about making money. And that may mean cutting costs whatever that takes. Read about some of the disasters that ensued following the takeover of hospitals by private equity.
7) Related to that: Hospitals used to be genuine charitable organizations. Most started as a charity run by religious groups, or as charitable county hospitals, or as teaching hospitals. Fund raising was done to cover the costs — including the patients’ fees. Patients were not really seen as a source of income.
8) Obamacare has increased costs. The requirements take up doctors’ time in a way that was not prior to the institution of it. More stuff is “required” to be covered that shouldn’t be.
9) EMTALA has driven costs up. Okay, it is a good idea that emergency rooms not turn away someone who can’t pay. But they also can’t tell people to go to “Doc-In-The-Boxes” instead of the the ED. Something that could be handled for a fraction of the cost gets seen in the ED, and the cost has to be covered by something.
10) Medicaid is a mess. For people who can’t afford the “bronze” plans (which are not exactly all that affordable), going on Medicaid isn’t much of an option.
11) Obamacare screwed up the insurance industry terribly.
12) Litigation has screwed up the medical and insurance industries making both insanely expensive. (which has driven up the cost of a tone of stuff.)
13) Technology is expansive to adopt, even though in the long run, it saaves money (and often lives.)
I was at the dentist yesterday. I got my annual bitewing, and as I watched the technician, I thought how much the digital age has simplified xrays. I remember about 20 years ago, I worked in facilities at a research lab. My boss did a cost analysis to see what the ROI would be if we bought the digital equipment, and get rid of our dark rooms for developing xrays and other things. When it was merely a comparison of the new equipment vs chemicals and disposal of the chemicals, the ROI was pretty long, but once he factored in the labor costs of developing and the cost of rededicating the use of the dark room to other uses, the ROI was MUCH quicker.
When I was a kid, our local doctor did actually accept chicken and beef from people. And didn’t charge people for some things. And his wife acted as a his free bookkeeper for a number of years. He did do house calls. He was MUCH loved. Those days are gone. His son went into medicine. He became a radiologist and stayed in a major metropolitan area. He only came home to visit family.
Physicians were once small business owners who were invested both in their practices and in their patients. Now they are employees of hospitals or large corporations. They often are hired to work a specific shift or to see X numbers of patients per day, and leave when that is accomplished. They now look forward to retirement just like other people.
At one time, medical students and residents were trained with the concept that the workday was over when all the patients’ problems were under control. Now, they are literally punished if they work too many hours in a week. These attitudes carry over into their professional lives.
Physicians could see double the number of patients per day if they had to document and justify only what is medically relevant in the most efficient way. They instead are forced to interact with computer systems, check boxes, evaluate irrelevancies, and document it all. When they are searching for past medical history, they have to dig through all of the irrelevant data recorded by others to eventually find what they are looking for. Many times, it’s quicker and easier (although never less expensive) to repeat the study rather than find previous results.
The medical profession is becoming feminized- 37% of practicing physicians are female, and >50% of entering medical students are women today. Female physicians see substantially fewer patients in a career than do their male counterparts- they see fewer patients per day, are more likely to work shorter days, take more time off, and retire earlier.
The number of medical students and medical schools is increasing rapidly, but the bottleneck is in residency training. Most residencies are funded by medicare, and the number of residency slots has not kept pace with the number of graduating medical student applicants. Foreign medical grads are being edged out of American residencies. It was once a requirement everywhere for a foreign medical grad to have several years training in an American residency to get a license, but now some states are allowing selected foreign residency grads to practice here.
Medicare is broke. In addition to not wanting to spend additional money to fund residency positions, it knows that every additional residency graduate will become a practicing physician, who will see patients and generate bills for medicare to pay for. Medicare is incentivized to ration medical care by limiting providers.
Getting doctor appointments in Indiana is no problem. Even appointments with neurologists.
Due to the cascading series of medial problems I experienced in the past year or so I see a lot of doctors, and I see them often. And I’m doing a lot of PT too. Still, no problem.
Is this because Indiana is a solidly red state that is well-governed? Don’t know the answer to that one. But I’m quite satisfied with the situation.
Also I’m in the Franciscan Healthcare system. All my doctors are in that that system. I’m also quite happy with Franciscans. The Catholics know how to do healthcare.
And, I like seeing the crucifixes and portraits of St. Francis on the walls of all the Franciscan medical centers, hospitals, and offices.
Blood Whisperers – name I call Indian (India) Doctors by in private. Do western countries focus a lot on blood work in Medical Schools?
Was living with a teacher one time and I forget how it was discovered I had Hepatitis C – she immediately made an appointment for me to see some American doctor. The doctor wanted to do minor surgery to take a liver biopsy—a sliver of the liver would be taken. Never happen for whatever reason I don’t remember.
Some years later, I think blood in the stool, and another test showing Hepatitis C. Ended up with the two Indian doctors from the hospital. One was going to become my primary, and the other was going to do a colonoscopy—a probe thingie.
The one doing the colonoscopy also had a hobby (?) of treating Hepatitis C, and was apparently well known for his treatments of it. Later at his office, he asked if anyone ever tried to treat it, and I mentioned the American doctor who had wanted to take a biopsy of my liver. He shook his head—knowingly, but also in a way that it was typical of American doctors.
Involved with three different Indian doctors during this time – all were Blood Whisperers … readers of the blood or whatever—blood could apparently speak to them. After a year of very expensive medication, lots of blood work, I was cured or it was in remission…whatever that is called, I have never had another Hepatitis C blood test result.
Years later, my female German primary doctor wanted to see what he had asked for on blood work…it was on some paper work I had of his. She used it to get blood work, and that also came back not showing Hepatitis C. Believe she said it was still there but gone…I don’t remember.
Americans doctors perform minor surgery to get an organ biopsy – Indian doctors read the blood…? Seemed so…