not pregnancies in the traditional sense but IVF, as far as I understand. Many of my friends who are wealthy are doing only IVF to screen for negative genotypes
I don't really understand where this notion comes from. I've used Slack; I've used Teams; I find Teams more than adequate for my organization's use-case. I'm sure that's not the case for everyone, but "Teams is complete shit" is such an odd over-generalization from my vantage point.
For me it is the slowness and bugs. I complained on occasion about Slack's responsiveness but Teams on my Mac is on another level of unresponsiveness. Also it doesn't seem to use the macOS APIs for notifications, Teams notifications show up even in Do Not Disturb mode. Tapping the notification is hit-or-miss as to whether or not it will actually load the relevant discussion.
Teams is also really bad at emoji support compared to Slack.
I've been using Teams for only a few months after having used Slack for years but in the time I've used it I've come to despise it.
Boil=and-bite only provides cushion between teeth. Sleep apnea mouth guards are designed to thrust the jaw forward, so as to mechanically assist in keeping the airway open. They're so very different in effect and structure that if you feel you're benefiting from a boil-and-bite, you've almost certainly mis-attributed something somewhere.
Not necessarily. Boil & bite mouthguards can help you keep your mouth closed while you sleep, which might be enough to fix your breathing in some cases.
My understanding from my readings in the field of mythology is that the parent post is precisely correct: Campbell was an enthusiastic amateur who did a whole bunch of cherry-picking to suit his passionate holding-forth on the topics, but without systematic study.
If he was alive today, he (still) wouldn't be a PhD, but he'd have a YT channel, a vigorously active twitter page, and maybe have penned a couple of D&D modules.
Some healthcare is vital (emergency intervention for heart attacks), some healthcare is grey-area quality of life (do I need glasses vs. LASIK?), and some healthcare is pure luxury (cosmetic). These are not all created equal.
Additionally, removing the profit motive has its own consequences. Ever notice how the front-desk staff that serves as your docs' connection to the rest of the healthcare sector generally suck? Try to get a preauth, or a drug renewal, or an etc. There's a reason they suck: if your doc is working with a price ceiling (as most are, due to health insurance if not due to socialized medicine), they have a hard cap on their annual income for the year. The difference between a 2/10 and a 10/10 service staff doesn't make a single extra cent of income for the doc, but they have to pay the difference in salary straight out of their annual take-home. How many docs are going to get an 80K/yr front desk vs. a 40k/yr front desk just out of charity?
>Ever notice how the front-desk staff that serves as your docs' connection to the rest of the healthcare sector generally suck?
Compare this to for-profit clinics like One Medical, where your appointment typically starts exactly on time and front desk staff are courteous, helpful, and responsive to calls and emails. This holds true to every location of theirs I've used across major US metros (NYC, SF, PHX, CHI) [1].
Anecdotally, one time I forgot my eyedrops on a trip to SF. I tried to get a hold of my ophthalmologist's office back in NYC so they could send a prescription to a pharmacy in SF. On hold for 25 minutes, disconnected, tried one more time then gave up. Opened One Medical app, requested a virtual visit, had a Dr on a video call in 3 minutes who confirmed my eye drops and submitted the prescription to the pharmacy I was sitting in.
I'm not sure how much of it is down to profit motive and I'm sure there are tons of other confounding factors, but it's hard to not notice the huge difference in experience.
[1] I work in the healthcare industry and I'm a happy One Medical customer; I initially got it as a perk thru work but upon leaving I coughed up the money to continue using them.
so let's clarify a few things.
All the things you described that suck (e.g. preauth, drug renewal, etc) are made to suck, on purpose, by ... drumroll ... you insurance company which, believe it or not is usually a for profit entity (USA USA USA) and therefore is incentivized to take your money and not pay any out in premium. Paying for your care to them is a loss, and what they do is try to minimize loss ratio. (remember obamacare loss-ratio cap checks from eon ago?). So how does, a for profit company that you paid premiums to ration your healthcare to minimize loss ratio: by creating the most arcane, convoluted, confusing and inefficient process standing between you and your care provider. This is not a bug with front desk, this is a feature of your for-profit insurance.
The flip side of the coin are of course all the STEMI docs, who show up there just to perform a dangerous and provably useless medical procedure day in and day out, because profit:)
It's like digging out an outhouse, it's ** all the way down.
Part of the problem is informational. Payors, which may include those backed by nonprofit (like BCBS) and government (CMS), are tasked with reducing un-necessary and duplicative services. This is a critical duty in bending the high cost of healthcare.
Payors identify specific procedures or treatments which represent things they want more information about before they commit to paying for it. It is difficult work on the healthcare provider side to understand what requires pre-auth and provide the payor's decisional information. There is a HL7 group that is working on the problem, the DaVinci Project:
Interoperability challenges have limited many stakeholders in the healthcare community from achieving better care at lower cost. The dual challenges of data standardization and easy information access are compromising the ability of both payers and providers to create efficient care delivery solutions and effective care management models. The goal of the Da Vinci project is to help payers and providers to positively impact clinical, quality, cost and care management outcomes.
Yes, let's clarify a few things. For starters, I'm a physician, and have formerly worked in health insurance at the management level. I assume your comment was aimed at someone at a different level of familiarity with the topic. I'd be happy to re-evaluate my understanding of your comment if you'd care to clarify with the newfound knowledge that I'll understand a more nuanced argument, if you care to provide one.
Responding to what you have written, however:
1. I provided a direct explanatory mechanism for how physician reimbursement caps lead to low-quality auxiliary services - by pointing out that investing in an activity or service that provides no marginal revenue is a strictly money-losing proposition. You assert, without mechanism or evidence, that this is strictly due to "for profit insurance." You need to clarify how the insurer, and their profit motive, creates this result - as the mechanism I put forward simply requires that the physician is has a fixed fee schedule and is at capacity volume. I won't go so far as to assert you should take my word on it, but you could do worse than listening to a doctor say "this is exactly what's going on in my and my friends' practices."
2. The majority of healthcare dollars in the United States flow through Medicare and Medicaid. Given that these services reimburse quite a bit lower in dollars/service than for-profit insurers, they actually make up a larger volume of total services rendered. I can't argue with a statement as vague as "usually a for-profit entity," but I can state more precisely that it "will be a non-profit entity for more than 50% of services and more than 50% of reimbursed dollars."
3. Minimizing loss ratio has nothing to do with what I said at all. If you can put forward a mechanism that translates my front desk expenses into reduced MLR for the payor, I'm listening with open ears. Look at this thought experiment: let's say my insurer's MLR stays flat, and I can accept a 100$/yr subscription fee from all of my patients to improve front-desk service, with the caveat that I'm taking a profit off the top. Would the insurer care? No? Is there anything the insurer's payment processes would do to affect this? No? Then the issue is my profit motive, not the insurer.
4. The convoluted payment processes are there to aid the insurer in sorting through their giant piles of paperwork (you didn't think that administering a health insurance network was low in bureaucracy, did you?) and, more cynically, to create pitholes for us to step into so patient care is denied reimbursement. You're going to have actually, again, provide a mechanism by which that translates into "Doctor doesn't improve services offered." Because I can tell you that if the bureaucratic hurdle that is insurance billing doesn't step me from billing in the current environment, then it's not going to stop me from billing for higher amounts if I could get them.
From the insurance side: I found the throwaway's reference of MLR very confusing and seems to be misinformed about the ACA market and MLR caps in particular.
Exchange plans are just about the most price sensitive insurance product I can think of; in ACA markets typically the lowest premium plan will capture the overwhelming majority of the signups. Insurance co's are highly incentivized to optimize their MLR to provide the maximum amount of care up to the rebate threshold, while driving costs down as much as possible to ensure you can offer the lowest premium plan on the exchange and be the take-all winner.
Also, so much of prior auth, step therapy, etc are dictated by federal or state regulations and not necessarily what the insurer would like or prefer to do.
There are plenty of pain points in our insurance industry but to carte blanche blame "for profit" companies seems really lazy.
Most of those lab values are more or less worthless outside of context - which is why so much time is spent on training docs on physio, pathophys, and history taking. I know that it's frustrating to hear, but it's why every "helpful" tech solution to date has resulted in increasing doc griping and burnout.
Even simple charts for numerical variables would be helpful though. For example, evaluating growth over time is important in pediatrics. In my country, mothers receive a booklet with all the charts and pediatricians are supposed to fill it with data during consults. When I open one of these, I usually find only two or three data points. Surely EMR software could do the same thing automatically.
In the US, growth charts for peds are already built into every EMR I know of. But even that isn't particularly nuanced: I want different charts at different ages based on, for instance, whether the kid is bottle or breast-fed. The difference will impact an interpretation of being under- or over-weight, and using the wrong ones can create the appearance that the kid is dropping off the growth curve at around two years old (which is to say, without context you can't even interpret just the trend itself). The EMRs aren't even at the "IF feeding==bottle, display.curveA; ELSE display.curveB" level of sophistication.
Which is another way of saying "even where it looks like the numbers matter unto themselves without context, nope, you still can't meaningfully interpret them without context."
What country were you in? In the US, a nurse is highly standard.
If you're not getting a c-section, the usual array is: OB/GYN, plus or minus a resident or assistant, doing the delivery and doing any post-delivery laceration repairs; and a nurse who brought in instruments and is on hand to assist with repositioning the mother, getting more equipment, etc. In most places it's 1-2 nurses. If everything is expected to be, and remains, stable a pediatrician will swing by at some point to check in. This isn't generally a major source of referrals for the pediatrician - (a) many people have already established a relationship with a pediatrician in anticipation of the birth, and (b) in many reasonably sized hospitals the guy who drops by is either a hospitalist or a neonatologist, and they don't have an outpatient practice. Anesthesiologist may drop by to start an epidural, but otherwise isn't present on a continued basis.
If in the OR for a c-section, you'll have the OB and a resident or an assist; one nurse just looking after scrub and tools; a second nurse on hand for additional assistance and to receive the kid for the initial clean-up; an anesthesiologist handling your anesthesia; plus/minus a med student or two either holding instruments for the OB or speaking with the anesthesiologist. If everything is and remains stable, peds will swing by. If the kid is unstable or things go sideways, peds +/- their resident will be on hand for the delivery - a neonatologist if the hospital has one.
I've seen some variation in different places of course, but that's pretty much par for the course.
(When I was in the latter part of med school I had a brief fling thinking I'd do OB/GYN, so I did sub-I's in a few different hospitals around the country. Thank god that idea passed.)
OB is ridiculously stressful, in an antagonistic kind of way.
1. A good subset of patients have wildly unrealistic ideas about pregnancy and delivery, and when their ideas meet reality it's not always reality that wins.
1.B. You will be the target of their ire whenever their desires are not fulfilled, because patients seem to think docs are actually in charge of something at the hospital. We usually are not.
2. It's wildly litigious. Their child was perfect (in their imagination) before being born; then you got involved, and now their child is not perfect. You must have fucked something up in the delivery and ruined the perfection of their child.
3. Way too much family involvement. When you're doing surgery, you're usually dealing with a patient's attempts to understand what's going on. When you're doing OB, you're dealing with the patient, the husband, the mother, mother-in-law, etc. Each person will come up with their own distorted vision of how things should be, and when it doesn't align with reality, the doctor is an idiot who doesn't know what they're doing. (Doctors are not perfect - just people - but it seems like every single person without medical training seems better equipped to identify the proper medical course of action than a physician is.)
4. Lots and lots of on-call time. Lots of unexpected interruptions and lots of drop-everything-and-drive-to-the-hospital.
5. There used to be good money in it. There isn't now, which makes all of the above grate on one's nerves.
The results of the above really add up to demolishing the spirit of OB/GYNs. Points 1-3 really make you feel like you're persistently at war with patients, which is the worst feeling ever. I've never been on anyone's side but the patient's, and having them treat me like an enemy ruins my job, and ruins my ability to do my job.
I ultimately chose to pursue a niche thing that shares a name with an existing medical specialty, but is a distinct niche. I can't really identify it without doxing myself, so forgive me for not.
