Who’s your hospitalist?

Me: Hi, I’m Dr. Pal and I’ll be taking care of you here in the hospital.
Patient: Where the hell is my real doctor?
Me: He’s at the office seeing patients. He doesn’t come to the hospital anymore.
Patient: Why the hell not?
Me: Well, it’s complicated, but it’s getting harder and harder for doctors to pay their overhead. They have to see more and more patients, and in the time it takes to come to the hospital and see one patient, he can see 5 or 6 in the office.
Patient: What’s wrong with him just getting up earlier?

OK, time for a brief lesson on modern medical practice. First of all, I’m an internist. In the old model, an internist sees patients both in the office and in the hospital. Over the last decade or so, there has been a shift in practice. Fewer and fewer outpatient primary care doctors see their own patients in the hospital. Most now use “hospitalists”, internists who specialize in taking care of hospitalized patients.

There are several reasons for this.

First, hospitalized patients are much sicker than they used to be. To meet the “severity of illness”, and “intensity of service” requirements, you have to be pretty darn sick. This means that hospital care is more complex and specialized. Still, it’s not impossible to keep up with both outpatient and inpatient medicine.

Second, there are the financial pressures. Margins are very thin in small practices. Medicare pays me perhaps seventy bucks to see a patient. In the time it would take me to go to the hospital, I could have seen a whole lot of patients, and seeing a hospital patient doesn’t pay all that much more. Not only that, but to pay the bills, you have to see lots and lots and lots of patients, which leaves even less time for other things, such as family, eating, urinating.

I’m in a unique situation, in that I need to be at the hospital every day to teach, so seeing my own patients is no big deal. But for most internists, it’s becoming impossible. Taking care of hospital patients is not just the 10 or 15 minutes at the bedside; it’s the paperwork, phone calls, and pages; the discharge planning, the specialists. Each hospital patient is more work than any 5 office patients, for the same pay.

Where does that leave patients?

For the most part, patients get excellent care from hospitalists. Those of us who see patients in the hospital learn to develop a rapport quickly, and we communicate closely with the outpatient physician (hopefully). Still, patients can feel a bit abandoned by their doctor. Many outpatient doctors still call up or pay a brief visit to their sick patients. These visits aren’t billed, and because the doc isn’t actually managing the patient, they don’t need to come daily. These “social rounds” are important, and give the doc the flexibility to give inpatients some TLC, but without the responsibility of all that hospital care entails.

In many of my posts about the nature of medicine, there has been a bit of back and forth about whether medicine is somehow different from other professions. When a patient looks up at you from their hospital bed and says, “why can’t he just get up earlier?”…well, for me, that answers the question.


  1. Many people do not understand the economic realities of medical care (and I include other health professions under that rubric). Overhead rates in a general dental practice, for example, generally run upwards of 70%. That means that at least 70 cents of every dollar collected goes to pay staff salaries, rent, insurance, utilities, supplies, lab bills, etc. That does not include paying off debt incurred for educational loans (the average dentist coming out of school nowadays owes upwards of $200,000.00).

    I’d guess that the situation for physicians, optometrists, podiatrists, etc. is similar.

  2. When my mother was dying in a small rural hospital, there were no hospitalists, and her cardiologist took on the job. He did an excellent job of making sure Mom got the best care they could provide, and keeping Dad and I in the loop and making sure we were fully informed whenever we needed to make a decision. However, he never did contact her primary care physician, who didn’t find out about her death for a month after it happened.

    A few years later, my father was dying in a larger urban hospital, and was assigned a superb hospitalist. He did all the things Mom’s cardiologist had done, plus kept dad’s other doctors informed of what was going on. When Dad actually died, he was seeing other patients, and he’d apparently just missed me. Within half an hour of me getting home, he called me with his condolences.

    So in my experience of hospitals and serious illness, hospitalists are a good thing.

  3. It is interesting how the patients have to come to expect (or DEMAND) that their doctor get his or her ass into the hospital to see them. After all, as the Democratic party has interpreted the Constitution, American citizens have an inalienable “RIGHT TO HEALTH CARE.” Of course, it’s not really in those exact words in the Constitution, but that’s what they meant by “life, liberty and the pursuit of happiness,” isn’t it? After all, the founding fathers wouldn’t have set up the Medicare system if they didn’t really believe it was a right… right? Oh, wait a sec… that’s not the way it happened, is it? Actually, they never set up ANY kind of health care system. Hmm, maybe that’s the way they intended it, do you think? Sure, you say, in those days health care was cheaper and people could pay for it. But do you think all Americans could pay for it? Do you think doctors just treated everyone free of charge?

    The only people I know of who are happy to save lives, free of charge, are superheroes. After all, “Action Comics” probably would have never really taken off if Superman handed out bills to everyone he saved… somehow, I think he would have lost some of his nobility and grandeur. On the other hand, as most of us are aware, Krypton never really exploded, and Superman never actually made it to earth (at least not yet). In the REAL WORLD, that kind of work is relegated to professionals. Whether they are doctors, dentists, paramedics, fire fighters or police officers, they are people who are PAID for their service. Furthermore, the free market and laws of supply and demand dictate the reimbursement for each particular service… EXCEPT for medicine. Even in dentistry, insurance only pays a small fraction of the actual bill… the rest is paid by the patient. For some reason, our society has come to believe that, despite their years of education, grueling call schedules and mountains of debt, physicians’ fees should be determined by a government agency which is run by people who don’t even practice medicine. Some people feel that this government agency should be EXPANDED, and allowed to dictate these fees for ALL patients, not just the elderly and disabled.

    Like the former Soviet Union which tried (unsuccessfully) to dictate the prices and the supply of commodities like bread, the USA is slowly becoming a socialist country. By granting the government greater power to regulate and centralize the economy, we are destined to become the very tyranny we fought so long and hard to defeat. I believe government regulation, when set up properly, is a good and necessary thing which helps prevent the kind of corruption that caused the recent financial crisis. However, there’s a very big difference between regulation and control, and a nationalized health care system sounds a lot like control to me.

  4. My experience as a patient has been different. My doctor, who is an internist, will either diagnose or send to a specialist. When sent to a specialist, I consider the specialist my doctor. I consider whom ever doctor I am sent to to be my doctor. Of course my insurance company requires that I see my regular doctor and get his permission before seeing any specialist. I cannot go directly to a specialist on my own or the insurance will not pay.

  5. I call Poe on DWMD. Nobody’s that dense, right?

  6. @DWMD: Wow. That was a rather boring rant.

    A few things to consider:
    – The US’s founding fathers also didn’t set up a national vaccination program, the FDA, or any number of other health-related organisations now run by the US govt. Does that mean they shouldn’t exist?
    – The US’s founding fathers also didn’t set up the NSA, the FBI, or the CIA. Clearly they and many other government departments should be abolished.
    – Part of living in the 21st century is realising that things are different to how they were in the 18th century. 27 constitutional amendments would also tend to attest to that.
    – Many other countries have national healthcare schemes of one variety or another, and they don’t seem to have turned into stalinist dictatorships. Further, the data supports them: The US pays more money for a lower quality of healthcare than pretty much every other first-world country.

  7. Shorter DWMD:

    Oh Noes! Teh Socialism! It Burnzez!!!one!

  8. OK, I’m obviously preaching to closed-minded liberal elitists here. The US pays more money for health care, but in countries where it’s socialized, even unlimited money can’t buy you the quality of health care we get in this country. That, genius, is why places like the Mayo Clinic are populated with wealthy foreigners. If medicine were so great in their countries, they wouldn’t fly their private jets here to get care. So NO, I don’t accept your assumption that the US provides inferior care. A liberally funded study may show that, but there is an abundance of evidence to show otherwise. Also, why are half of our medical residents in this country from other countries? Because health care is so great in their homelands? Also, why do Canadians sneak across the border to get into DETROIT (of all places) to get health care? And before you open your big mouth, I am a physician in the Detroit area, so I’m speaking from personal experience. Additionally, I even know a physician from Windsor, Ontario, who opened an office in Detroit to practice because he can’t make a living in Canada. So, it seems better from a patient’s and a doctor’s point of view. Do you see doctors in Detroit running across the border to open offices in Windsor? I don’t think so.

    Hey Nick, my rant may have been boring, but yours is just plain stupid. Are you a physician? Do you have any knowledge about health care other than what you read in your liberal blogs? Go to school, dumbshit, and then we’ll talk, okay?

  9. Oh, and before you start typing, asshole, I do agree that it is a shame there are 48 million uninsured Americans. But why is it the physician’s responsibility to pay the price? I have no problem with an increase in taxes to help COVER those uninsured people, thus putting the burden on the taxpayer. But I do have a problem with the government taking control and becoming the only buyer of health care. They are currently the only buyer in the defense industry. That’s a pretty efficient system, don’t you think???

  10. Wow. I thought we were having a discussion, but it turns out you were just looking for someone to slander and insult.

  11. Actually, it was your elitist and condescending tone that brought out the worst in me. Sorry. Consider that the next time you wonder where the term “Liberal Elite” comes from. In case you’re interested (as if you would be)…

  12. Um, ok. Back on topic. I’ve never really understood the whole “my doctor” concept. As a child, we had one pediatrician we would go to, but when I became an adult and had to deal with the realities of insurance coverage, “my doctor” is whoever takes the insurance I’m currently carrying. I’ve never had a “relationship” with a doctor other than going in, getting examined, getting a prescription and paying. I’ve only had one bad experience with a doctor (damn idiot decided to crack my back when I was in there with the flu, fever and aches. Stupid D.O.), most of the rest of the doctors I’ve been to have been competent. And usually my insurance lets me go to specialists directly.

    At any rate, it surprises me more to think of a doctor visiting me in the hospital. My expectations, based on my (limited) experience, are that if a doctor finds something wrong with you and has to send you to the hospital (or a specialist, for that matter), you get handed off to the next set of doctors. It wouldn’t occur to me to expect to see my regular doctor in the hospital. My assumption would be that the hospital would handle the rest.

    Anyway, I suppose the situation is different if you have a chronic condition and have to repeatedly see a specialist. And it totally makes sense to have a doctor who is familiar with your history. Probably makes seeing any patterns easier.

    Thank you for providing a peek into the real world of the medical practice. Most people have no clue about the realities of medicine as a profession. It’s very enlightening to get a glimpse like this.

  13. @DWMD

    I really don’t see how Nick’s post sounded elitist. Perhaps condescending, in that he used sarcastic phrasing, but unless you interpret “elite” to mean “anything that disagrees with me” I don’t see it there. The wikipedia article you linked clearly identifies “liberal elite” as a stereotype and an ad hominem attack. Ad hominems are pointless and distracting, and your opinions might be taken more seriously by readers if you didn’t use them – even if your opponent is being rude.

    I agree that physicians shouldn’t be asked to bear the financial (or workload) burden that some plans for socialized medicine incorporate. I don’t think that a universal health plan has to necessarily penalize doctors in the way you describe. So we’ve got the issue of doctors being overworked and underpaid and the issue of millions of Americans with no health insurance and no money to pay for medical bills. I’d like to think that these problems can both be eased (if not solved) and that the solutions aren’t mutually exclusive and that socialized medicine can work, but my ideas generally incorporate higher taxes, which I’m guessing you might not like.

    If you’re a doctor, you must have some idea of how devastating illnesses and injuries can be for patients who already /have/ health insurance. Do you have any ideas (short of Superman coming) that might help the uninsured if we toss out the idea of socialized health care?

  14. Richard Eis

    Warning English:
    i would not expect my doctor to visit me in hospital…that would be odd. I expect nurses and doctors versedin the same practices to take over…

    What i dont understand is how care can cost so much yet doctors appear to be under paid. Could you lay out the american health service from your point of view for us brits please…as we really don’t see how this system could work long time.
    All i see are middle men getting rich and no improvement in health care…am i right…what protection should outsiders take in america…what cover is best….?
    I will be spennding some time in america soon…what should i do given your health service?????

  15. Hey Richard Eis,

    I recommend you purchase travel insurance that covers medical emergencies and doctor’s visits, though I don’t know how long you’ll be hanging out here. Make sure it’s complete coverage and that the deductible is as low as possible and the cap is as high as possible. This is if you really want to cover your bases.

    In an emergency, you can go to the emergency room(in Britain I believe they call it casualty) and they cannot deny you care if the emergency is genuine. They will bill you afterwords. Though you don’t live in the US so unless the credit unions also operate in Britain, in theory you could skip out on the debt, but that would be dishonest.

    I can’t help you with a complete explanation of the US healthcare, except that it’s extensively privatized, but you already knew that.

    Allow me to apologize in advance for pummeling you with questions- Let’s benefit from a little cultural exchange here, I have questions about your system would you say that NHS over there in Britain is extensively flawed? Obviously there are going to be issues and problems. More specific questions you may be able to answer as an average run-of-the-mill person:

    Would you say the quality of care in your experience is good or bad?

    Does quality depend on your neighborhood, or parish/county/what have you?

    Is abortion available for women?

    What out-of-pocket costs are there, if any? And I mean any.

    Have you seen any doctors express real frustration with the system?

    I apologize in advance for jumping on you with all these questions. I don’t know if you can answer all of them. What can I say? I’m curious.

  16. @DWMD,

    Considering the sarcastic tone you took with me previously because I’m but a mere 22 year old student, I wouldn’t talk so much about other people being elitist.

    Didn’t think that would come back to bite you in the ass, didja? Now I get to watch you sputter, or run. Either is fine by me.

  17. Bravo DWMD.

    SarahH, as a patient with a chronic health condition I have a few ideas that might work and preserve the heathcare system.

    One thing that folks must understand is (and this is an answer to you– Richard Eis) is that American Heathcare funds the worlds’ heathcare. We are the engine that makes advances in medicine possible; drug companies, medical device manufacturers, and associated concerns all want to make money and that drives the system to keep coming up with new ways to make money. The free market works, except when other countries come in and regulate medicine.

    When that happens, other countries, (to give one example) cap drug prices at a low price and prevent the drug manufacturers from charging more. So who ends up paying the cost of research and development that a drug company needs in order to keep producing new drugs? Americans do. That is just one example of some of the ways that Americans have been footing the bill all along to keep R&D alive and well in the world.

    So one of the ways to reform health care is to make sure that it is open to the free market, so that prices that are too high can come down, and prices that are too low can go up. This means that “fee for service” is the best way to go.
    People, both in the US and abroad, must pay the REAL COSTS associated with every drug, every MRI and every procedure and test that they opt for. This puts the the burden on the patient to stay well and to make sure that they are getting what they bargain for when seeking out care. It also gives people the CHOICE about their health care, and fee for service is the mechanism by which we get to keep our choice.

    So what about those that can’t afford catastrophic care or even routine care? Here is where insurance comes in. Like car insurance or any other insurance, people need to be able to buy a plan on the free market–not be limited by where they work, or what state they live in. Most folks today don’t stay at the same job or in the same state for their lifetime. Like car insurance, you stay with the company that gives you the best deal where you live and you shop around if you are not happy.This keeps insurance companies competitive, and it’s the best way to make sure they stay honest and stop limiting people and increasing their own costs. Let them compete with each other to get customers.

    So routine medical costs, like doctor visits can be paid out of pocket up to a certain amount, until the insurance kicks in. No referrals–you pick any doctor on the planet and see them. This will force the doctors to compete as well; when they compete for your business, you can be sure that they will be motivated to provide better care. The better docs can and will be able to charge more as they should. And the charlatans will be run out of town on a rail, like they should be. If a doctor is of the liberal ilk, he may choose to practice in a low income area; or perhaps there can be incentives for those docs that practice in low income areas to get refunds on their student loans; this will make sure that all income levels are covered.

    In this type of scenario, the government would provide backup only. Those that can not afford to pay market rates for insurance will get help based on income in the form of vouchers. Plans will not be able to deny anyone with pre-existing conditions as long as they pay– same like “no fault” car insurance. The government can also provide medical savings accounts so that people can take high deductibles for out of pocket expenses, and save money. If they don’t get sick, the savings account can be rolled over to the next year. This will make sure that people get preventative care. You will get a big tax break for a medical savings account, and that break will get even bigger if you don’t use the account too much–meaning if you loose weight, eat right, and stay healthy, you build that fund so you can take a bigger and bigger deductible on your insurance costs every year.

    The government needs to get out of the health care business; even medicare– and let the free market do its thing so doctors can get paid what they are worth, and people can pay for the care that they need and have a choice about what that care consists of. That choice needs to be between the patient and the doctor. I don’t want the government or an insurance company telling me how many MRI’s I need. I want to pay my doctor a fair fee, and only use the insurance if I need it for a catastrophic condition. The doctors will save on paperwork, the insurance companies won’t have to deal with the doctors, and everyone will be happy.
    Fee for Service.
    Be there or be square.

  18. Thank you, Patient! It’s nice to see I’m not alone here.

    Chemist… you have a point. I was acting elitist with you. But on the other hand, you are an idiot, so you kind of deserved it.

  19. Actually, there’s a growing number of Americans going outside the US for health care.
    Does anyone have any #s on people coming here for medical care vs. Americans going elsewhere?

  20. sea creature

    DWMD, there are a lot of good reasons for free markets to be part of health care. However, there is one issue that I have never seen addressed where I think there needs to be some regulation, which is the issue of how insurance companies deal with people who have health problems. Once you have a medical condition, insurance companies no longer want you as a client, so the incentive for them to actually provide quality service is gone. This eliminates one crucial way in which markets function, which is by compelling businesses to provide a quality product or service or else lose their customers.

  21. DWMD. The free market offers two options. The options are (1) pay the free market rate for health care or (2) if you can’t afford the free market rate, die. Any sane human would have noted that “pure” Capitalism (i.e. pure free markets) do not work any better than “pure” communism.

    That is YOUR attitude. And, since you are an idiot, you deserve any elite snobbish comments that come your way.

    Now, I would like to know, if doctors are not making any money and hospitals are not making any money, who IS making all this money? Health care costs keep rising faster than inflation and have been for a long time. How is that? SOMEONE is making money or you all would go out of business.

  22. They will bill you afterwords. Though you don’t live in the US so unless the credit unions also operate in Britain, in theory you could skip out on the debt, but that would be dishonest.

    Technically, this is correct, but I would point out that no hospital in the US expects to actually be paid in full by its “self-pay” patients. If you want to avoid ruining your credit and have run up a million dollar+ bill due to serious illness, just work out a plan to pay a token amount monthly until everyone gets tired of the paperwork and drop the whole thing. The hospital will be happy to get anything and not have to spend money harassing you, your credit won’t take a hit, and the residual bill will eventually get eaten by the hospital.

  23. The government needs to get out of the health care business; even medicare–

    That would be a shame, because Medicare patients actually get better care than self-pay patients or even patients with private insurance.

  24. If you want to see how the American health care system worked before government regulation, I recommend William Rothstein’s From Sects to Science.

    You’ll find for example that patient’s belief that “And the charlatans will be run out of town on a rail, like they should be” and that lettign “let the free market do its thing so doctors can get paid what they are worth” did not occur.

    Which is not surprising given that she does know that people are ” able to buy a plan on the free market–not be limited by where they work, or what state they live in”

  25. Wow. This post underscores exactly how little I know and understand about the american healthcare system! In Sweden, doctors work at hospitals, and a hospitals is where doctors work, period. Going to a hospital and not seeing a doctor would be like going to a bakery and not seeing a baker! It’s just inconcievable to me. Some doctors set up private practices but the vast majority are full-time employees at hospitals (or smaller healthcare institutions). So I really have no clue at all what this discussion is about. Doctors visiting their patients at the hospital? Surely it’s the other way around! 🙂

  26. Well,

    in contradiction to some statements above, I don’t see that the USA have one of the world best healthcare systems. Best by what standards? There seems nothing that you can’t get in other high developed counties. But in other countries this benefits go to more people.

    I don’t see the point in this Free Market discussion above. Free Markets are not intrinsically stable. They can and do break down. That is surly not what you want for a healthcare system. However the dichotomy between either free markets or communism is obviously false. So what’s the problem? Making your (healthcare) market more free will solve the problem? I don’t think so, looks like the “Free Market is magic” gambit anyway.

    One last thing:
    You have an odd meaning for the phrase “liberal elitist” over there in the USA (according to the wikipedia article). For me that would be a person that is part of the elite who is also liberal. Where the latter should mean that he is interested in creating or supporting a society where every individual has the most freedom possible under some constrains.
    Do you want your members of the elite to be not liberal?

    best regards,

  27. To clarify for Felicia, hospitalists are internists based at the hospital who specialize in the care of sick, hospitalized patients. You’re likely to have more face to face time with them than you would were your own doctor to visit. It’s actually a pretty good system.

  28. hospitalists are internists based at the hospital who specialize in the care of sick, hospitalized patients.

    So how long before the specialty “internal medicine” breaks into two specialties and people take residencies in either hospital based internal medicine or community based internal medicine? Because the amount of information that one needs to keep up with to be both a hospital and a community based internist is getting excessive. (I say, studying for the internal med recert exam.)

  29. Anonymous

    I’m a fan of hospitalists in general. If I’m in the hospital I’d prefer to be seen by a physician who not only specializes in this sort of thing, but has had a good night’s sleep. I don’t think that expecting more work and longer hours out of already-overburdened primary care physicians is good for either physicians or patients.

    That said: I wish that hospitals and private practices had better channels of communication when a hospitalist takes over a patient’s care. My 89-year-old mother was recently hospitalized for a serious infection (she got excellent medical and nursing care and is fine now), and it was a bit difficult explaining to her why her primary care doctor wasn’t seeing her personally. That was nowhere near as difficult as getting her regular internist into the loop, which we considered crucial due to all the meds Mom has been on (and because her network of specialists has her primary internist as its hub.) It took some weeks to get everything straightened out to the point where Mom was comfortable with her care, and with the revised list of medications that resulted from the whole episode.

  30. Are you a physician?… Go to school, dumbshit, and then we’ll talk, okay?

    Actually, it was your elitist and condescending tone that brought out the worst in me.

    Oh the irony…

  31. Chemist… you have a point. I was acting elitist with you. But on the other hand, you are an idiot, so you kind of deserved it.

    This coming from the person whose brilliant solution to problems in the Middle East is essentially kill ’em all and let God sort ’em out.

    I hope for your patients’ sake that you’re better at medicine than at dissecting issues having to do with health care.

    Go to school, dumbshit, and then we’ll talk, okay?

    I knew a Fulbright scholar who was an MD, and later got an MS in Public Health. When we roomed together he talked about how little his MD had to do with his new course of study. No one here is claiming special knowledge except for you, but I fail to see how you’re such an expert based on schooling that focuses on the health of the individual. Everyone else is happy to admit it goes as far as personal experience, and maybe a little research with some reason sprinkled in.

  32. Dianne, the board is already planning to split things up, so that by the time i recert, i will probably have to pay for two separate exams (and presumably the precert modules)

  33. @seacreature:
    You have a good observation of one of the problems with insurance–dropping people who need coverage due to catastrophic conditions. But like any other type of insurance, there are categories made for these situations; think of assigned risk pools, and other mechanisms to keep the insurance companies from abandoning coverage. Plus, in the case of the hypothetical plan that I am envisioning, the government would step in and cover those people who exceed reasonable costs due to a catastrophic condition, making sure that the sickest stay covered.


    Who is making money? A great share of the costs goes to actual administration of health care plans meaning paperwork, tracking, and all types of associated costs. It costs doctors, hospitals and other entities money to chase down payments, review files and re-submit errors in billing. This is true for both medicare payments and insurance company payments. Administration of plans has been costing us more and more every year.

    @Dianne: Thanks for that informative article. Medicare may provide better care just because when people arrive at the hospital there is no question about how and what the hospital will be paid. But there is still a problem with having a large inefficient system growing even larger and more inefficient. Plus more and more doctors are opting out of medicare; this trend may impact patient care in the future if it hasn’t already.


    Thanks for the book recommendation. While a look at 19th century medicine may be interesting, I do not believe that you can compare apples with asparagus. The health care system of today is much more complex than it was even 30 years ago. If you want to go back to 1978 type medical care, I am sure you can find insurance companies that would be happy to cover your costs for drugs and medical tests that were state of the art back then. Things are vastly different now and I recommend reading “Crisis of Abundance” by Arnold Kling to flesh out some of the reasons why we can’t go back to 1978.

  34. “One thing that folks must understand is (and this is an answer to you– Richard Eis) is that American Heathcare funds the worlds’ heathcare.”
    Just because you believe in your own BS doesn’t make it true. I’ll give you an example: I take Provigil. Made by an american company … because they bought the company that invented the drug here, in France, thanks to the massive cash they made selling the drug on the US market.
    US drug companies spend much more on advertising and marketing than on research. That’s not “funding the world’s healthcare.” That’s milking the golden goose.

  35. Medicare may provide better care just because when people arrive at the hospital there is no question about how and what the hospital will be paid.

    Quite possibly. IMHO, Medicare and Medicaid are easier to work with than private insurance for one simple reason: the people who run them could care less whether you get paid or not. In contrast, the people running private insurance companies have a positive motivation to see that you do not get paid. So, clunky as the government insurances are, they are easier to deal with than the private insurance companies.

    The problem is, if we went to a true “free market” system, then we would have to be willing to allow people to die on the doorsteps of hospitals without doing anything to help them if they could not prove that they could pay. This means that not only do poor people die, but wealthy, well-insured people who step out of the house for a quick walk around the block without bringing their insurance cards with them, and get hit by a car or have a heart attack while out also die. Do you want to risk dying because you didn’t think you had to take your wallet on an evening stroll at the wrong time? If we want to do anything other than this free market model then the government gets involved. (I shudder to even think about what a disaster it would be to ask the hospitals to try to absorb all costs of treating poor patients or–even worse–to try to judge which comatose patient could and which couldn’t pay eventually.) One can have complete government insurance without competition as in Canada, mixed systems like in Germany, or some other model. But I don’t know of any non-developing countries that don’t have at least some form and level of government insurance.

  36. One thing that folks must understand is (and this is an answer to you– Richard Eis) is that American Heathcare funds the worlds’ heathcare

    As others have pointed out, this is not entirely true. To the extent that it is, it’s not the private sector that does it: drug companies spend about as much money on drug development in the US as elsewhere. The US’s advantage is in its public funding: the NIH and similar government agencies fund a huge number of researchers and make the US the best place to be to do medical research. So it is the evil Socialized Medicine component of US health care that provides the very thing that conservatives like to tout as the reason that the US’s model of incomplete coverage is best. Sigh.

  37. @Patient: You say that the rising costs go into the administration of plans (and isn’t that in itself evidence of the inefficiency of insurance-based medicine)? Since the costs are rising faster than inflation, oldfart’s point stands: Someone is making more money each year off an equivalent level of medicine. Who is that?

  38. The Blind Watchmaker

    Early on in practice, and before the days of hospitalists, I would get to the hospital for rounds very early in the morning. It was still dark. The patients were asleep. I would wake them up and ask them how they were feeling.

    “Ahhhgghh”, “whhattt, ahhgg”, were typical 5:30 am responses.

    “Are you still weak?”, I would ask.

    “Uhhmm, whaatttt?” “Uhh, huhhh”.

    “Well, I’ll be back tomorrow (for another stimulating visit)”, I’d say as I would hurry on to the next groggy patient.

    My office is across town, and the first patient will be there at 9 am.

    To find out how my hospital patient was really doing, I would (try to) find his nurse. At that hour, I would find the night shift nursing student, who would tell me that his actual nurse was on break or getting ready for sign out. She also has the chart and I could probably find it down the hall in the sign out room. I would look for her and the chart, often feeling like an intruder on their little night-time club.

    After managing to see the patients, find the nurses, find the charts, track down tests, and reading specialist’s notes, I would then write some orders and put the charts in the orders rack. Hopefully, things would get done. Now, off to the office.

    In the office, during appointments, I would start getting pages from the hospital. Now the patients were awake. Some were wondering why I haven’t seen them yet. What?? I was just there! Now lab results are coming in and the nurses are back from break and sign out. They have lots to tell me.
    Family members would come in and demand to talk me “right now!”

    My office patients would then have to sit while I fielded phone calls.

    Well, at least I was getting paid for the hospital work. At least I thought I was. Then after going to a billing service and looking at electronic billing records, I realized that for the effort, I had actually LOST money. You see, you cannot bill for a diagnosis if a subspecialist is billing for the same diagnosis. In the words of my patients, “Ahhaggghh”.

    Now we have a full time hospitalist. He is THERE, while I am HERE. He can see the patients when they are awake. He can meet with family members when they are there. He can go see films and track down tests as they are being done. He can actually talk to the subspecialists at lunch in the dining room.

    At first, some of the older patients were a bit upset to learn that I would not be coming to the hospital at 5:30 am to wake them up. However, now they are happy to know that my associate is there all day. They know that we are a team. It works.

  39. Wow, lively discussion here.

    I just wanted to add that in areas where doctors are hard to come by, the problem is that there aren’t enough to give people quality care.

    By that I mean that they can’t possibly get to know all of their patients and become familiar with their history, enabling them to quickly recognize complications and issues. There are just too many of them.

    If your hospitalist is able to communicate with a doctor who knows you, you are truly blessed.

    If you don’t know you are blessed, it’s hard to be grateful.

    Many blessings

  40. @ NM:
    Leaving aside your zoological mixed metaphor (“milking the golden goose”) I am guessing that the American company had all that cash because unlike in some European countries, you can actually make a profit here developing drugs. You might want to check out the percentage of major drugs developed in Europe vs. the US in 1980 vs. today. Investment goes where it can get a return. Advertising as a transactional cost depends on market activity. The money for R&D must come from private profits or subsidies; the former is available these days mostly in the US. If the latter were doing the job in Europe, price controls on US made drugs would be less of an issue.

    I am not arguing that government has no role in helping those that can’t afford decent medical care. I am arguing that controlling costs—the main objective we face—is better done by introducing as much market discipline as possible. The government should not be providing, administering or even regulating health care so much on the supply side, but rather helping people who need it on the demand side. As for NIH research, you have thrown down a gauntlet by assuming that public funded research accounts for more of the US edge in productivity than private R&D. That is a difficult issue to debunk in a short instant given the difficulty of gathering statistics on either side of the issue. Can you demonstrate that the state of basic research is more advanced in the US than in Europe? If not, then I would look to the private sector which actually DEVELOPS the drugs by applying basic research to account for the US edge in pharma productivity.

    If administrative costs were the main reason health care costs have risen, the argument to remove redundancy through a single payer system would be stronger. But, the main source of rising health care costs have been technology improvements. The only way to control this is to introduce more market discipline and stop insulating everybody from the REAL costs of their health care.

  41. @Patient:
    I don’t understand your argument here. Earlier you said that the cause of rising healthcare cost was increasing administrative cost. Now you say it’s due to technology improvements (I presume you mean more and better, but expensive treatments).

    The only way to control this is to introduce more market discipline and stop insulating everybody from the REAL costs of their health care.

    What exactly is “market discipline”, and how would you improve it? And in a system such as the US, where people _aren’t_ ‘insulated’ from their healthcare costs, how is this applicable?

  42. Sorry not to be clear, Nick Johnson. Administrative costs are a piece of the increase, and technology is another piece. One can argue which is a larger piece depending on what the parameters are, and there are other pieces too that contribute to the increases in costs that I did not mention.

    As to market discipline; people today ARE insulated from the real costs of health care. Do YOU shop around for a better price? No.. because you expect the insurance to pay it all, or pay a large portion of the bill. If you are not insured, then you just expect someone–the government, the hospital, (not you) to pay for it. Plus we also expect the finest health care, the latest and greatest medical tests, medicine, treatment as if cost were not a factor. So market discipline in this case would refer to a system that allows people to understand what the true costs are to them if they opt for “the best” rather than “the very good” or the “adequate”. There is no need for everyone to see the top orthopedist when they break an arm unless there is some very specific complication that only he can treat. Nevertheless, many people will choose the top guy as long as THEY are not paying the bill. This makes it difficult to have a market system when people are not acting on REAL information of the REAL cost of all the top quality care that they desire. In a single payer system provided by the government, the government would be deciding who gets to see the top doctor at the top price–not you. Rationing of resources is the reality that they are seeing in Europe right now when someone with a head injury waits 18 months for an MRI. Anyone who thinks that we can all have our cake and eat it too is mistaken. Someone will always be there to control costs no matter what system you pick. That is the dirty little secret the single payer, universal health care folks don’t want you to know about. The American Medical Association is proposing a type of free market system that may address some of your concerns. You might want to look at their proposal at voicefortheuninsured.org

  43. The money for R&D must come from private profits or subsidies; the former is available these days mostly in the US. If the latter were doing the job in Europe, price controls on US made drugs would be less of an issue.

    Actually, Patient, as Dianne already stated, a lot of that funding in the US comes from U.S. government agencies. Research here is hugely subsidized by either the federal government or university endowments – most of the money made by the pricate sector goes to marketing or profit.

  44. As for NIH research, you have thrown down a gauntlet by assuming that public funded research accounts for more of the US edge in productivity than private R&D. That is a difficult issue to debunk in a short instant given the difficulty of gathering statistics on either side of the issue.

    It’s a fair question. In fact, there is data out there. Unfortunately, I have managed to forget the author’s name and don’t have the report with me at the moment. I will try to dig it out before this thread becomes completely buried and irrelevant, but can’t promise anything.

    It’s an interesting examination of health care in various countries overall and shows both the advantages and disadvantages of the US’s health care system. For example, the rate of new drug uptake is generally higher in the US than in Europe or Japan. Not completely–drugs such as imatinib that are clearly superior tend to have quick uptake in all countries–but generally. Note, however, that I said the US’s health care system, not free market health care. Drug uptake in South Africa, the only other vaguely developed country without universal health care, is actually extremely slow.

    Again, apologies for not having the source material available.

  45. Rationing of resources is the reality that they are seeing in Europe right now when someone with a head injury waits 18 months for an MRI.

    Counter-request: Do you have any data on the frequency of such things occurring? My anecdotal experience has been just the opposite: When I lived in Europe, I had immediate access to emergency care (at a remarkably low cost, even though I was self-pay for minor procedures) and was able to get appointments for non-emergent care within a week of requesting them. In contrast, it took me over 3 months to get an appointment with an internist in the US. And have had patients stuck waiting for MRIs (for follow up of chemotherapy, for FSM’s sake) for months at a time*. However, I would hesitate to draw any conclusions based on these anecdotes, but would be interested to know whether anyone has done any systematic research on the question.

    *In the interest of full disclosure and reassuring US-Americans, the patients in question did not, in the end, have to wait months for their MRIs. However, I had to beg and nag the radiologists extensively before they got appointments in a reasonable amount of time. What if the radiologists hadn’t given in? What if I hadn’t known how to work the system? It’s all too operator dependent to feel safe.

  46. This comment is for Karen, who posted above about her experience with hospitalists.

    Karen – My name is Heather and I’m with the Society of Hospital Medicine. I’m delighted to hear that you had such a positive experience with hospitalists. Would you mind if I contacted you via email to talk more about your experience?

    Thank you!

  47. Fernando Magyar

    Very interesting to read the comments on this post.
    I’ve been a US citizen since 1965 I am currently employed by a small company that doesn’t provide me with health care. I am by birth and ancestry legally entitled to citizenship in two other countries besides the US. One of those countries is considered a third world country by people who live in the US, I have received quite good free health care in that country. Right now I strongly suspect that I will no longer be able to afford any health coverage here in the US despite the fact that I have paid into numerous health and dental plans over the years that I have lived and worked here. By coincidence I also have extended family members who are physicians in all three of the countries in which I could claim citizenship so I have some insider knowledge of these different systems. The US in my opinion has by far the best quality of health care for the elites but when it comes to providing even basic health care for the bulk of it’s people it fails most miserably.
    I have no idea how to fix this system but what I do know is that the system is completely broken. Oh, side note, my girlfriend works in corporate finance, management level for a major hospital group. Interesting business to say the least 🙂

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