[HN Gopher] Physicians' attitudes about caring for people with d...
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Physicians' attitudes about caring for people with disabilities
Author : bookofjoe
Score : 61 points
Date : 2022-10-30 13:49 UTC (9 hours ago)
(HTM) web link (www.healthaffairs.org)
(TXT) w3m dump (www.healthaffairs.org)
| photochemsyn wrote:
| This is yet another argument for the transition of American
| health care from a primarily private for-profit operation to a
| socialized medicine model. Compare to the British NHS, which
| takes this issue into consideration and devotes resources to it:
|
| https://www.england.nhs.uk/2017/09/nhs-england-launches-prac...
|
| Yes, you can still get privatized health care if you want to pay
| for it in Britain, you can hire a nurse and doctor to follow you
| around 24-7 if you can find any willing to do so at the rate
| you're willing to pay.
| hn_throwaway_99 wrote:
| This was the thing that was so baffling to me about this study.
| I read the interview quotes, but then was baffled by the
| study's conclusion where they focused on things like
| "attitudes" and "structural barriers" (I kinda hate that term
| because it's easily interpreted in different ways).
|
| Meanwhile I'm screaming "Duh, it's money!". Meaning that:
|
| 1. The study, for some reason seems reluctant to come out and
| say "treating those with disabilities costs more". Which seems
| pretty patently obvious when you read many parts of the rest of
| the study: they talk about needing more specialized equipment,
| needing to take additional time, etc.
|
| 2. Thus, in a private care system where reimbursements aren't
| changed for treating people with disabilities, there are tons
| of embedded incentives to not want to deal with those with
| disabilities.
|
| The only was to get rid of these unwanted incentives is to
| fundamentally change the for-profit nature of American health
| care. Good luck with that.
| lotsofpulp wrote:
| >2. Thus, in a private care system where reimbursements
| aren't changed for treating people with disabilities, there
| are tons of embedded incentives to not want to deal with
| those with disabilities.
|
| >The only was to get rid of these unwanted incentives is to
| fundamentally change the for-profit nature of American health
| care. Good luck with that.
|
| As I understand, in the US, it is often the government itself
| that is not sufficiently reimbursing.
| bombcar wrote:
| Yeah, there's a simple and probably not that expensive
| solution - anyone who is disabled (define it by SDI or
| whatever) automatically triggers an $X payment direct to
| the doctor/facility/hospital whenever they interact with
| them. Adjust X to be moderately above the costs.
|
| Suddenly all the normies would be on the outside looking in
| as the doctors would be fighting over the disabled
| patients.
| bradleyjg wrote:
| Our entire framework of accommodation is a mistake. If we wish
| for people--disabled, pregnant, whatever--to be subsidized we
| should collectively bear the costs. We shouldn't insist that
| whoever they randomly come across be forced to eat those costs.
| That's both unjust and a recipe for resentment, reluctant
| service, and hidden avoidance.
| bombcar wrote:
| Some of the costs are "universal" (such as requiring all
| commercial buildings have wheelchair ramps) and so don't need
| to be "funded". Other costs are not universal and only appear
| when serving a customer/patient/person with the condition.
|
| And we _already_ handle the worst cases (where someone is
| disabled such that they need round-the-clock assistance, the
| state will hire said assistant; everyone expects Walmart to
| provide a handicap stall, nobody expects Walmart to change
| someone 's diaper), so why not handle more?
| lob_it wrote:
| I think anybody that saw the "pay to play" debacle with all of
| the medical journals at the turn of the century approach "medical
| and health (i call it healff, because they obviously got two
| "F's" in the subject) with realism and a bit of scepticism.
|
| https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702092/
|
| "fabrication, falsification, and plagiarism" indicates the
| industry itself is beyond a crisis.
|
| The comments/article show that a "for profit" system is
| everybody's problem, but even socialized healthcare does not
| provide even coverage for a long list of ailments.
|
| The news coverage in Austrailia on Teo and neurosurgeons shows
| where disabilities as a plaything are equally as unethical.
|
| https://www.news.com.au/lifestyle/health/neurosurgeon-charli...
|
| The only recourse for disabled and ablebodied persons is to keep
| trying until you find a trained professional that can accomodate
| your specific needs (provided you can afford their services).
|
| Perhaps people with disabilaties would be better served seeking
| healthcare at medical education facilities, where
| training/learning is still paramount versus the scar tissue
| already embeded in the system (not being paid for services from
| insurers, unreasonably low rates, etc).
| cebert wrote:
| I have heard that person care providers that incentivize them to
| keep the medical costs per patient low, especially for HMOs. If
| there are doctors who are reluctant to have patients with
| disabilities, could metrics KPIs be in play here?
| bombcar wrote:
| Almost certainly, and another reason to be very careful when
| implementing KPIs - I've seen setups where a customer being
| disabled would "turn off" the KPIs around patient care times,
| etc, just like how we don't time limit the SAT for people with
| difficulties.
| marcinzm wrote:
| My partner has a number of chronic medical conditions. In general
| dealing with doctors is a pain for various already cited reasons.
| One advantage of the American system is that, with the right
| insurance, you can book almost any specialist with no gate
| keeping. We've eventually found a few very helpful doctors who
| spend a lot of time with their patients. The general things that
| tie them together:
|
| - Older (40+) so already made money and paid off their medical
| school loans.
|
| - Their own small practice rather than part of a larger medical
| system or having partners.
|
| - Negative reviews about long waiting times. If a patient needs
| more time then they spend it but that does make other patients
| have to wait.
|
| Covid has been very helpful as more routine visits can now be
| done over the phone rather than having to go somewhere.
| bombcar wrote:
| This applies for many things in general, if the only negative
| reviews are about wait times, you probably have a winner on
| your hands.
| trh0awayman wrote:
| One low-hanging fruit to help the medical system is to
| replace/supplement GPs. GPs just route to a specialist, with some
| treatment short-circuits along the way. Sometimes you are forced
| through this pipeline for insurance reasons. There's a shortage
| of these doctors, at least in the US.
|
| Create what WebMd should be: an actual working expert system.
| Take some modern medical textbooks and create a basic expert
| system. You can use ML for any imaging/sound/whatever needs, and
| you can schedule lab tests yourself. It might never be as good as
| a great GP, but how often do you have access to a great GP?
| bombcar wrote:
| The idea behind a GP is _supposed_ to be someone who knows
| _you_ and your history, and can help recommend care, but they
| 've been forced to become gatekeepers for the insurance system
| to reduce specialist use. The incentives are all sorts of
| misaligned.
| logicalmonster wrote:
| Could the ADA itself be the cause of at least some of this
| hesitation by some doctors to want to deal with disabled
| patients?
|
| With a disabled patient, there's a larger chance that something
| about your medical practice (the parking lot, the hallway, the
| stairs and ramps, the chairs in the waiting room, the equipment
| in your office, etc) aren't going to satisfy somebody and you're
| faced with a dumb legal headache even though you might have been
| genuinely trying to satisfy everybody and would be willing to
| provide reasonable accommodation.
| CoastalCoder wrote:
| I just assumed that ADA requirements made their way into
| commercial building codes a while ago. And because of that,
| physicians would rarely bump into that issue, whether leasing
| office space or building new space.
|
| Am I mistaken?
| Siddarth1977 wrote:
| Unfortunately, it's not that simple.
|
| ADA requirements are incredibly complex, at times very
| specific and at times very unclear and open to
| interpretation. The truth is that almost every building could
| be found to be in violation, no matter how hard the builders
| tried to make it ADA compliant.
|
| In practice, this rarely matters. 99% of people with
| disabilities are just trying to get around, not looking for
| an opportunity to sue. But, the risk is still there, all it
| takes is one litigious individual to make your life a lot
| worse.
| rdtwo wrote:
| Usually it's the building inspector that gets you because
| they have a different view of Ada code then you do.
| ChrisMarshallNY wrote:
| I believe that you are correct.
|
| The doctor's office, as a business, already needs to abide by
| the ADA. It could be a convenience store, and still have the
| same requirements.
| fhsm wrote:
| This is true but really doesn't capture much of the truth.
| As a first approximation you can split spaces into licensed
| and unlicensed spaces. The former are the conventional
| purview of "private practice". The latter are the typical
| purview of "hospitals". These are in quotes because this is
| merely a correlation and neither concept has a strict
| definition. Critically without domain knowledge it's
| unlikely you'd be able to tell which a "doctors office" is.
|
| An unlicensed space is a business with all the usual
| obligations and the doctor is a doctor with all the usual
| obligations. When you move to the practice of medicine to a
| "hospital" (again as a licensing and finance idea which is
| separable from a sort of basic idea of building X) all that
| comes along but now with an additional regulatory overlay.
|
| Big picture this doesn't change much about the Ada except
| to say that many medical practices are happening in spaces
| where the Ada is just the beginning.
| [deleted]
| octokatt wrote:
| This is covered in the article, and yes. Specifically:
|
| > Physicians reported feeling overwhelmed by the demands of
| practicing medicine in general and the requirements of the
| Americans with Disabilities Act of 1990 specifically; in
| particular, they felt that they were inadequately reimbursed
| for accommodations.
| nvr219 wrote:
| It probably is but it's important to remember that without ADA
| this would be much worse. It's not like physicians were so
| great with people with disabilities before 1990.
| chromatin wrote:
| Yes, since ADA mandates that accommodations must be provided at
| no cost to the patient (an unfunded mandate). Here is a tidbit
| from the article:
|
| Participants described both financial and time-related
| challenges of accommodating communication needs. One non-rural-
| practicing primary care physician stated: "I took it upon
| myself to actually hire an outside service to do [sign language
| interpretation]. They billed the office. ...Their bill was
| higher than what we were making, so it was a losing venture.
| ...It cost me $30 per visit for that patient, out of pocket."
| bombcar wrote:
| This is the problem - people reduce "ADA mandates" to "lol
| you had to install a ramp or elevator" but it's much more
| than that.
|
| As a society we need to provide for those who are disabled,
| but we need more than just "lol pay for it" as a method. From
| one point of view a sign-language interpreter for someone who
| is deaf and cannot read is entirely a "reasonable
| accommodation" and from another (losing money on the
| transaction) it is not.
|
| While there's no guarantee that every customer is
| "profitable" we should work to make sure that the "disabled"
| aren't always in that group. For example, the ramp is a one
| time cost and amortized over all customers forever, and so
| it's not noticed much. But the interpreter was - because
| there is nothing that disconnects the cost from the service.
| If instead there was a city-wide pool of translators and
| interpreters that can be summoned/scheduled, and the pool was
| paid for by a tax/fee across _all_ interactions, then it
| would barely be noticed, and those who have to use it wouldn
| 't feel like they got cheated.
| chromatin wrote:
| Downvoted for directly answering the parent post's question
| and supplying a supporting reference to the posted article.
| Nice.
| knaekhoved wrote:
| Absolutely - the ADA makes it incredibly risky to deal with
| disabled people in any kind of formal interaction, so anyone
| who can avoid it rationally will do so.
| Test0129 wrote:
| The ADA is a definitely a case of great idea, terrible
| execution. Unfortunately, doctors (and really businesses in
| general) are forced into a no-win situation where as you stated
| you either comply in the fullest legally, or face a potential
| customer looking for a reason to sink your business. Where I
| live, the ADA is also responsible for some of the large
| increase in home prices over the last 20 years.
|
| I wish it differentiated between necessary things like ramps,
| spots in a waiting area, etc, vs unnecessary things. There are
| just simply too many disabilities for even an honest, well
| intentioned business owner to keep up with. Of course, without
| retaining an insanely expensive lawyer.
| kayodelycaon wrote:
| What's an example of an unnecessary thing?
| Test0129 wrote:
| I dunno, that's the point. Since it only technically
| requires "reasonable accommodation" it's up to
| interpretation. "Reasonable accommodation" has been used by
| ambulance chasers to sink businesses. I'm sure a set of
| absolutes could be codified.
|
| I'm getting downvoted to death for having an opinion again
| so I'm just gonna leave the topic.
| lotsofpulp wrote:
| The ADA should have been the government providing
| disabled people with sufficient cash to purchase the
| services or products they need to address their
| disability, or the government can provide it directly.
|
| But by diffusing the responsibility across businesses,
| the government can say they helped people without
| spending any money or taking responsibility to help
| people.
|
| For example, why would a doctor need to arrange for
| translation or sign language services? If the government
| wants to give a disabled person those benefits, the
| government should pay the disabled person to purchase the
| services of a sign language interpreter, or provide them
| one directly.
| ad404b8a372f2b9 wrote:
| This is entirely ineffective, in fact that's what the
| government does in many countries including the U.S.
|
| You cannot address the second-order effects of the lack
| of accessibility by throwing pennies at disabled people,
| unless you want to write them million dollar cheques. The
| problem can only be solved by giving them equal access to
| healthcare, education, employment and society in general,
| when you do this you allow them to become productive
| members of society who are self-sufficient. Giving
| someone a 1000$ in welfare every month is not going to
| help when they were prevented from going to school,
| finding a job, and getting out of their house at all.
| kelseyfrog wrote:
| How does a disabled person purchase a ramp or handrail
| for the building they are trying to enter?
| zo1 wrote:
| They hire someone to carry them? They fund an insurance
| pool that allows them to dial a handy caretaker within
| distance when they need it? Maybe it's enough to fund
| stair-capable wheel chair robots. Who knows. Maybe they
| just call ahead, check, and then ask a friend or family
| member to go with them.
| kelseyfrog wrote:
| Lol, thanks. I haven't laughed this hard in a long time.
| What an absolutely terrible solution.
| [deleted]
| kayodelycaon wrote:
| Reasonable accommodation isn't significantly onerous in
| the vast majority of cases. You don't have to provide the
| accommodation a person wants. For example...
|
| - Ordering via phone could be an acceptable accommodation
| for an inaccessible website. (Just don't place the person
| on hold for half an hour.)
|
| - Pen and paper can be used for communication when verbal
| communication isn't possible.
|
| - If someone is blind, you may be able to read things for
| them.
|
| I'll often get people still objecting to this level of
| accommodation because it is still inconvenient.
| logicalmonster wrote:
| > Reasonable accommodation isn't significantly onerous in
| the vast majority of cases.
|
| You are correct that a reasonable accommodation isn't
| particularly hard in many cases.
|
| The disconnect in communication here is that you're
| thinking in terms of a reasonable person.
|
| Unreasonable people exist.
|
| There are unfortunately some disabled people that would
| refuse to be satisfied by almost anything you provide
| them. The ADA lawsuits don't magically vanish just
| because you try and be reasonable and they refuse to be
| satisfied in turn hoping for some payday.
|
| The vast majority of disabled people are probably
| thankful for the accommodation, but it just takes 1
| ambulance chasing jerk to pursue a dumb case that sinks a
| business.
| kayodelycaon wrote:
| One unreasonable person can ruin a lot of things. You're
| never getting around that. I wish ADA wasn't handled by
| lawsuits, but everything is the US is a fucking
| lawsuit...
|
| The problem I have is many businesses don't even try in
| the first place. They don't know anything about ADA and
| point to the one unreasonable person as justification to
| do nothing.
|
| There are far more businesses being "unreasonable" than
| there are people filing ADA lawsuits.
| logicalmonster wrote:
| > The problem I have is many businesses don't even try in
| the first place.
|
| Is this perception accurate? I have my own life
| experience and thankfully do not have any disabilities
| that I know of, but it definitely doesn't seem this way
| to me.
|
| For example, if a disabled person went into a restaurant
| and asked for a bigger seating area to accommodate their
| wheelchair or crutches or whatever, is there a restaurant
| out there that wouldn't try to rearrange the tables or
| move stuff around where possible? I'm using this example
| because I worked in different restaurants in the past and
| all of them were happy to carry tables up and down stairs
| to make space and even force other seated customers to
| move to ensure that anybody who wanted extra space was
| accommodated.
|
| Not sure what else you want to see from stores.
| [deleted]
| extra88 wrote:
| You are correct that "reasonable accommodations" are, in
| fact, reasonable and don't have to be exactly what a
| disabled person asks for (though listening to people when
| they tell you what they need is important).
|
| > Ordering via phone could be an acceptable accommodation
| for an inaccessible website
|
| A particular person may find ordering by phone to be
| acceptable but in court cases, it has been found to not
| be equal to using an accessible website. One example is
| in the Domoino's case [0] (it references experiencing
| long hold times but there are other reasons it is
| unequal).
|
| [0] https://www.lflegal.com/2021/06/dominos-
| june-2021/#A-phone-i...
| kayodelycaon wrote:
| Domoino's had 45+ minute wait times. That's what got them
| in trouble.
|
| Phones are an acceptable alternative if you can provide
| equivalent service.
| extra88 wrote:
| A screen reader user can read all the information in a
| decent online menu way faster than having a Domino's
| employee read it to them. A customer who is deafblind or
| is blind and has a speech disability would need to use a
| TTY relay service, which makes it even slower.
|
| It is not unreasonable to make an ordering website
| accessible; Domino's even admitted it would only cost
| $58,000. $58K would be a lot if every individual
| restaurant in the country had to spend that much.
| Thankfully, that's not the case, most don't have an don't
| need their own bespoke ordering site, they license a
| platform.
| User23 wrote:
| > If someone is blind, you may be able to read things for
| them.
|
| You should see the look on the receptionist's face when
| she has to, oh no, fill out the stupid overly repetitive
| paperwork doctors give their patients. The last time I
| did it I had to fill out my name and address like five
| different times.
| thepasswordis wrote:
| I really wish I could just (safely) order whatever medications,
| tests, and treatments I want online.
|
| Let me consult a doctor if I need one, but also: don't gatekeep
| treatment from me because the doctor is having a bad day, doesn't
| like me, etc.
|
| I have a _severe_ , debilitating anxiety disorder. It's extremely
| frustrating, and sometimes I will have to leave classes I'm
| teaching, social functions, etc. for no apparent reason because
| my body starts an anxiety attack.
|
| This flares up once every 3-5 years and has for most of my life.
| The solution to this, which has worked for most of my life, is:
| xanax. Take a small amount of xanax before an anxiety trigger, do
| the trigger, and break the trigger->anxiety association/cycle. It
| takes like 3 doses total, and the rest of the pills go in the
| trash (or in the medicine cabinet, and then eventually the
| trash).
|
| Almost every time I have to go through some weird and insulting
| dance with a doctor essentially pleading with them for this
| medication, I get told I'm a drug addict, and finally after
| explaining that no actually I'm a 40 year old semi retired
| founder/software developer, not a homeless unemployed addict,
| which is what your leading questions about what I do for a living
| led you to think, I might get a prescription for the drug that I
| have been taking rarely, but to great effect, for 30 years.
|
| I *HATE* the medical system. I hate it. People talk about how the
| rich get access to some other medical system that gives them what
| they want with concierge doctors or whatever. Well I'm rich and I
| don't get that. I'd pay almost anything to just get a license
| that says "this guy is responsible, successful, and a massive
| contributor to society. Let him do whatever the fuck he wants and
| order whatever the fuck medications he needs."
| marcinzm wrote:
| Do you go to a different doctor every time, and is it a general
| doctor or a psychiatrist?
| wholinator2 wrote:
| You can just keep the pills. If you're really that strong about
| avoiding addiction why do you feel the need to throw them away?
| Broken_Hippo wrote:
| I'm not sure where they said they got rid of them to avoid
| addiction: It is more that they have to convince medical
| staff that they aren't simply looking to get high but want
| health instead.
|
| But outside of that, getting rid of unused pills is good
| practice. These pills are going to expire. Once they do, you
| can no longer rely on them doing what you expect. Plus, a lot
| of folks don't like to keep stuff they aren't using around
| the house - it is always a bit of upkeep or storage.
|
| And that doesn't even get into it being safer around
| children. It is easier to prevent children from getting into
| such things if they aren't in the house.
|
| FYI: Check with your pharmacy about bringing unused medicine
| to them to dispose of properly instead of putting it in the
| trash.
| bookofjoe wrote:
| >But outside of that, getting rid of unused pills is good
| practice. These pills are going to expire. Once they do,
| you can no longer rely on them doing what you expect.
|
| Disagree completely.
|
| Source: retired neurosurgical anesthesiologist (38 years
| practice)
|
| Reasons:
|
| 1) When you need those pills you won't have them
|
| 2) Properly stored pills (dark shelf/cabinet) lose
| potency/efficacy VERY slowly: perhaps 10%/year. So 5-year-
| old pills will still work fine. Take one, see if does what
| it did originally; if not, take another.
|
| 3) If you're traveling and need that medication, good luck.
| You'll wish you'd saved them.
| berberous wrote:
| I am not a doctor or chemist so I do not want to speak
| definitively, but I highly doubt most common drugs (Xanax,
| Advil, etc) really lose much efficacy past their expiration
| date (at least within some reasonable time, like 10-15
| years). Happy to be shown evidence otherwise. I wouldn't
| rely on this for say, antibiotics to treat an infection,
| but I wouldn't hesitate to take a 5 year old Xanax.
| csdvrx wrote:
| > But outside of that, getting rid of unused pills is good
| practice. These pills are going to expire. Once they do,
| you can no longer rely on them doing what you expect.
|
| Evidence required.
|
| Expiration dates are put on many things as a CYA, but I
| don't expect dry chemicals destined for human (or animal!)
| use kept in an airtight container protected from the
| sunlight to degrade within 10 years.
|
| _Should_ they degrade, the question is into what, and how
| much: 5% degradation into what the human body breaks the
| chemical into should have no consequence.
|
| > FYI: Check with your pharmacy about bringing unused
| medicine to them to dispose of properly instead of putting
| it in the trash.
|
| Or just keep it and use it as needed, solving both of your
| problems at once!
| orbital223 wrote:
| Most medicine has expiration dates. If he needs it only every
| 3-5 years, it's unlikely the pills will still be usable.
| csdvrx wrote:
| > it's unlikely the pills will still be usable
|
| Pills (and chemicals) are not SSL certificates: they don't
| cease to work at the expiration date + 1 second.
| TylerE wrote:
| And in the US at least, FDA requires a max expiration
| date or one year, despite many being shelf stable for
| probably decades.
|
| I know I read somewhere about morphine pills from WW2
| medkits being found to still be useful 60+ years later -
| like say 30-50% of stated dose.
| bombcar wrote:
| The US government tested a bunch of old World War II
| medication they found laying around, and it had something
| outrageous like 98% efficacy or whatever.
|
| Maybe a liquid medicine would go bad but I suspect pills
| are forever.
| ars wrote:
| > it's unlikely the pills will still be usable.
|
| Yes it will. The pills don't _actually_ expire. They will
| work unchanged for decades.
|
| See: https://www.health.harvard.edu/staying-healthy/drug-
| expirati...
| amalcon wrote:
| For medication like this, the doctor will usually prescribe a
| specific number of pills at a specific dosage. The number
| will rarely exceed what you ask for, and asking for large
| numbers of pills is treated (not unreasonably) as a sign of
| drug seeking.
| Calavar wrote:
| This is true in general, but as a doctor, I've never
| written a prescription for only 3 Xanax pills. Usually more
| like 10 to 30 depending on the situation. The only time I
| write for a single digit number of pills is for
| antibiotics, where I know ahead of time exactly how many
| pills they will need.
| somehnguy wrote:
| Anecdotally I've received a script for exactly 3 Xanax
| pills. The eye surgeon prescribed them for my LASIK
| surgery.
| tux3 wrote:
| >and asking for large numbers of pills is treated (not
| unreasonably) as a sign of drug seeking.
|
| Something that keeps tripping me up with the label of drug
| seeking, is that in this situation the person is correctly
| drug seeking in a situation they've previously had a
| specific problem diagnosed and have had positive
| experiences with a therapeutic. They simply need to subject
| themselves to the ritual, follow doctor's orders, and not
| _look like_ they are drug-seeking to successfully drug-seek
| the therapeutic.
|
| What bother me is the implicit confusion between seeking
| drugs to treat a specific problem, versus not. Confusion
| creates damage both ways, with an insufficiently
| individualized approach people subject to drug addictions
| may not be sufficiently protected (many are still
| successful finding someone who will fuel their addiction),
| while people not subject to drug addiction receive
| substandard care.
| dennis_jeeves1 wrote:
| >I _HATE_ the medical system.
|
| A teeny nitpick, it's never the system, its always collectively
| the people, and common people at that. I have toyed with the
| idea of getting a medical degree but it's a lot of time, effort
| and money, to get over the issues you correctly pointed out,
| but it appears that searching and finding a doc that is
| disgruntled with the 'system' and who might be co-operative
| with things that I need is higher.
| knaekhoved wrote:
| You can order xanax on the darkweb, FYI.
|
| I mostly agree with you - the problem is that doctors are
| trained to deal with the lowest common denominator of patient:
| an addictive idiot who would kill themselves with benzos or
| opiates, given the chance. 90% of doctors are absolutely not
| equipped to deal with high-agency, high-intelligence patients.
| I've had a few doctors that were smart enough to work with me
| on experimentation or nonstandard treatment, but they are few
| and far between.
| zen_1 wrote:
| You can also order fentanyl labeled as xanax on the
| darkweb...
| hotpotamus wrote:
| You can order unscheduled drugs from pharmacies in India like
| alldaychemist.com. That means no benzodiazepines, but there are
| drugs with off-label anxiolytic indications like hydroxyzine,
| propranolol, or clonidine to name a few. I don't disagree with
| you regarding our medical system.
| chiefgeek wrote:
| Sorry to hear about the suffering you endure with your
| condition. Have you investigated any somatic work? How about
| psychedelics? Over the past 10+ years, I've gotten myself off a
| 200mg dose of Zoloft, along with Wellbutrin and Adderall
| through a combination of the above. I've seen others heal
| similarly.
| jrm4 wrote:
| ad404b8a372f2b9 wrote:
| Every day I thank god that I was born disabled and not black,
| since I've started talking to Americans I've learned it's the
| absolute worse thing you can be, regardless of the issue being
| discussed or personal circumstances.
| Test0129 wrote:
| I have a lot of experience with doctors. I've found regardless
| of what you look like unless you're going to a concierge clinic
| you wont even get the time of day from most of them. It seems
| to be a volume business, and thus they just go through the
| motions. Much like tech with engineers, the good doctors seem
| to leave as soon as you find them.
| klyrs wrote:
| Well, that's an anecdote, but numerous studies indicate that
| black people, indigenous people, women, people in poverty,
| transgender people, are systematically mistreated by health
| care systems in north america. I know HN loves to pretend
| that racism only affects white people, but it just ain't so.
| Test0129 wrote:
| > I know HN loves to pretend that racism only affects white
| people, but it just ain't so.
|
| Do you normally just make things up?
| jt2190 wrote:
| From the synopsis:
|
| > Physicians reported feeling overwhelmed by the demands of
| practicing medicine in general and the requirements of the
| Americans with Disabilities Act of 1990 specifically; in
| particular, they felt that they were inadequately reimbursed for
| accommodations.
|
| In the U.S., primary care is becoming more and more
| industrialized, with patients limited to very short visits.
| Patients hate this because they have real medical issues that
| need addressing; Physicians hate this because they want to help
| their patients solve their medical issues. This industrialization
| is particularly detrimental to anyone with chronic health
| concerns, anything that requires attention and thought.
|
| Edit: Counterintuitively, the industrialization really has the
| potential to provide cheaper, better health outcomes for
| everyone. Unfortunately, it seems like "we're not there yet" with
| what is possible with current tech, similar to self-driving cars.
| caddemon wrote:
| It's not even remotely efficient industrialization though.
| Doctors spend a lot of time doing things that could easily be
| done by someone with much less training. Doctors would have
| more time to spend with patients that actually need their
| expertise if we had a better system for delegating tasks and
| triaging patients.
|
| It kind of reminds me of how the medical industry in the US is
| more privatized than most places, yet pricing actually works in
| such an anti-capitalist way (even for elective/non-urgent
| procedures). They really manage to capture the worst of both
| worlds.
| bombcar wrote:
| When you work out "who is responsible for mistakes" you start
| to realize why doctors wouldn't even _want_ to delegate
| tasks.
| [deleted]
| ad404b8a372f2b9 wrote:
| A lot of modern medicine is factory work, there is no time or
| interest for the patient. It's the same reason people with
| symptoms that aren't immediately obvious get diagnosed with
| anxiety.
|
| It can be life-destroying when it's systemic, a lot of disabled
| people find that when they age out of pediatric care no one will
| touch them, not doctors, not physiotherapists, nobody.
| candiddevmike wrote:
| Does this apply globally or just in the US? Do folks in other
| countries with disabilities have better experiences?
| ad404b8a372f2b9 wrote:
| Same thing globally from the people I've talked to, I only
| have personal experience with American and European
| healthcare though.
|
| A problem we have in Europe is that the regulation of medical
| professions prevents anyone from paying for better care.
| There were times in my life I would have paid any amount of
| money to see a professional but was unable to find anyone who
| could take my money. That means we all receive equal care but
| it's equally poor and the government doesn't put the
| necessary resources in place to improve it.
| bombcar wrote:
| > There were times in my life I would have paid any amount
| of money to see a professional but was unable to find
| anyone who could take my money.
|
| Isn't that when you fly to the Mayo Clinic and throw money
| at the silly Americans?
| Arisaka1 wrote:
| I am far from disabled but I have multiple chronic issues,
| one of them being 100% visible to the naked eye and I've been
| told by multiple doctors to "not stress about it".
|
| And we're taking about a nail color change, a fingers
| temperature change during winter, and a constant feeling of
| headache that feels like worms are throwing a party under my
| hair (which they clearly don't).
|
| Also, for what it's worth, I'm from Europe and I tried both
| the free and the private health sector in my country. My only
| other options are to fly abroad for "medical tourism", but
| that would require a lot of money.
| knaekhoved wrote:
| > And we're taking about a nail color change, a fingers
| temperature change during winter
|
| This sounds like pretty normal stuff...
| sen wrote:
| I'm physically disabled and have various mental issues (ASD,
| ADHD, Bipolar, and some other minor things, all diagnosed).
|
| In Australia I find our medical system to be incredibly
| supportive of disabled people as long as you don't go to the
| "bottom of the barrel" doctors (eg local big medical
| centres). Those places are purely set up to churn people
| through for sickie notes or basic scripts. Every town has
| "family practice" GPs and even with me having moved all over
| the country I've always found them to be very accomodating.
|
| Almost any appointment can be done over the phone or
| Telehealth (government video conference system) if I don't
| feel I can make it in that day. Scripts can also be done like
| that then SMSed to my phone, or emailed direct to my local
| pharmacy who drop the medications off same day for free (paid
| by government). If I do have to go in physically to an
| appointment, they always have my full medical record thanks
| to our MyGov system and have a tl;dr on the screen when I go
| in, so I'm not wasting time going over everything again and
| again (which is how it worked before MyGov).
|
| Overall I love our medical system. It's absolutely not
| perfect but I've lived overseas in a few places and despite
| loving the idea of living overseas again (and having various
| serious issues with other aspects of this country) I stay
| here purely for the medical support I get with my conditions.
| octokatt wrote:
| N=1, but I can confirm the experience of being disabled and
| getting medical care is mutually frustrating. Taylorism and one-
| size-fits-all fails hard.
|
| Appointment times are standardized, despite patients not being
| standard. I know I'm going to take extra time. I have multiple
| chronic conditions, getting treatment is a mess. But I can't
| arbitrarily ask for more time during booking; it's all automated
| now. Worse, I need to confirm the doctor kept in mind _all_ of
| this in my treatment plan, because I've had awful reactions when
| they haven't.
|
| This is terrible for the doctor. I'm making them go over time, be
| late to the rest of their appointments for the day, and asking
| them for extra energy and brain cycles for treatment, for no
| extra money.
|
| And that's not even including accommodations I might need.
|
| I don't blame doctors for not wanting me in their practice.
| Controls put in place by administrators and insurance companies
| make me a pain in the ass to treat instead of a fun puzzle.
| Incentives make me more expensive, with lower payoff and higher
| risk.
|
| Which... is fucked.
| eska wrote:
| * I'm making them go over time*
|
| Saying this as a non-disabled person, please don't think of
| it/word it this way. It's not you, it's the disability, and
| you're not responsible for it. If you take some time because of
| it I would gladly accommodate you as a service provider and
| show understanding as the next patient in line.
| threatofrain wrote:
| If people prioritized their values this way then store owners
| would also fail to serve disabled people.
| iancmceachern wrote:
| Me too, get yours, I'll gladly accomidate.
| Test0129 wrote:
| > Worse, I need to confirm the doctor kept in mind _all_ of
| this in my treatment plan, because I've had awful reactions
| when they haven't.
|
| I'm not disabled but do have some chronic stuff. A couple
| decades ago I started carrying my medical record (well...the
| synopsis) to the doctors office for this reason. Especially
| when you end up in a clinic rather than a real private practice
| you're often not guaranteed to even see the same doctor twice.
|
| > This is terrible for the doctor. I'm making them go over
| time, be late to the rest of their appointments for the day,
| and asking them for extra energy and brain cycles for
| treatment, for no extra money.
|
| Though I'd not worry about this. My insurance EOB stated for a
| simple visit and bloodwork the doctor charged well over $1300.
| I saw the doctor for exactly 10 minutes. Make them work a
| little for their money.
| arkades wrote:
| That's not what the doc gets paid. That's the pretend amount
| that the insurer and doc have agreed upon, before their
| agreed upon discount.
|
| Source: doctor.
| lotsofpulp wrote:
| My EOBs have always stated what the healthcare provider is
| owed per the insurance price. It shows what was billed (the
| fantasy number), then the insurance price (or the
| discount), and patient responsibility (dependent upon an
| individual's deductible/copay/oop max).
|
| Is that not true?
| arkades wrote:
| You're more literate than most patients. You're right, it
| should list all of the above. I think your post reads
| (and per other poster, I'm not alone) that you had a
| $1300 normal outpatient visit, so I read that as you
| misreading your bill.
| Test0129 wrote:
| No, I know neither the doctor will see that, nor will I
| pay anywhere near that. It wasn't a "complex" visit,
| though there were a lot of convenience. Medicine
| consulting, in-house blood work, etc.
|
| Sorry for the confusion. I stated the EOB to hopefully
| clarify that. Assuming that they got even 90% of that the
| doctor would be pushing $200+/hr. just to take my
| temperature.
| johannbok wrote:
| That's right, only there is no normal physician visit
| that bills $1300. The absolute highest reimbursement
| you're gonna get for an outpatient visit - a level 5
| evaluation and management first-time patient visit plus
| double-coding an 'prolonged visit for high complexity
| care' (some handful of insurers allow triple-coding a
| G2212) - (a 99205 + G2212 x 2) is 244.99 + something like
| $30 (I don't recall the G2212 reimbursement off the top
| of my head, but it's in that ballpark), for a total of
| about $275. +/- some adjustment for geography.
|
| That's not what patients pay - that's the total allowable
| reimbursement to the doc via medicare.
|
| I use medicare numbers here because almost all private
| insurers negotiate as %medicare. If I'm a hot specialty
| people are willing to pick an insurance plan over (say,
| cardiology) and there's a shortage of my folks in the
| area, I might negotiate up to something like 110-120% of
| medicare. Most of the time I'll be happy to get 105%
| medicare, and some folks will end up getting something
| like 95% of medicare.
|
| To hit $1300 there'd have to be:
|
| -A procedure, likely an inpatient or facility service,
| such as a small outpatient surgery, or an infusion. -
| Your doc has an in-house blood work lab and your insurer
| doesn't cover it, and the bill is actually a lab work
| bill
|
| That latter bit is a gray area - it's actually barred
| under the Stark Law, as clinical lab work is considered a
| Designated Health Service that's barred from self-
| referral, if it's a third-party lab that they own or co-
| own. If it's their own actual in-clinic lab, though, I'm
| unsure of how that works out (I don't run my own lab, so
| I just know of this second-hand).
|
| If you have a private-information-redacted copy of a
| 'normal' bill for $1300, I'd be happy to eyeball it -
| either to let you know something is off and worth
| appealing, or to learn something new for my self.
| lotsofpulp wrote:
| I did not intend to claim that the doctor got paid $1,300
| for a consultation (that person wrote they received lab
| work too).
|
| I was clarifying what arkades claimed, which I
| interpreted as the EOB does not state the true
| remuneration for the healthcare provider.
| colechristensen wrote:
| Every EOB I've ever seen includes both the fantasy number
| (that no one ever pays or is charged) and the discount
| negotiated rate which is what the provider actually gets
| paid including your portion and the insurance paid
| portion.
| User23 wrote:
| You as the doctor actually explicitly signed off on the
| real price? Not some administrator somewhere? Did you have
| any real input, or is your relationship to the insurer more
| like a driver's relationship to Uber?
| arkades wrote:
| When working for a hospital, it's an admin somewhere.
| When in private practice, the insurer generally has
| geographic monopoly, so I sign off on whatever they shove
| in my face if I intend to accept their patients. The only
| time I have a real say in price is in private practice
| for uninsured patients, which is where I set aside a
| piece of my time for charity care.
| Dove wrote:
| Dude, you need direct primary care. When you pay the bills and
| no one else is involved, the doctor works for YOU. It's a
| profound difference, and one that it sounds like you need more
| than most.
|
| https://www.dpcare.org/ is a good place to start, but I
| guarantee there's direct primary in your city - just google for
| it.
| octokatt wrote:
| This sounds good, but I have health insurance to cover for
| catastrophic health failure, which is very probable for me.
|
| I'd need to pay for both direct primary care and health
| insurance, and primary care payments wouldn't count towards
| my deductible.
|
| This is a situation without fast solutions.
| parkerhiggins wrote:
| Spot on. It becomes more clear when you ask who pays medical
| professionals salaries?
|
| Insurance companies do.
|
| Insurance companies are medical professionals' bosses.
|
| The customer receiving treatment has no influence on the
| standard of care.
| johannbok wrote:
| This is partly true. In no small part because they tend to
| control the bulk (or all) of our patient supply. In part
| because people have gotten the idea that insurance equals
| care, and vice versa - so people tend not to think about
| high-impact moments where it pays to go cash.
|
| For instance, I specialize in neuromodulation for highly-
| treatment-resistance psychiatry. I'm very good at what I do;
| my mentor is (IMO) better, and one of the absolute best in
| the country. A single consultation session with him is around
| $200 if he happens not to take your insurance. If you have a
| highly-treatment resistant condition, and are about to embark
| on a course of neuromodulation, it absolutely behooves you to
| go to him for a single session consultation to plan out your
| intervention before going to some local mediocre whatever to
| actually slap the equipment on your head and carry out the
| intervention.
|
| For instance, people have incredibly debilitating autoimmune
| conditions. Rheumatic conditions are notable for their
| polymorphic presentations. It absolutely behooves you to go
| to an absolute top rheumatologist for one to three visits to
| confirm your diagnosis before going on a lifelong adventure
| of immune modulating drugs.
|
| But folks hear "this guy doesn't take my insurance" and treat
| it as equivalent to "I can't get care there," even when they
| can afford it. I have a chronic condition, it's terrible, and
| my absolute world-famous specialist costs me about $250/yr -
| a small fraction of my monthly insurance premium. Less than
| my monthly prescription costs. Yet people will go to whatever
| specialist happens to be near them, while bearing all those
| other costs, and not investing in the linchpin.
| syedkarim wrote:
| Who is the top rheumatologist? Who would you recommend? My
| mother is in constant pain and has gone to a dozen
| different specialists. We are near Chicago, but I am happy
| to take her anywhere in the country.
| bombcar wrote:
| Many people do not realize how _cheap_ it can be to do
| direct-consultations; and it can 't hurt to ask.
|
| Even a doctor pulling down $1m a year is only about $500 an
| hour, and that could be entirely worth it to get their time
| and dedicated.
| lotsofpulp wrote:
| Most customers could not afford the treatment at the standard
| of care they want anyway, hence the reason they purchase via
| insurance.
| amalcon wrote:
| People (in the US) purchase insurance mostly because the
| insurance premium is 90%+ paid by either their employer or
| the government. Everyone understands that the total price
| is a scam, but the <=10% that you pay out of pocket has an
| excellent ROI.
| [deleted]
| VancouverMan wrote:
| And those pricing distortions are due to significant
| government-imposed regulations and restrictions that
| tightly limit the supply of doctors and medical services,
| even in the face of increasing demand.
| gamblor956 wrote:
| That's false, but why let the truth get in the way?
|
| The limitation on doctors in the U.S. is based on the
| available funding for residents. The government supplies
| the money because private institutions largely are
| unwilling to do so.
| lotsofpulp wrote:
| Is it true that unsubsidized residencies would not be
| profitable? If so, I would not expect private
| institutions to opt to lose money.
|
| https://www.reddit.com/r/medicine/comments/a0pufi/comment
| /ea...
| johannbok wrote:
| Government regulations have been dragging back price of
| care for ages. Multi-month waiting lines to see a doctor
| are largely about price ceilings. If docs could price up,
| their waiting lists would go down commensurately.
|
| Constrained physician supply doesn't do much when
| physicians can't raise prices in the face of greater
| demand.
|
| People in these discussions always make things about
| physician costs. The majority of expenditures in the
| healthcare system are on drugs and equipment, followed by
| procedures - physician visits make up a tiny fraction of
| that.
| uoaei wrote:
| A large portion of _patients_ ( _customers_ seems like a
| dirty word in this context...) can 't even afford
| insurance!
| lotsofpulp wrote:
| Of course, because the root problem in the US is most
| people cannot afford the healthcare that they expect to
| receive. Hence all the political maneuvering to
| redistribute wealth, and the corresponding efforts to
| avoid having one's (present or future) wealth
| redistributed.
| selectodude wrote:
| That's half true - we've also made it difficult, if not
| illegal, for people to receive a lower standard of care.
|
| Anybody with a chronic condition needs to go see a doctor
| at least once a year in order to get the same
| prescriptions they've been on for decades. There are
| dozens, if not hundreds of conditions that could be
| handled by a pharmacy.
|
| I need an asthma inhaler every so often. I have to call a
| medical doctor in order to receive a prescription for an
| asthma inhaler. They're non-narcotic, I will always have
| asthma. But I need to bother a doctor for a medication
| that should be over the counter. It's silly.
| User23 wrote:
| Interestingly this wasn't the case in living memory in the
| USA. The insurance cartels have effectively greatly
| increased prices while commensurately lowering the standard
| of care.
| kingkawn wrote:
| Medical institutions have been kept onboard with massive
| increases in revenue that subsequently led to expansions
| of the institutions that are now dependent on that higher
| revenue to exist.
| lotsofpulp wrote:
| My dad told me in the 90s to avoid injury because the
| family could not afford healthcare. I distinctly recall
| hospital bills being in the tens of thousands even back
| then.
|
| I doubt newer cancer care, medicines, imaging, or other
| care would be cheap in any world, with or without
| insurance.
| Buttons840 wrote:
| I worked at a company that did background checks on doctors.
| Part of that involved involved checking doctors licenses in
| all 50 states, which all do things a little differently. I
| was paid 6 figures a year to help automate this, and this
| company had a few hundred other employees who would make
| calls and do other things to support the companies goals. It
| was all very expensive and could have gone away if only there
| were some standardized ways for all the states to report
| these things.
|
| I realized then that I was part of the problem, not on a
| personal level, but part of everyone's high medical bills
| ended up in my pocket as a developer at this random
| healthcare company awkwardly filling our niche.
|
| 15% of US workers are in the healthcare industry, and they're
| not all doctors and nurses. All those people have to be paid,
| and all of them have to be paid by that ridiculously high
| medical bill you just received. Sadly, making healthcare
| cheaper will involve pushing a lot of these people out of the
| industry, and that won't be politically popular. The
| insurance companies are going to have to become smaller and
| lose some profits before things get better.
| chromatin wrote:
| As a sibling commenter notes, it's great that you recognize the
| real root of this is often not a lack of empathy by physicians,
| but instead constraints of the system and especially the
| payors, who are not patients but insurers (or the federal
| government). Frankly, I'm surprised a small community-based
| primary care physician practice is even financially tractable
| in 2022.
|
| This bit from the article was also very interesting to me:
|
| Participants described both financial and time-related
| challenges of accommodating communication needs. One non-rural-
| practicing primary care physician stated: "I took it upon
| myself to actually hire an outside service to do [sign language
| interpretation]. They billed the office. ...Their bill was
| higher than what we were making, so it was a losing venture.
| ...It cost me $30 per visit for that patient, out of pocket."
| lotsofpulp wrote:
| > who are not patients but insurers (or the federal
| government).
|
| Or state government, in the case of Medicaid.
| pg_bot wrote:
| You might want to seek out a direct primary care clinic.
| kgeist wrote:
| Here in my country, to officially be recognized as a disabled
| person, you're required to undergo full medical examination every
| year (which can take weeks) and spend hours in lines to be
| reevaluated, otherwise your status will be revoked -- even if
| your defect is congenital and is not treatable (it's like they
| expect my bones to magically grow back one day). I've seen lots
| of people who can barely move be forced to stay in lines for
| reevaluation for up to 4 hours. I felt it's somewhat humiliating
| to be forced to prove you're still disabled like that so I
| stopped bothering. So thanks to our healthcare, a miracle
| happened and I'm not disabled anymore. I suspect they do it
| because their budgets are tight (we're talking about Eastern
| Europe) and they can't afford to pay benefits to everyone, but
| still the attitude is far from pleasant, it makes you feel like
| some kind of leech.
| dontbenebby wrote:
| https://en.wikipedia.org/wiki/Panspermia -- I have literally
| never had a doctor who was supportive of my disability, and when
| I finally sought out someone "queer friendly" they were more
| condescending and rude than most of the straight ones I'd
| interacted with. Purposefully unhelpful to the point I started
| reminding folks, why would you only kill _yourself_? These
| doctors might not harm you, but they 'll purposefully avoid
| helping you, and that's the same.
|
| (Maybe _I_ should walk around Scott Township handing out fifty
| cent pieces so _my_ opinion matters in 30 years like the local
| party officials used to in the park down the road from St Clair
| hospital -- I like how it 's the same thing as if you hit a 21 in
| blackjack. I notice little things like that.)
|
| Some of that is due to bouncing between insurances, so I
| clarified I'm eligible for an Italian passport to reduce the "Hi,
| I'm a shitty specialist but feel free to peruse a review website
| and pray to christ you don't have any meltdowns while I siphon up
| a few copays to pay for the degree I felt entitled because I
| refused to raise the minimum wage".
|
| I hope it's coming through that while sometimes I can be intense
| in the comments section, if someone is so distrustful of the
| medical system they're considering emmigration it should be taken
| as an extreme signal.
|
| But that's the problem -- no one ever has interacted with me like
| a victim or a peer in a medical context. I remember saying I
| wanted to be a horror writer and cautioned it might be better to
| stick to nonfiction when I was a teenager.
|
| That's why I did things like point out when I turned 18 in
| February, I'd be legally able to buy an AR-15 during the 30 days
| it would take to try to evict me prior to graduation, because my
| parents were that kind of petty -- to this day they treat 911
| like a customer service line... I had a cop bang on my door the
| other day because I hadn't called my mom.
|
| (I tried telling them hey, I actually looked into being a
| domestic violence counselor, you need to stop coming here without
| a warrant, my mom is abusive and this is false concern but they
| just kind of ignored me -- the police, much like politicians,
| never actually seem to care what I say unless they agree, which
| is fine, but people tend to regret not listening to me.)
|
| I hope for his safety he doesn't do that to someone with more
| severe anger issues, I've given up on trying to find a solution
| to that issue though -- I haven't had two weeks of quiet
| enjoyment of my home since Trump took office, and folks keep
| having increasingly terrible meltdowns when they fuck around and
| find out that I don't need to break the law to get them in line.
|
| At this point, I'm debating if I should renew my medical
| marijuana card, since it seems like I'm just... rewarding a bunch
| of extortionists.
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