!No future for healthcare in Kentucky
 --- 
agk's diary 
28 November 2025 @ 05:04 UTC
 --- 
written on GPD MicroPC
in bed with Evy
 --- 
Healthcare has no future in Kentucky. Healthcare and
prison industries replaced coal in eastern Kentucky.
Former miners are now mined for pain, insulin,
diabetic amputation, alcohol and fentanyl detox,
dialysis, heart surgery, cancer, chronic obstructive
pulmonary disease, long-term acute care and skilled
nursing, and for-profit hospice.

But healthcare may be a bubble. My old friend Anne
Tagonist wrote in 2009:

| ...the government thinks the problem is people not
| able to access health care. The insurers think the
| problem is people getting health care they don't
| need from overpaid doctors, and the providers
| think the problem is not enough of the right
| health care being provided....
| 
| the health care industry is the life raft onto
| which the entire collapsing American economy,
| beset with layoffs, failing industries, unretire-
| ment, and evaporating investments is jumping? ...
| This isn't just a matter of autoworkers becoming
| transcriptionists, or kids dropping out of
| computer science classes to become nurses.
| 
| Health care institutions are still somehow a
| growth industry.... There is a perception that
| clinics, dialysis centers, ambulance companies,
| nursing homes, urgent care centers, specialty
| surgeries and other assorted health care detritus
| make lots of money. As a result, people with money
| to invest are paying to open them all over the
| place.
|  
| Each facility hires a given number of nurses,
| receptionists, janitors, and other professionals,
| which make them very attractive to municipalities
| looking for something to subsidize to "bring jobs."
| In a surprising number of cases, the majority
| owners are actually doctors and hospitals, who are
| (of course) in a position to direct patients to
| their new investments. This can get ridiculous --
| while never proven, there are rumors that a un-
| named nursing home in my old service area was
| partly owned by a given doctor because anyone who
| came to the hospital for any reason and drew him
| as an attending got sent there.
| 
| The end outcome of all this investment is, of
| course, more people who are directly benefited --
| and in the case of low-education employees, depend-
| ent -- on more and more people getting more and
| more "care" for whatever reason.
| 
| Right now, much of the operating expenses of the
| industry are covered by investments and growth-
| subsidies, all of which are paid on the assumption
| that they will eventually be repaid once the
| clinics et al are established enough to turn a
| profit. However, it seems entirely likely that
| without a steady flow of investments and subsidies,
| there would be no profits, and in fact the indus-
| try would collapse or be forced to contract
| severely. Not only are all these new facilities --
| far too young to be paying for themselves out of
| revenue -- at risk, there is also a trend in the
| design of hospitals that parallels the rise in
| satellite specialty clinics -- the regional center
| movement.
| 
| Hospitals are fabulously expensive, fixed, and
| dependent on their immediate geographic area. To
| compete with each other for patients, and more
| importantly for bond issues and investments, they
| have to show not only that they are good
| facilities but also that they have something the
| surrounding hospitals do not. There are a number
| of designated "centers" hospitals can aspire to
| become, assuming there's nothing else like it in
| their region. For instance, a regional cardiac
| center, a regional stroke center, or a regional
| cancer center can draw patients away from other
| hospitals, instead of relying on those who get
| sick in their immediate twenty-block radius.
| 
| The problem -- or rather the opportunity -- is
| that qualifying as such a center requires a
| fantastic outlay of cash -- 24-hour prepped
| operating rooms, on-site specialists, extra rooms
| and facilities and machines... So hospitals have
| to qualify for enormous loans and bond issues,
| which jobs-hungry municipalities and rich people
| without any real estate to bank on are more than
| happy to provide. And so the immediately available
| cash pool goes up for a few years... along with
| the long-term debt which will eventually have to
| be repaid from unproven (and unlikely) profits.
| Which will have to come from... you.
| 
| And that's a bubble.
|
| ...what is this "care" being provided...? Well,
| mostly late-term interventions, based on a modern-
| ist disease model that identifies "disease" with
| measurable derangements in a physical body....

There's a profound shortage of doctors. Last month,
blogger Yves Smith paraphrased her friend IM Doc on
her blog Naked Capitalism:

| ...the long-standing primary care physician short-
| age ...is extending into other specialties....
| 
| Medical schools cut the size of their classes. I
| believe this started in the 1980s but it might
| have been as late as the 1990s.
| 
| This may have been the result of an expected demo-
| graphic decline in the US; experts were surprised
| that the 2000 census showed a population increase
| since a fall had been widely anticipated. The rise
| was the result of immigration and higher birth
| rates among Hispanics....
| 
| The bigger driver [of cuts] was the expectation
| (or plan?) that rather than growing its own
| doctors, the US would increasingly rely on foreign-
| educated physicians.... [This] did not work out.
| Doctors who came to the US to practice in large
| measure went back home.
| 
| Even with the inducement of attractive pay levels,
| they were put off by the time, stress, and risk
| involved in fighting with insurance companies.
| Word of their negative experiences got out quickly
| in medical communities in their home countries, so
| far fewer medical students there... tried practic-
| ing in the US....
| 
| A big second contributor to the primary care and
| now specialist shortages is the corporatization of
| medicine. Outside New York City and concierge
| practices, most doctors seem to find it necessary
| to work with a big medical system. That means as
| an employee as opposed to a solo/small firm pract-
| itioner. That in turn means that they have lost
| control over how they practice medicine. The loss
| of autonomy and dealing with a money-driven as
| opposed to care-driven bureaucracy has resulted in
| quite a few doctors who retire early.

Doctors who remain gravitate to specialties. The
generalist doctor is vanishing across my country,
replaced by (1) nothing, (2) Nurse Practitioners,
Physicians Assistants, and computer programs.

Medical school professor KLG wrote this month on
Naked Capitalism:

| Primary care is more than what in my childhood was
| called the "general practitioner" Or GP. As under-
| stood today, the core primary care specialties are
| Family Medicine, Internal Medicine, General
| Surgery, Pediatrics, Obstetrics & Gynecology, and
| Psychiatry, with Emergency Medicine sometimes
| considered primary care.
|
| Emergency Medicine was not a recognized specialty
| until the 1970s, and when I needed stitches or an
| x-ray (often enough to know the Emergency Depart-
| ment well) before going off to university, the
| hospital called one of my two family doctors who
| then drove the half mile from their nearby houses
| to care for me.
|
| ...Dr. Rosenbaum begins [a recent paper in the New
| England Journal of Medicine] with the description
| of the career arc of one Dr. H:
| 
| > After her internal medicine residency, Dr. H.
| > joined a Midwestern practice, inheriting a
| > primary care patient panel from a retiring endo-
| > crinologist. At first, the work was hard for the
| > right reasons. She diagnosed and treated a wide
| > range of diseases, built long-term relationships
| > with patients and families, and -- until the
| > rise of hospitalists -- cared for them in the
| > hospital as well. Becoming the consummate intern-
| > ist was exactly what she'd signed up for. "Life-
| > long learning and getting to help people," she
| > recalled. "It was the best job in the world."
| > 
| > She didn't recognize that this traditional
| > generalist role was in peril until about 15
| > years later, when she joined a multispecialty
| > practice owned by a nonprofit foundation. The
| > work was initially fulfilling, but as the
| > insults to primary care accumulated -- shorter
| > visits, unmanageable inboxes, a staff exodus
| > during the Covid pandemic -- Dr. H. gradually
| > lost her capacity to function as her patients'
| > doctor.
| > 
| > Like many primary care physicians (PCPs), she
| > adjusted to the squeeze by working more. Without
| > staff support, she roomed patients, took their
| > vitals, and scheduled tests and follow-up. When
| > leadership threatened to cut physicians'
| > vacation days if their documentation was late,
| > she started spending hours at night charting,
| > despite caring for a young child and a chronic-
| > ally ill husband.
| > 
| > But one change she couldn't work around was the
| > lost capacity to see her patients when they were
| > sick. Forbidden from double-booking to accommo-
| > date them, she often didn't hear about patients
| > who needed her until after a centralized triage
| > system had diverted them to urgent care.
| 
| Urgent care. In my recent family experience,
| urgent -- yes, and expensive. Care, not so much.
| But the regional for-profit but technically non-
| profit hospitals are making a killing.... this
| happened to one of Dr. H's patients:
| 
| > A patient with recurrent herpes infections... 
| > called seeking a refill of valacyclovir. The
| > staff, following an algorithm, told her she
| > required a clinic visit since she hadn't seen
| > Dr. H. for a year. With no appointments avail-
| > able, she was sent to urgent care, where the
| > clinician wouldn't prescribe valacyclovir with-
| > out a culture. Dr. H. eventually received the
| > message and refilled the medication.
| > 
| > But as similar situations, often with much
| > higher stakes, recurred, she began wondering:
| > What does it mean to be someone's doctor if you
| > can't be there for them when they need you?
| 
| ...Our doctors were [once] there when we needed
| them... from birth to death including general
| surgery that did not involve the heart or brain or
| bones. And if they were unavailable, a local
| colleague was happy to take call for them....
|
| health care may not have been universal but few
| who needed care were unable to get it.  As one
| internist friend put it (paraphrase), "We usually
| got paid, but when we didn't that did not make any
| real difference to us but was life changing for
| the patient and his or her family."
|
| [Even today,] ...Primary care receives less than
| 5% of US healthcare spending but is responsible
| for 35% of doctor visits.
| 
| Nevertheless, many people (except for those who
| need a PCP) are beginning to believe "primary care
| can be delivered less expensively by advanced
| practice practitioners such as nurse practitioners
| (NP) and physician assistants (PA)."
| 
| Several friends were some of the first PAs. They
| were trained well and have now retired after a
| lifetime of providing good care in partnership
| with a physician. The same is true of the first
| NPs.
|
| The angels who walked the earth while managing my
| chemotherapy were oncology NPs and oncology nurses.
| But this was done in a large oncology practice
| under the supervision of five oncologists, who
| worked closely with three radiation oncologists on
| the first floor of the same building that I got to
| know too well. It is not clear that NPs and PAs in
| stand-alone practices are the answer to the short-
| age of PCPs.  And there is good evidence that NP
| and PA programs are not as rigorous as they were
| at their beginnings.
| 
| But more importantly, the primary role of the PCP
| is to be the generalist who understands the needs
| of her patients through long and continuous
| contact and care, as the one doctor who coordin-
| ates multispecialty care when that is needed. The
| PCP is the captain who leads the team providing
| the care. Without him a gaggle of oncologists,
| surgeons, and radiologists can be like the comm-
| ittee of blind men describing an elephant.
| 
| ...Where [specialists] ...are present condition-
| specific outcomes are better, and I have my ENT,
| medical oncologists, and radiation oncologists to
| thank for my current good health. But my internist
| diagnosed the problem ...and started in motion the
| plan that resolved my cancer. Despite difficulties
| the modern hospital system has put in place to
| improve "efficiency," my internist continued to
| monitor my care until I was released by my special-
| ists.... These relationships may be called the
| "paradox of primary care":
| 
| > Despite better disease-specific outcomes for
| > individual patients treated by specialists, pop-
| > ulation-level data suggest that places with
| > higher ratios of primary to specialty care have
| > healthier populations, better-quality care,
| > greater equity, and lower costs...
| > 
| > U.S. states with a higher density of generalists
| > spend less and deliver more effective care than
| > specialist-heavy states.... patients with
| > multiple chronic diseases have similar function-
| > al health status whether treated by generalists
| > or specialists, but ...generalists use fewer
| > resources.
| 
| Of course, ...A community that is willing to
| invest in primary care will probably invest in
| social services that improve health in general,
| [but]:
| 
| > primary care has been atomized into its revenue
| > generating parts, leaving many PCPs unable to
| > build the longitudinal relationships essential
| > to this integrative function. The specter of
| > extinction thus looms large. Primary care's
| > sustained relevance depends on offering a
| > service people can't obtain from specialists,
| > retail clinics, or virtual substitutes. If its
| > relational core is removed, will the public get
| > their health and well-being needs met elsewhere?
| 
| ...We have described Neoliberalism as the dogma 
| that "the market is the measure of all things,
| including those that cannot be measured."  When it
| comes to health and wellbeing, MAHA and its
| minions [say] ...Only those health metrics that
| can be measured count, beginning with your plasma
| glucose level.... influencer culture "has rendered
| the idea of a long-standing doctor irrelevant,"
| especially when a wearable will tell you every-
| thing you need to know....
| 
| an escape from corporatized medicine may be
| possible. From Dr. Rosenbaum:
| 
| > Given the high rates of burnout among PCPs, one
| > of the more surprising findings in my reporting
| > was the sense of joy and gratification described
| > by some of the rural PCPs with whom I spoke.
| > Though practicing in resource-poor settings is
| > challenging, constraint evidently breeds creat-
| > ivity.
| > 
| > An uninsured patient in florid heart failure
| > who's declining the hospitalization that would
| > bankrupt him and force him to sell his farm? He
| > makes a plan with his trusted physician to come
| > to the clinic daily for IV diuresis and weight
| > and electrolyte checks. A woman with nephrotic
| > syndrome who can't get to the nephrologist at
| > the academic medical center 3 hours away? Her
| > physician emails with the nephrologist and
| > learns to manage her disease himself.
| > 
| > Does rural physicians' gratification arise from
| > autonomy, opportunities to treat widely varied
| > diseases, their central role in their communit-
| > ies? Yes, probably all those things. But most
| > strikingly, these physicians "meet patients
| > where they are" regardless of circumstances.
| > Most of U.S. primary care, constrained by large
| > health systems, has been denied this crucial
| > ability.
| 
| > It's no mystery why. Health care systems often
| > profit from hospitalizations, specialty referr-
| > als, and testing. As Larry Green, a family
| > physician and distinguished professor at the
| > University of Colorado, told me, "Good primary
| > care is increasingly bad for business."
| 
| ...this is a roundabout way of making the essen-
| tial point that the rural primary care physician
| must be the best doctor. Otherwise, his patients
| will simply die according to the first rule of
| Neoliberalism, "Because markets, go die." It is
| heartening to see that many of our graduates come
| to see this naturally, and then return home to
| take care of their community that comprises their
| patient population.
| 
| And what became of Dr. H, with whom we began?
| 
| > She and her colleagues wrote several emails to
| > practice leadership describing lack of staff
| > support, missed messages, their sense of failure
| > over letting patients down. "I cannot in good
| > conscience with consideration of the oath we
| > have taken as Physicians continue to practice
| > this way for very much longer," Dr. H. wrote.
| > But no one seemed to care.
| > 
| > ...the message I found most haunting was one
| > about the fundamental mindset shaping primary
| > care's trajectory. "Perhaps this is what the
| > administration wants," Dr. H. wrote: "to replace
| > the ones who know with those who do not know
| > better, those [who] have been indoctrinated into
| > your system which has eliminated humanity from
| > the equation."
| > 
| > One evening while finishing her notes, Dr. H had
| > a premonition that she would die early. "You
| > always hear about the doctors who really care,"
| > she told me, "the ones who tried really hard and
| > then fall over and have an MI." So when she
| > glanced over at her unread journals and noticed
| > a flyer seeking physicians for a concierge
| > practice, something clicked. "The universe had
| > answered my prayers for a long and prosperous
| > career," she said. She picked up her phone and
| > made the call.
| 
| ...The family doctors of my youth, from the GPs to
| the surgeons to the occasional pediatrician and
| psychiatrist, practiced what can be fairly called
| "concierge medicine." When you needed them, they
| were there. They were also paid well enough to be
| at the top of the local wealth pyramid, not too
| different from the bank president or the children
| who inherited one of the lucrative local business-
| es (until they ran it into the ground in the third
| generation).
| 
| They were pillars of their local world, at times
| somewhat apart as befit their ...earned authority,
| but nevertheless always an integral part of the
| community. A surgeon was on my chemical worker
| father's team in the scratch bowling league. They
| were also sometime fishing partners. This was not
| unusual then.... those doctors ...had long and
| prosperous careers lasting from the 1950s into the
| 1990s.

Squeezing doctors that remain and replacing them
with independent NPs and PAs is partly the purview
of intrusive, energy and data hungry computer
programs emanating from another bubble, according
to IM Doc:

| When I started 35 years ago -- my notes were done
| with me stepping out of the room and recording the
| visit in a hand held device run by duracells. It
| was then transcribed by secretary on paper with a
| Selectric. The actual hard copy tapes were 
| completely magnetically scrubbed at the end of
| every day by the transcriptionist....
| 
| Furthermore, I have occasion to revisit old notes
| from that era all the time -- I know instantly
| what happened on that patient visit in 1987. There
| is a paragraph or two and that is that....
| 
| the note generated [by AI] ...will be 5-6 back and
| front pages literally full of gobbledy gook with
| important data scattered all over the place. Most
| of the time, I completely give up trying to use
| these newer documents for anything useful. And...
| just think about the actual energy used....
| 
| ...in about 6-18 months our software will be up-
| dated. Oracle is apparently investing billions in
| AI as is Epic. It will take all incoming lab
| results for each patient and craft a pages long
| note with details about their labs and if they are
| normal or abnormal and what they need to do etc.
| 
| It will be able to go through ...their entire
| chart -- the arrays we have in the system as well
| as every single page of scanned pdf -- and the
| national vaccine database -- and put a paragraph
| at the very beginning of each communication dis-
| cussing each and every deficiency in their health
| maintenance.
| 
| In each terminal station, audio visual equipment
| will be set up and we will supposedly never touch
| a keyboard again. It will immediately alert us if
| there are billing issues on anything we are order-
| ing. It will analyze each incoming voicemail and
| computer message from patients and craft a compl-
| ete response with the current standard of care for
| the issues via up to date.
| 
| If information is requested or required from any
| outside source -- starting in 6-12 months Epic and
| Cerner and VA systems will all be interlinked and
| the system will go and gather all documents needed.
| If it cannot find it -- it will automatically send
| Release of information to any doc in the USA.
| 
| ...I have been repeatedly told this is all for two
| reasons. (1) The absolute dearth of primary care
| MDs all across the nation. The ..."hospitalist"
| movement ...has decimated the general internist
| cohort -- almost no one straight out of training
| is going into outpatient ...internal medicine.
| This is on top of mass retirements and transition
| to concierge care causing a horrific deficit in
| outpatient internal medicine.
| 
| (FYI - I am personally seeing 20-25 people every
| day with an NP seeing another 12-15. I see 2-3 new
| people a day. Most new patients are very compli-
| cated and require much attention. My next new
| patient scheduled visits are in FEB or MAR -- and
| a routine follow up is in about 6 weeks. I routine-
| ly have people calling on the phone that my nurses
| can tell are deathly ill and we put them in as
| overbooks all the time. On this past Friday I had
| an acute renal failure with Creat of 5, a new
| onset rapid afib, and a massive leg infection --
| all being overbooked. ...2 of these patients had
| been seen in urgent cares by NPs and had been
| completely misdiagnosed and mishandled and had sat
| at home for days with festering issues that could
| have killed them.)
| 
| ...(2) the system is now being backfilled with NPs
| [nurse practitioners] and PAs [physicians' assist-
| ants] and these AI systems are being set up in
| large part because of the extreme knowledge and
| practice and experience deficits in these types of
| providers. The AI systems are thought by the MBA
| crowd to be a failsafe and a very reasonable aid
| for these NPs and PAs who were never trained to be
| physicians. There is no other way to put it.
| 
| What was once a way of having NPs see overflow
| under the direct supervision of general internist
| MDs has now turned into a situation where they are
| all over this country all on their own. On their
| own except for the AI systems telling them what to
| do and how to answer patient questions.
| 
| The system is literally imploding because of this.
| Routinely every day I have 1-2 patient disasters
| in my office because of bad care that was given
| days or weeks ago by people who are simply not
| trained. The specialists are now overwhelmed with
| cases of all kinds of things that in the past had
| been handled by general internists. There are
| multiple sub-specialties that were already in dire
| shape numbers wise -- but now are just absolutely
| torpedoed. This is most acute in endocrinology,
| rheumatology and neurology. But ENT and urology
| are close behind.
| 
| ...This AI and the absolute crushing case load is
| not what I signed up for in any way shape or form.
| This is not the medicine of decades ago when I
| started. And all the while, with all this crushing
| load, I am on the phone every day with insurance
| companies begging for care for my patients...,
| patients screaming at me and my staff because we
| did not get back to them in a timely manner, etc.
| I must say -- I was trained to be strong and
| resilient - but this is about to break me. I look
| forward to retiring soon.

Finally, Anne Tagonist again, on preventative care:

| If you think we can't do acute and chronic disease
| management well in this society, we can't do
| prevention worth a goddamn, and for many of the
| same reasons. It isn't just a matter of resource
| allocation or training.
| 
| we don't, honestly, know why people who move from
| a traditional culture to a westernized society
| suddenly get Type II diabetes up the waz, or why
| high blood pressure causes strokes, or why high
| vitamin D levels prevent cancer but vitamin D
| supplements don't, or any of that crap. It's an
| unmapped country -- we can see mountains but the
| hell if we can get there.
| 
| Should there be research? Of course, but lets look
| at a few things we do know and consider for a
| minute whether knowledge is actually the problem.
| 
| What does the doctor always tell you, that the
| acupuncturist and the, I dunno, shaman always
| agrees with?
| 
| Stop smoking. Well sure -- if you smoke. Also?
| Reduce your sugar and fat intake, eat more veget-
| ables, and exercise more.
| 
| There is so much research supporting these life-
| style changes that it isn't even worth citing....
| And compared to spending the rest of your life
| (after, say, age fifty) on an oxygen hose or
| paralysed on one side of your body? Jeez, how hard
| could eating vegetables be?
| 
| And yet, after something like a hundred years of
| public health research and practice, we have a
| negative success rate.... People are more sedent-
| ary, eat more sugar, less vegetables, and have
| predictably higher rates of disease as a result.
| 
| Can we manage the worst effects? Of course --
| antihypertensives work, so do antidepressants and
| other drugs. And I'm not saying all these diseases
| would disappear if people all lived like Lance
| "even Lance Armstrong got cancer" Armstrong....
| But where the gap appears is in the distance
| between knowing what preventive and lifestyle
| changes to promote..., throwing literally gobs of
| money at their promotion on one side, and people
| actually doing those things on the other side.
| 
| Cue the excuses -- brain addictions! Advertising!
| General unworthiness of Americans!
| 
| But this is beside the point, which is that we
| don't yet know how to do preventive medicine right.
| So until somebody ...actually gets people doing
| the things that prevent disease, starting with
| the above but continuing on to other proven
| strategies, like spending time in groups with
| friends (which you would think would be fun) I
| disagree with the proposition that the problem
| with preventive medicine is that it just isn't
| done. It isn't done because we don't know how to
| do it.

The topmost healthcare issue in the news cycle right
now is the rapid uninsuring of working people and
the poor. As underlying fundamentals crumble:
 
1. Private insurance companies hiked monthly rent
   and raised costs insured people have to bear
   before insurance pays anything, posting record
   profits and exec bonuses year after year. Cost
   increases were kept from being a political
   problem for the last 5 years by taxpayer money
   (tax refunds) that expired this month, doubling
   insurance rent, even if unused, to the price of a
   new car annually for many.
2. Public insurance for seniors (Medicare) has been
   largely sold to private for-profit insurers
   ("Advantage"), putting retirees in the same boat.
3. Public insurance for disabled and poor people is
   being rapidly dealt death by a thousand cuts.

A particularly mercenary administration recognizes
the other political party is heavily financed by
insurers. Dramatically cutting the number insured
could deny opponents campaign finances.

It also accelerated the rapid die-off of rural
critical access hospitals, which heavily depend on
Medicare and Medicaid.

I loved Medicaid. For the six years I had it I saw
my doctor annually til she quit for a concierge
practice. My cheap generic meds were free to me. I
got my teeth cleaned regularly, and an x-ray when I
broke my knee. Medicaid paid for my daughter's
pediatrician visits and dental check-ups, and for an
x-ray when she broke her wrist.

What I miss was primary care that never cost much,
care from the 5% of healthcare spend that accounts
for 35% of doctor visits and is endangered for the
many reasons above, regardless of insurance.

If that 5% of primary care spend can be rescued from
insurance companies and dependably financed, maybe
with aid from Kentucky or its counties (such as 
trustworthy liability shields and dependable public
service debt forgiveness), then the overpromising,
under-delivering debt-ravenous monster "healthcare"
may die without taking the whole practice of
medicine with it.