[NA] Health Insurance. US vs. Elsewhere

But again, is that drastically different from other rich countries in 2021?

In the other rich countries, you go on a waiting list for non-emergency procedures (not a heart attack). That's how they throttle the costs. A knee replacement, a shoulder clean-out, varicose vein or sinus surgery? You could wait months. Here? If you wait over a few weeks is mostly because you deferred for some reason.
 
I've worked on patients from many countries, and their systems are horrible



Had a USA ACA breast cancer patient here a last month that her father sold retirement assets to pay for breast cancer surgery at MD Anderson as only one surgeon here locally accepts ACA and he now has a one year wait ...
And this is better? You have to choose between retiring comfortably or having your daughter get breast cancer surgery?

The number one cause for personal bankruptcy in the USA is medical bills. That’s unconscionable.
 
In the other rich countries, you go on a waiting list for non-emergency procedures (not a heart attack). That's how they throttle the costs. A knee replacement, a shoulder clean-out, varicose vein or sinus surgery? You could wait months. Here? If you wait over a few weeks is mostly because you deferred for some reason.
Most countries with universal healthcare allow an alternative private stream where you (or your insurance company) can pay for you to skip the queue if you want. Canada is unusual (or even unique) in not allowing that, but the U.S. wouldn't be compelled to follow the Canadian model rather than choosing one of the many others available. And all those countries that allow private insurance for people to skip the queue (like in the UK) still come in about 1/3 under the U.S. even when you add all private and public spending together. So that's not the explanation either.

The U.S. isn't expensive because it offers better care; the U.S. is expensive because it offers that care inefficiently, through a plethora of private insurance channels that all cover different sets of treatments, resulting in huge administrative overheads and delayed/complex decision making for healthcare providers. That's the most-likely main cause (though of course, other things, like underuse of MRI machines that someone else mentioned, and tort costs, would be minor contributing factors). Note how "healthcare administrator" is a much-more common job title in the U.S. than anywhere else.
 
resulting in huge administrative overheads and delayed/complex decision making for healthcare providers.
And one part to this problem is that every state has a separate set of requirements which require duplicate admin costs x50 even for the same company. Allow insurance companies to sell across state lines and it will be interesting where that will take the costs.
 

They may CLAIM 16 days, but I guarantee you I was seeing patients with WAY LONGER wait times all the way down in El Paso as late as January 2020 just prior to Covid outbreak. Maybe Ontario ONLY thinks they have a fast response time. Also, article claims AFTER decision made ... my patients were in a "wait hold" for surgry consultation for 9 months ....
 
And this is better? You have to choose between retiring comfortably or having your daughter get breast cancer surgery? The number one cause for personal bankruptcy in the USA is medical bills. That’s unconscionable.

No, it's ACA which I was illuminating was BAD! If you go back and re-read I think it'll make sense. Insurance programs in the 1980's were far better and WAY cheaper than current despite medical costs being HIGHER.
 
They may CLAIM 16 days, but I guarantee you I was seeing patients with WAY LONGER wait times all the way down in El Paso as late as January 2020 just prior to Covid outbreak. Maybe Ontario ONLY thinks they have a fast response time. Also, article claims AFTER decision made ... my patients were in a "wait hold" for surgry consultation for 9 months ....

That's like the wait times at the VA. The reports handed to the VA secretary look great while vets who want to schedule procedures get the busy signal.
 
That's like the wait times at the VA. The reports handed to the VA secretary look great while vets who want to schedule procedures get the busy signal.
I have received care through the VA that is on par or of higher quality than is typical on the civilian side. I never have a problem seeing my primary whenever needed including walk ins. Sure, some things like optometry and dental have to be scheduled several weeks or months out, but anything emergent gets you seen five minutes ago. As a bonus my ortho is a reserve Viper pilot so whenever I see him we get to tell lies about who can drink more and wether door kickers have a greater sexual prowess than zoomies. It may not be perfect but it's not bad.

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No, it's ACA which I was illuminating was BAD! If you go back and re-read I think it'll make sense. Insurance programs in the 1980's were far better and WAY cheaper than current despite medical costs being HIGHER.
Yes, but this has been a problem long before ACA was around. You can’t pin our tremendously expensive healthcare on ACA. We, as a nation, can do better for all people living here.
 
Yes, but this has been a problem long before ACA was around. You can’t pin our tremendously expensive healthcare on ACA. We, as a nation, can do better for all people living here.

Why did insurance rates go crazy with introduction of ACA though?
 
I'm going to drop out of this thread now. It's been an informative and civil one, and I've enjoyed the discussion.

We have a lot of things we need to fix in our own healthcare system in Canada, some of which are similar to the problems in the U.S. (e.g. poor conditions in long-term care, and not enough hospital beds per 1,000 people, both of which made the impact of C19 much worse), and some of which are different (e.g. wait times for some elective surgeries, or poor healthcare access for indigenous people in remote northern communities).

I know it will be hard to fix the systemic healthcare problems in the U.S. because you have strong vested interests who benefit from the status quo, and also because partisan political types have chosen to use it as yet another identity test (if you think X you're Democrat, and if you think Y you're Republican), which is the scourge of U.S. politics.

But the U.S. is a great country, and I have faith you'll all work it out. You'll know when you've succeeded because you'll be able to boast about your major healthcare indicators (like life expectancy or maternal mortality) rather coming online posting excuses for them.
 
9 pages, and I saw some nods to it, but most hospitals do have their pricing buried on their website. Keyword “charge master” should get you there. Same procedure, even same surgeon, two hospitals in the same system will get you a 25% swing easily. Or same hospital, two insurance plans, same deal. The system is…sub-optimal in many places, where care and costs diverge, that any change to chip away at the problem is welcome. That’s the only realistic way to make progress given the breadth of issues.
 
9 pages, and I saw some nods to it, but most hospitals do have their pricing buried on their website. Keyword “charge master” should get you there. Same procedure, even same surgeon, two hospitals in the same system will get you a 25% swing easily. Or same hospital, two insurance plans, same deal. The system is…sub-optimal in many places, where care and costs diverge, that any change to chip away at the problem is welcome. That’s the only realistic way to make progress given the breadth of issues.

What the hospital charges is irrelevant. What they contracted for with your health plan is what governs your expense. For any elective surgery, that is an answer you have to obtain from your insurance company. Make certain that not only the surgeon and the hospital, but also the anesthesiology group is in-network ('par') for your plan (and take your business somewhere else if they are coy about sharing that bit of information).
 
What the hospital charges is irrelevant. What they contracted for with your health plan is what governs your expense. For any elective surgery, that is an answer you have to obtain from your insurance company. Make certain that not only the surgeon and the hospital, but also the anesthesiology group is in-network ('par') for your plan (and take your business somewhere else if they are coy about sharing that bit of information).

But that's like going into the store and having to pay more (or less) for bread because you wear Levis jeans instead of Wranglers.

Any procedure should be charged the same within the same hospital regardless of the doctor or room number it's performed in.

No wonder this system is so ****ed up.
 
But that's like going into the store and having to pay more (or less) for bread because you wear Levis jeans instead of Wranglers.

Any procedure should be charged the same within the same hospital regardless of the doctor or room number it's performed in.

No wonder this system is so ****ed up.
If you've ever seen the IDC10 coding list for medical billing, it would blow your mind. A hysterectomy maybe a "standard procedure" but there are all sorts of things that may have needed to be done mid-procedure that are billed as separate items. Some require different consumables or complications that used specialized equipment not needed for the routine procedure. Some of it is piddly little crap that shouldn't really need to be reimbursed, but some things are significant and must be billed as such.

Sucks that it's nickel and dimed, but that's what we get for dealing with insurance companies.
 
But that's like going into the store and having to pay more (or less) for bread because you wear Levis jeans instead of Wranglers.

Any procedure should be charged the same within the same hospital regardless of the doctor or room number it's performed in.

No wonder this system is so ****ed up.

The charge is usually the same.

The charge may be $1000 for a service.
- medicare pays $240
- medicaid pays $180
- blue cross pays $320
- Aetna pays $241, but the provider has to pry it out of them
- united simply denies payment
- uninsured patient with assets gets bill for $1000, after some arguing and screaming puts $600 on a credit card to make it go away
- uninsured patient without assets gives fake adress and social security number, pays $0
 
Fwiw, I am just heading out to pick up a family member at the university hospital in germany. Pretty straightforward medical condition. When it happens, you have to do A, B, C and depending on B you may have to do D. Doesn't matter where you are in the world, those are the things that need to be done. Well, they did A ,sort of half-assed B and then the weekend set in and all medical care stopped. Saturday morning the hospital discharged him to get B-D done as an outpatient, knowing well that the services are not available to outpatients. I am sure the performance measures look great !
 
Yes, but this has been a problem long before ACA was around. You can’t pin our tremendously expensive healthcare on ACA. We, as a nation, can do better for all people living here.

without an honest approach to the true causes of health costs, we never will.

lawsuits adds costs directly.
The doctor’s malpractice insurance restricts practice and increases the number of HC professionals you need to visit.
Doctors practice a legal defense before they practice medicine - what they must do is dictated by formulary.
No doctor dares to refuse treatment that is demanded, whether it is needed or not.

if you do root cause analysis, this is all driven by tort problems. If we can fix those things, lots of cost will come out.
 
without an honest approach to the true causes of health costs, we never will.

lawsuits adds costs directly.
The doctor’s malpractice insurance restricts practice and increases the number of HC professionals you need to visit.
Doctors practice a legal defense before they practice medicine - what they must do is dictated by formulary.
No doctor dares to refuse treatment that is demanded, whether it is needed or not.

if you do root cause analysis, this is all driven by tort problems. If we can fix those things, lots of cost will come out.
Do lawyers ever actually benefit society? Nurses do doctors do, garbage truck drivers do, waiters, barbers, but lawyers? I just can’t think of any reasonable benefit. It seems like there’s just my lawyer battling your lawyer. Most countries get By just fine without them, by and large.
 
Do lawyers ever actually benefit society? Nurses do doctors do, garbage truck drivers do, waiters, barbers, but lawyers? I just can’t think of any reasonable benefit. It seems like there’s just my lawyer battling your lawyer. Most countries get By just fine without them, by and large.

There is some use to having lawyers around to maintain checks and balances. But like accountants (I respect 'em, but the function isn't a value add), the profession overall doesn't add to the human experience. Unfortunately, lawyers write legal rules and accountants write accounting rules (and tax code) and those laws and codes are not written with the intent of putting lawyers or accountants out of a job...
 
Citation please.
To add to the above… there are plenty of “citations” on the effects of ACA to the cost of medical care. They’re just hard to find as most only address it on a state by state issue and not a national issue--and in my opinion, by design as ACA specifically created an exchange for every state.

The most prolific citations are those of individuals who saw their medical costs rise exponentially in most cases. Personally my costs went from about $220 per month to over $2500+ per month if I would have stuck with that final policy and it wasn’t removed from the exchange due to high cost. Keep in mind the ACA actually started in 2010 but in the 1st week of 2014 it started the process to offer 12M+ people “free” insurance via Medicaid expansion and an additional 12M+ people heavily subsidized medical insurance up to a certain income bracket. In my state alone over 400K+ were added to the Medicaid roles. Guess who got to pay for it? If you did not receive insurance through an employer and had an income outside the ACA subsidy limits, you got hammered. Nobody wrote a citation on those folks.

Regardless, the citations are there if your choose to look, like how many insurance companies quite various state exchanges because they couldn’t make a profit which in turn jacked up costs to everyone in that state. And so on. I’ve debated this same question for 7 years now and have never lost the debate simply by keeping my insurance bills and receipts. Perhaps ask those in your state for their "citation"?
 
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Do lawyers ever actually benefit society?
Yes. Given that over 50% of governing bodies at the state and national levels are lawyers/attorneys, we have no choice. However, where a lawyer/attorney comes into their own is when they defend you from that same body or worse a plaintiff. At the center of any society is the law. Just see what happens when it's not.;)
 
Citation please.
Mine more than doubled and I got less coverage. And that doubling only came after ACA and after years of nominal (less than 10% and sometimes no) annual increases.
Oh, but I am now covered for pregnancy and having all my non-existent lady parts examined, so I've got that going for me.
 
My insurance was relatively unaffected by ACA because I was grandfathered and I liked my health insurance so I could keep it. Then after a few years my insurance apparently didn't like it so they sent me a letter saying they were no longer going to offer my plan and I could seek coverage on the exchange. Apparently I could no longer keep my plan... The new ACA insurance decreased coverage exposing me to risk of financial devastation in the event of the need to actually use the coverage, and it was a 500% increase in the cost of the premium over the plan that I had before ACA.
 
Yes. Given that over 50% of governing bodies at the state and national levels are lawyers/attorneys, we have no choice. However, where a lawyer/attorney comes into their own is when they defend you from that same body or worse a plaintiff. At the center of any society is the law. Just see what happens when it's not.;)
Still, to a large extent, they are a self-licking ice cream cone. The example provided is still my lawyer defending me against the governing body’s lawyer. If you removed the money from the process and paid them a fixed wage, would there be as many lawyers? But I agree that we, as a modern society need lawyers and laws. I just think that their perception of value is greater than actual. They have made it so that I can’t even practically defend myself in traffic court
 
My wallet and the fact that I am paying almost $1800 a month for less insurance than I had before ACA when I was paying about $875 per month.

Mine more than doubled and I got less coverage

Sorry you guys saw increases. The world is an imperfect place. If you look at health care as a whole, you'll find that insurance costs moderated during ACA (note that I said "during" not "because of", because the world is also a complicated place). In any case, this is why it's important to not accept anecdotes as being truth. Only by looking at the big picture can you make a credible claim that ACA caused prices to go up, and in this case, the data doesn't support that position.

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Only by looking at the big picture can you make a credible claim that ACA caused prices to go up, and in this case, the data doesn't support that position.
Not quite. The intent of ACA was not to control "total expenditures" but to get a select group of people medical coverage be re-configuring who would pay for it. So your graph does not address those increases. It was those with individual policies vs group policies that took it the hardest. The graphs below show this increase and the speed at which it happened right at the start of ACA in 2014. As you can see the plot of those with individual plans skyrocketed past group plan costs in a matter of a year. So while you consider the examples above as "anecdotes" they are actually the hard facts of the matter. As I stated earlier, there are many citations on these rate increases if you so choose to look, but to state that ACA did not cause individual costs to significantly increase is simply false.
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Still, to a large extent, they are a self-licking ice cream cone.
My reply was to your 1st question, but like any unperfect system this is also true. It's no different than no tort monetary caps or the ongoing legacy oil company cases in LA where the only people that benefit are the law firms on both sides. Regardless, until we stop electing a majority of legal counselors to office they will be manning the ice cream machine 24/7.
 
Not quite. The intent of ACA was not to control "total expenditures" but to get a select group of people medical coverage be re-configuring who would pay for it.

Fair point. ACA was the coverage of last resort and that pool of people tended to be sicker than average, so costs were higher. This is why I support single payer instead of ACA.

So, see if you agree with this. The ACA didn't cause insurance rates at large to go up, much less the cost of health care, but did cause the prices to go up for individual payers because they got a new group of sicker people into their pool.
 
Fair point. ACA was the coverage of last resort and that pool of people tended to be sicker than average, so costs were higher. This is why I support single payer instead of ACA.

So, see if you agree with this. The ACA didn't cause insurance rates at large to go up, much less the cost of health care, but did cause the prices to go up for individual payers because they got a new group of sicker people into their pool.

The people who already had insurance saw their rates go up to cover those that were paying 0.

So yeah the total expenditure per person stayed the same, but when you add a pool that arent paying anything how else do you keep the per person the same? By bending those over who are already paying in.

Broken down to simplest. I pay 1000 and am insured. 1 person isnt paying anything and is uninsured. Total cost per insured is 1000 per. Now lets add the uninsured who isnt paying anything and keep the 1000 per insured the same to sell it to the public. How do we do that? Not by having the person paying 0 pay 1000, but by having the person already paying 1000 now pay 2000. Hey look the cost per insured the same!
Well no **** Sherlock, but look who's shouldering that.
 
The people who already had insurance saw their rates go up to cover those that were paying 0

I think that's half right. The first part is almost true. Saying "people who already had insurance" is too broad. More correctly it would be "individual payers who qualified for and already had insurance".

The second part was that people who previously were uninsurable had access to insurance for the first time and no longer had to fear bankruptcy, at least, dying, at worst, if they got sick. Characterizing them as people who paid 0 isn't accurate.

In any case, like I said before, this is one reason I don't support the ACA and instead support single payer. And this is despite the fact that the ACA *helped* me. My rates went down and it was very valuable to us to be able to keep our son on our insurance for longer thanks to ACA rules. But, like I also said before, basing public policy on individual anecdotes isn't good government, which is why I kept pounding the table for citations.
 
ACA was the coverage of last resort and that pool of people tended to be sicker than average
That is not correct. Outside of employer plans, ACA became the only coverage option. ACA offered expanded Medicaid coverage up from the existing $11,500 single income limit to $16,000. This provided “free” insurance coverage to millions in various states. From single income limits of $16,001 to $49,999 ACA subsidized those individuals premiums/deductibles by 20% to 100% depending on type ACA policy used. Now anyone (single) beyond the $49,999 limit was paying full price which ironically hit the small business owner the hardest as few qualified for group rates. So ACA was hardly a true “coverage of last resort” otherwise everyone regardless of income would have been on it. Whether anyone who received coverage through Medicaid expansion or through the subsidized exchange was any sicker than average I would not know but they still received their coverage at a substantial cost reduction.
So see if you agree with this. The ACA didn't cause insurance rates at large to go up, much less the cost of health care,The ACA didn't cause insurance rates at large to go up, much less the cost of health care,
Not really. One thing ACA did from the get go was change how the money flowed between patient and provider. For example, it drastically decreased certain provider reimbursements and created a new separate path for the ACA subsidy/penalty moneys to follow through the IRS. Some people have claimed this was by design to keep the ACA costs within historical trends. Even the “father of ACA” had problems explaining this issue before a sub-committee. So considering the IRS handles the subsidies/penalties and HHS handles the exchanges I would be suspect on any medical expenditure comparisons from what I’ve experienced, read, and been told. As they say follow the money…..

As to a single payer system, I don't think it will address any of the current issues any better. Just look at existing single payer systems. Given how 20% of people self insured themselves prior to ACA and those younger/healthy individuals that were "supposed to pay for ACA" decided to not buy ACA coverage and pay their $900 penalty instead, I think re-establishing a tiered group of catastrophic medical plans with no age limits and allowing any insurance provider to offer plans nationally without state oversight would get us to a better place that provides each person the ability to select their level of coverage and cost. And not another system that mandates nuns to pay for birth control and pregnancy coverage.
 
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I think re-establishing a tiered group of catastrophic medical plans with no age limits and allowing any insurance provider to offer plans nationally without state oversight would get us to a better place that provides each person the ability to select their level of coverage and cost.

Here's the rub. We tried this, and it results in many medical bankruptcies. When you only offer "catastrophic" plans, and particularly with no rules, people will opt for the coverage that costs them the least, or close to it. $10,000 deductible? Sure. There is a huge percentage of the US population that can barely scrape together $1,000 for an emergency car repair, let alone $10,000 for a broken arm. Unregulated? So we'll put a $1,000,000 lifetime cap on the policy (many policies used to have lifetime caps). Sounds low-risk, until you get an aggressive cancer that requires multiple years of treatments. People are really bad at assessing risk, and if you can't adequately assess risk, picking medical insurance is worse than playing Vegas.

It fundamentally comes to that you can never fairly assume that the consumer of medical services or purchaser of medical insurance is a well informed consumer, so a "free market" assumption is always going to be a poor starting point to assume. Most of us, as pilots, are used to complex systems and needing to understand lots of fine print. That isn't how the average Joe or Jane lives their lives.

My other personal pet-peeve with our current system is that there are huge administrative and time costs that are not captured by any of the normal metrics. I'm referring to: 1) the vast resources private companies and governments have to pour into administering health plans for their employees; and 2) the huge amount of time both the insured and uninsured need to spend to pay medical bills and sort through explanation-of-benefits to ensure they aren't getting screwed over by the provider or their insurance company. Virtually all of this goes away under a single-payer system (unless an employer chooses to offer a supplemental plan, as would likely be allowed). Will there still be battles over coverage with a government-paid system? Of course, but this happens regularly with private insurance now, and an "independent" ombudsman program could help to address that concern.
 
When you only offer "catastrophic" plans, and particularly with no rules,
I believe I stated “reestablish” catastrophic plans as it relates to ACA putting an age 30 limit on them. That age limit affected millions to include me for no apparent reason than to force people to buy full coverage that was not wanted.

And never said “no rules” or “unregulated” either. But requiring the same insurance provider to abide by different rules for the same policy in each state is not cost effective either. A single group of rules and regulations at the federal level seems to work for just about every other similar situation except private medical insurance. Which will also substantially reduce the current “huge administrative and time costs” you mentioned.

While I don’t follow your “medical bankruptcy” comment, if that is a concern you can apply an asset requirement/review to each plan as needed. They do this with Medicaid and other similar programs.
It fundamentally comes to that you can never fairly assume that the consumer of medical services or purchaser of medical insurance is a well informed consumer, so a "free market" assumption is always going to be a poor starting point to assume.
So you’re saying someone should make that decision for them? Should we also decide/force people to save for their retirements as well given over 75% of people age 50 have less than $100K in retirement? Regardless what medical system is used there will always be the 25% who expect someone else to make their decisions and take care of them. I understand that but to tweak the remaining 75% to accomplish that I don’t agree with.

For example, at one time my state had a robust charity hospital system that consolidated the Medicaid money and provided care to those who couldn’t afford care, fell through the cracks, or couldn't figure things out that you refer to. This system was managed and operated through the state medical schools and it worked. Granted there wasn’t a clinic in ever town and you may have to travel from one end of the state to the other to get certain services, but you got the care needed. And on average, care equal to or better than the private hospital system. Our charity system started it’s downfall with the original signing of ACA in 2010 and completely went away in 2014 because it didn’t fit into the “narrative”, i.e., insurance companies couldn’t make money.

So why not have each state form a charity system? They could manage it to handle the demographics and issues unique to their state and use the existing Medicaid monies. However, I don’t think there will be a simple solution to the core mess caused by ACA. It changed things to the point where you can’t get rid of it. Regardless, I have been having this same discussion for the past 7 years with a variety of people who tend to follow what I’ve posted earlier than a single payer system. Hopefully one day soon we can at least move in some sort of direction than the one we are on now.
 
I believe I stated “reestablish” catastrophic plans as it relates to ACA putting an age 30 limit on them. That age limit affected millions to include me for no apparent reason than to force people to buy full coverage that was not wanted.
Same here. If we are talking about a $10,000 deductible that some can't afford, we are also talking about an annual premium now that is greater than $10,000. I pay more than this (more than $15,000) to insure just myself as an individual with no subsidy. Granted, I'm on the older side of the spectrum. Not sure what younger people pay for an individual policy.
 
Should we also decide/force people to save for their retirements as well

We've been doing that for a long time (Social Security), and heavily incentivizing the voluntary retirement savings (deductibility of IRA/401k contributions). We've also been "forcing" people to pay for much of their age 65+ medical care by payroll deductions too. We've already made a huge proportion of medical care single-payer, adding most of the rest is really just a matter of degrees. Notice I said "most", I'm not at all opposed to retaining private supplement insurance offerings.

Lifting the administrative burden of health care off of small businesses would allow a significant decrease in overhead costs. It is proportionately less of an cost to large employers, though still not negligible. If you've haven't spent hundreds of hours of your life on the phone and computer dealing with medical payment issues, consider yourself lucky.
 
Yes, but this has been a problem long before ACA was around. You can’t pin our tremendously expensive healthcare on ACA. We, as a nation, can do better for all people living here.

Unfortunately I don't have to pin it, most of the massive increases have a near direct correlation. I've been in the field and practice on the border . Initially, medical procedures were sky high and our insurance costs were dirt cheap. The reverse is true now. Indigent care was provided at the county hospital at cost back then (I worked there) where the residents were awesome.

Fast forward to today, residents have limited shift time and "attendings" on-site 24-7 doing most of the work as they don't want to turn anything over to the resident. Residents graduate clinically extremely weak compared to the 1980's. Further, most physician are now employees of one of the big hospital groups with no incentive to "crank load" like they used to ... my OB-GYN friends cashed out and now operate at about 30%. When you go to the hospital you will get a "hospitalist" in most cases. If delivering a baby, coverage is Monday- Thursday only by the two docs in the group and hospitalists after that. ER will be a NP or PA. This will have dramatic effects on MD Anderson and Sloan Kettering in the very near future regarding research ... remember how England treated those infants years ago that other countries were offering citizenship in an effort to provide costly care? Socialized medicine works great as long as you don't get sick ... bad schedule B reimbursements destroyed the medical field resulting in all those employee physicians (the good ones and the bad ones are paid the same).
 
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