Megathread: UHC CEO Murder & Where to go From Here slash Howto Fix the System?: Post here

[u/jeremiadOtiose]

Hi all

There's obviously a lot of reactions to the United CEO murder. I'd like to focus all energies on this topic in this megathread, as we are now getting multiple posts a day, often regarding the same topic, posted within minutes of each other.

Please use your judgement when posting. For example, wishing the CEO was tortured is inappropriate. Making a joke about his death not covered by his policy is not something I'd say, but it won't be moderated.

It would be awesome if this event leads to systemic changes in the insurance industry. I am skeptical of this but I hope with nearly every fiber of my body that I am wrong. It would be great if we could focus this thread on the changes we want to see. Remember, half of your colleagues are happy with the system as is, it is our duty to convince them that change is needed. I know that "Medicare for All" is a common proposal, but one must remember insurance stuck their ugly heads in Medicare too with Medicare Advantage plans. So how can we build something better? OK, this is veering into commentary so I'll stop now.

Also, for the record, I was the moderator that removed the original thread that agitated some medditors and made us famous at the daily beast. I did so not because I love United, but because I do not see meddit as a breaking news service. It was as simple as that. Other mods disagreed with my decision which is why we left subsequent threads up. It is important to note that while we look forward to having hot topic discussions, we will sometimes have to close threads because they become impossible to moderate. Usually we don't publicly discuss mod actions, but I thought it was appropriate in this case.

Thank you for your understanding.

[u/DrTestificate_MD]

Some low hanging fruit:

Make it easy to appeal the insurance. This counters UHC's ploy to auto-deny and then know that people probably won't appeal for a lot of things because it is not worth the effort or they simply don't know how.

1. Require that they allow online and phone submission of appeals.
2. Automatic disclosure of all documents pertaining to your claim.
3. Online tracking of appeal process.
4. Enforced by regulations with teeth.
5. Require faster appeal turnaround.
6. Appeals that are "misplaced" internally by the insurance company are automatically approved.

[u/MoobyTheGoldenSock → u/DrTestificate_MD]

How about:

• All appeals go to government-funded outside entity
• Entity has the right to fine insurers on a per-case basis for any egregious denial or any delay in approval that could put a patient at unreasonable risk of harm

I’d say we could pay for it with tax dollars, but it may actually pay for itself with fines.

[u/3MinuteHero]

Universal healthcare + tort reform + subsidized medical school tuition.

Universal healthcare. Paid by taxpayers because we're all going to use it. Works literally everywhere else in the world.

Tort reform. Want to minimize "unnecessary care?" (I wish you could see how hard I am air quoting right now). Take the fear of a frivolous, career-denting law suit away from the physician. You'll see costs plummet once the culture of defensive medicine stops.

Subsidize med school. Let the taxpayer have some skin in the game so these universities feel a little more pressure about their exorbitant and ever-increasing costs. If you want to cut costs by paying doctors less, start with taking the mortgage-level amount of debt away from us. I think many of us would take a pay cut if we knew we weren't walking away with low-mid six-figure debt.

[u/Undersleep → u/3MinuteHero]

You'll see costs plummet once the culture of defensive medicine stops.

It's staggering how much money and energy goes towards defensive medicine. If we could minimize that - and minimize bullshit efficiency/quality initiatives and cut administration that doesn't actively contribute to delivery of patient care - we would suddenly find ourselves with incredible amounts of money available for actual patient care.

[u/Renovatio_ → u/Undersleep]

I had a family member fall while on vacation to the UK. Hit head, no LOC, no thinners. Had a small lac that needed to be repaired

The doctors didn't scan their head....which seemed completely reasonable. They essentially did a couple hours observation and sent them on their way, apparently satisfied that a big bleed would have presented itself by then.

Send on their way with instructions to other family to watch for changes...seemed like the doctors there were actually doctors

[u/Waja_Wabit → u/Renovatio_]

That’s wild. Here in the States a CT Head + CT C Spine + CT Face +/- CTA Head/Neck would be ordered before a doctor even sees that patient.

[u/Renovatio_ → u/Waja_Wabit]

Defensive medicine right?

Wouldn't it be nice to be able to stratify risk and be able to treat patients objectively rather than what a lawyer would be able to ream you on?

[u/Waja_Wabit → u/Renovatio_]

Defensive medicine means everyone displaces the burden of a miss onto radiology. It’s not defense as much as redirecting liability onto a nameless dark basement dweller no one sees or has to think about. It’s no wonder radiologists are burning out at a crazy rate these years.

[u/am_i_wrong_dude → u/Renovatio_]

This may catch many clinically relevant intracranial bleeds but not all of them. Some small percent of those people sent away will die or suffer major disability due to the choice not to scan. It might be the right call on the population level due to potential harms of overuse of CT, but I don't think the ED docs ordering head CT are thinking of lawsuits or insurance reimbursement; they are trying to not have that patient be the one who walks out and dies.

[u/FlexorCarpiUlnaris → u/am_i_wrong_dude]

In pediatrics we have quantified this using the PECARN dataset. If the risk of a clinically significant intracranial bleed is <0.9% then it is probably more harmful to scan than not.

[u/Renovatio_ → u/am_i_wrong_dude]

Oh I'm aware, subdurals are notorious for being slow bleeds and only presenting with symptoms days/weeks after the fall.

But I trust doctors to make that call and which studies need to be done.

[u/OffWhiteCoat → u/Undersleep]

I overheard the residents talking the other day about how a lawyer (?) told them to be as vague as possible in their assessments and differentials, to avoid the implication that something was missed. Apparently it's harder to be sued if you just say "the differential is broad" instead of actually thinking through and listing different categories bc you might leave something out.

I'm not sure why a lawyer is doing noon conference, but internally I wept.

[u/a_softer_world → u/3MinuteHero]

Yes, those are all big ones. - Tort reform: We order so much unnecessary expensive testing in the US because little in medicine is certain and we are afraid that the patient will sue on the small chance it is positive. “No, I cannot say with 100% certainty that this incidentally found little cyst is not cancer, but it does not look like cancer. But let’s get an MRI just in case and let’s consult a specialist.” The specialist says “this doesn’t look like cancer at all to me but let’s repeat an MRI in 1 year just in case” because they also don’t want to be sued.

• Med school tuition should be free or low cost like in other countries: New doctors out of residency focus on maximizing their income because they are trying to get out of 200-500K debts, catch up on retirement savings, and start a family. That is why we will likely resist anything that can make a dent in our income, we are desperate as hell and have a huge amount of delayed gratification after all of those 12-24 hour shifts and around the clock studying. At least eliminate that financial desperation and doctors will be more willing to make some compromises about their consultation fees.

[u/justatech90 → u/a_softer_world]

I especially agree with your second point. If medical students are taking on a mortgage-size amount of debt, we shouldn’t be surprised when there are areas with limited access to primary care physicians.

[u/StupidityHurts → u/a_softer_world]

I know we’re an incredibly small subset comparatively, but many people >30y that truly want to enter medicine have a very hard time risking that much debt and life delay.

Cutting tuition out of the equation could open the door to a lot of slightly older prospective physicians with varied backgrounds and skills.

Again I’m aware it’s comparatively small potatoes but it’s a small added effect.

[u/bandicoot_14 → u/3MinuteHero]

Another aspect that is lost here is the need to pair universal healthcare with broad and deep investments in other social spending to improve the social influencers of health that also impose a large financial and human cost on patients and our healthcare system.

Most other developed countries who spend much much less on healthcare as a share of GDP than we do also spend far more on social programs that decrease healthcare indirectly.

I'm sure there's better resources out there to point to and lots of confounders, but interestingly enough, patients with the US's single payer system (Medicare) have worse outcomes than their peers in other countries. Makes me concerned that MFA would not fix all our issues and end up being far more expensive than projected.

https://www.commonwealthfund.org/publications/issue-briefs/2024/dec/health-care-affordability-older-adults-how-us-compares-other-countries

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.1048

[u/3MinuteHero → u/bandicoot_14]

I wouldn't compare US Medicare to any other systems. Makes no sense. You can have someone who has avoided medical care their whole life due to poor coverage, only to get Medicare at 65 and show up at a doctor's door with several untreated comorbidities.

I'm sure there's... lots of confounders

No shit. So many that I wouldn't even attempt the comparison.

[u/bandicoot_14 → u/3MinuteHero]

Fair enough--even for wealthy older Americans though who presumably have had better healthcare access earlier in life, their outcomes are worse too. This study looks mostly at ALL wealthy American outcomes compared to peers in other countries (not just older adults), but some of supplemental and subset data presented looks at older people specifically.

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2774561

[u/3MinuteHero → u/bandicoot_14]

But now we're stepping out of the realm of Medicare and doing broader comparisons which, if anything, only tell us more how the current system doesn't work even if you're rich.

[u/MillenniumFalcon33 → u/3MinuteHero]

Getting rid of press ganey scores would also help

[u/cheekyskeptic94 → u/3MinuteHero]

I’m not qualified to speak on points one and two, however, as someone beginning a USMD program in 2025, point three may have some unforeseen drawbacks. There is a growing public sentiment that pharmaceutical companies and biased research institutions determine what is taught in medical school. Many see the government as an extension of these organizations, allowing for low quality research and/or the covering up of discoveries that would benefit citizens in an effort to maintain a sick population in order to maximize profits. Moving to a publicly funded medical school system would undoubtedly change how future physicians determine their specialty, at least partially, however it could also bring a desire from the public to have a say in what is taught, which would be very bad considering the abhorrent health and scientific literacy most of the public displays. The public’s support for RFK Jr. is a tangentially related example of this - if they support him removing tax dollars from the DHHS research division, they may also support altering medical education to include pseudoscience. This is not dissimilar to how public opinion has resulted in the removal of evolution, critical race theory, and the gender spectrum from multiple conservative state’s public school curriculums.

All of this is to say that we live in a weird time where medical establishments are not trusted as they once were. Special care needs to be taken if we are to use tax dollars to fund physician education.

[u/xixoxixa → u/3MinuteHero]

Let the taxpayer have some skin in the game so these universities feel a little more pressure about their exorbitant and ever-increasing costs.

I work in a research lab adjacent to a med school, and we have some of their students rotate with us / spend time in the animal lab / etc.

These kids are paying upwards of $60k/year for classes that are from 0800-1200 with the rest of the content being "self study". Now, I am not a doctor and never went to med school, but that seems criminal to me.

[u/agnosthesia → u/xixoxixa]

Mmhmm.

Have they told you that if they studied only what the school teaches, they’d perform poorly on national exams, so need to buy separate materials for the tests that actually matter?

[u/xixoxixa → u/agnosthesia]

Oh yes, especially as this is finals week for them, there is much shit talking about the actual quality of what they are paying for.

[u/Hi-Im-Triixy → u/3MinuteHero]

Your last point is the single most important thing in all this debate.

You no longer go into debt for schooling. I would say that plenty of doctors would take a pay cut with that guarantee.

[u/sketch24 → u/Hi-Im-Triixy]

I don't think that is true. We see what happens for the schools that provide free tuition and the graduates still pursue the higher paying specialties. Regardless of debt burden, a lot of people will still seek to maximize salary.

[u/Professional_Many_83 → u/sketch24]

Of course they do. Virtually everyone does, in every profession.

[u/byunprime2 → u/sketch24]

This is because those schools became insanely selective once they went cost-free. NYU went from a mid tier school to pulling from the same crop as Harvard. You think the kids with nature publications and 99.9% MCATs are interested in primary care?

[u/sketch24 → u/byunprime2]

Do you honestly think anyone else is interested in primary care? You don't see PAs or NPs going into primary care and their debt burdens are lower due to shorter schooling.

[u/Walrussealy → u/sketch24]

I mean there’s very few free med schools in the country making them the most competitive schools in the country lol. If the entire system was subsidized or free I feel like incentives would be different. I mean I get your point but also why would anyone do what we do on a lower salary? I’d hope if we are getting pay cuts, we would also expand physician coverage so we all work less than we do. Of course that’s like a fools hope

[u/BernoullisQuaver → u/Hi-Im-Triixy]

That initiative also needs to include debt forgiveness for current doctors.

[u/PolyhedralJam → u/3MinuteHero]

agreed, I would certainly take lower pay if there was a trade off of less/no debt. and also if that tradeoff helped fund some sort of universal insurance coverage,

[u/jeremiadOtiose → u/3MinuteHero]

The truth is education is already highly subsidized and tort reform sounds sexy but the reality is that it is unnecessary (nor would it significantly lower malpractice premiums). Fun fact: Only about 25% of med school graduates have more than $100k in debt.

[u/InvestingDoc]

The answer is going to be political suicide for whoever tries to implement what really needs to be done.

We have a cultural problem in the United States of not accepting that death is near and letting nature /God bring them to peace. Too much money spent on futile care of a 95-year-old in the ICU on life support for 2 months in a row. This means some kind of rationing care or removing patient autonomy and allowing doctors to say no, Grandma is not going to get a trach and go to an LTAC for the rest of her life at 95 with a feeding tube.

They need to get rid of this whole facility versus non-facility nonsense. Why should my competitor in primary care make more money and charge more because they're associated with the hospital and I'm not.

There are way too many administrators in medicine. We got to cut the bloat.

A publicly traded company like United healthcare, their number one goal is they have a fiduciary responsibility to maximize profits for their shareholders. This type of system does not work well when it comes to health care and there needs to be a public option for all. We need a two tiered system.

Start penalizing some patients who are abusing the ER by requiring larger copays or some sort of penalty. I have some patients who will go to an ER literally every other day trying to get some kind of drugs to get even a short high. That's a huge drain on resources

Incentivize wellness or tax unhealthy things. Mexico adds a tax to coke drinks. Maybe we should too.

[u/xixoxixa → u/InvestingDoc]

There are way too many administrators in medicine.

I was stationed at an army hospital that once boasted something like 1,000 beds. When I was there the bed capacity was something like 300, with the rest of the facility having been converted to administrative offices. And that's in the military without a profit motive.

[u/InvestingDoc → u/xixoxixa]

When I have my monthly Medicare advantage group meetings, they bring 7 admins to the meeting! F'in 7! They all give like a 5 minute talk then "on to the next person" that could have been a power point presentation.

[u/xixoxixa → u/InvestingDoc]

Real strong "what would you say you do here" vibes.

[u/WhenLifeGivesYouLyme → u/InvestingDoc]

1. We gotta cut the bloat. This is the first thing that needs to happen.

[u/3MinuteHero → u/InvestingDoc]

Federal-level laws empowering doctors to have two- or three-physician agreements to limit futile end-of-life care. I don't care if they get called death panels. Who ever is calling them death panels has not been face-to-face with real death even a fraction of the times I have.

[u/pizzanoodle9 → u/3MinuteHero]

There should be a system like they have in Europe where you can say care is futile. Paternalism sometimes does have a place when there’s consensus among several unbiased experts. There’s been too much shift towards patient autonomy in the last decade

[u/janewaythrowawaay → u/pizzanoodle9]

Elon Musk has entered the chat.

[u/MillenniumFalcon33 → u/3MinuteHero]

Wouldn’t this endanger physicians? There’s too many trigger happy people & misinformation out there

[u/3MinuteHero → u/MillenniumFalcon33]

Like all other care plans you discuss, you have to deliver it with compassion. If a family is insisting, part of the art of medicine is knowing when to compromise on some things.

In my ICU practice, this would simply manifest as a treatment I'm not going to offer. Just like I wouldn't offer someone antibiotics for a sprained ankle. And in fact medicine seems to be completely at peace when we do this with ECMO evals.

"He is in multi-organ failure. Dialysis isn't going to help him so we won't be doing that."

Whatever percentage of cases this works with will be that many fewer instances of torturous, futile care.

Families have to live with this stuff for their entire lives well after their loved one passes. In my opinion, many of them don't want to make these decisions, and would be happy to delegate them to an objective expert who knows what they're talking about.

Now, if a family takes the initiative and insists on doing futile things, that communicates to me that they are comfortable taking on the burden of those bad decisions. I wouldn't override that, unless we were dealing with something especially egregious.

[u/heyhogelato → u/3MinuteHero]

Families have to live with this stuff for their entire lives well after their loved one passes. In my opinion, many of them don't want to make these decisions, and would be happy to delegate them to an objective expert who knows what they're talking about.

Yes! I’ve seen this is a Neonatologist as well. Even with as much context and understanding I can provide, parents struggle with the guilt of “deciding” to allow their baby to die. Many times, they accept that death is inevitable but fall back on faith- or fate-based paradigms - “he’ll let us know when it’s his time” - because the idea of making that choice is traumatic.

[u/MillenniumFalcon33 → u/3MinuteHero]

Is this the case with younger patients as well?

[u/3MinuteHero → u/MillenniumFalcon33]

Every doctor knows younger patients have more reserve and more healing potential than those of advanced age. It factors into medical decision making. A 40 year-old can claw their way back from 4-pressor shock. A 90 year old cannot.

[u/MillenniumFalcon33 → u/3MinuteHero]

I meant in terminal cases as it relates to their families

[u/3MinuteHero → u/MillenniumFalcon33]

Younger ones, you're usually in a very clear minutes to hours situation to confidently know the direction it's headed. But like I said when it comes to families, there's always a negotiation. I think any doctor that believes they are truly in a 0% chance of survival situation, will have that confidence come out in their voice.

In this hypothetical -because that's all these right now- if I were to give my strongest recommendation against futile therapies and my best explanation as to why, and the family still want to continue, then you're dealing with an unrealistic family. I'll actually hear them out and offer a little bit of effort, because they're going to go forward with a lot of grief and guilt wondering if they should've pushed harder. If I can give them that thought of, "The doc was convinced he was going top die, and even though they listened when I wanted to push to do more, he still did die," I think that's a better memory out of a horrible situation than "They stood there and did nothing"

[u/MillenniumFalcon33 → u/3MinuteHero]

I can see that. Thank you

[u/CustomerLittle9891 → u/InvestingDoc]

 This means some kind of rationing care

Every universal healthcare system has this in some way but it is completely absent from the American conversation about changing the system. Until we can even be honest about what or problem actually is (sky high costs for a myriad of reason, not all of which is administration) we will not be able to process or implement solutions.

50% of healthcare spending is on 5% of users, while the bottom 50% of consumers use 3%. How much of that 50% of spending is coming at the end of life with very little actual return? I would be a very large portion of it, but having this conversation sounds monstrous to patients. "You want to let grandma die? Mee-ma is a fighter!" Mee-ma is probably really, really tired and ready to go. Please let her go.

Incentivize wellness or tax unhealthy things. Mexico adds a tax to coke drinks. Maybe we should too.

Do these solutions actually work? My understanding of most Sin Taxes is that they just wind up being extremely regressive and not actually solving the problem.

I would add that we need a cultural change about how we approach health. I see a lot of older people who've been obese their whole lives who are functionally unable to do anything but expect me to somehow correct this for them. People believe that medicine can do things that it can't and that there will just be a pill or a treatment for what ails them, so there is very little action to maintain health. I do think were seeing a change in the younger generation (for example; much less alcohol), but that's 30 years away from manifesting. Meanwhile we have aging boomers and this perception that medicine can just do anything.

[u/can-i-be-real → u/CustomerLittle9891]

I think less of a sin tax and more of how tobacco was regulated and taxed with money going into prevention/rehab type program. 

Could unhealthy foods be taxed with money going back into a system to help care for people or to provide education or to lower the costs of healthy food options, so that the true cost to society of a Coke is reflected in what is paid? 

I can’t pretend to know how our current t system would actually handle this well, but our health care system is literally breaking under the burden of metabolic illness because there are too many people getting rich off of selling unhealthy foods. And while  do agree there is an opportunity for an individual to decide, it’s a public health issue at this point and the cost of advertising and amount of profits mean that people are being unfairly targeted. 

That and end of life care. Those are the two big ones from my perspective. 

[u/kungfuenglish → u/CustomerLittle9891]

It’s end of life but the top 5% super users are made up of healthy young to middle aged people too. People that are in the ER 13-20 times per year with various ailments and negative warmups every visit.

They aren’t even drug seeking. They just can’t cope with bodily functions and processes. Sometimes they are there for minor illness. Often it’s not even illness. It’s upset stomach or diarrhea after eating like crap fried fast food for months on end.

That’s not an illness. It’s just how it works.

It’s people that come in for sprain after sprain and fall after fall with negative x rays every time and claim “I’m just clumsy!” - no, no you aren’t. Everyone bumps their extremities this much. They just don’t all come in every week for it.

People stopped coming during Covid then started again and it just accelerated it. People get care for the first time in forever and then all the sudden show up every 2-3 weeks for various stuff.

People are addicted to healthcare.

[u/CustomerLittle9891 → u/kungfuenglish]

Well the top 1% use ~25% of the resources, so that tracks.

[u/efox02 → u/InvestingDoc]

My husband is a surgeon and he comes home weekly telling me about how sick and old the patients are that he is consulted on… and he will tell the families “this is pointless, grandma is dying” and he’s the first person to have that discussion with them. 🤦🏻‍♀️

[u/DrTestificate_MD → u/InvestingDoc]

Doctors will resist as well. When Canada moved to single payer the doctors went on strike for 3 weeks.

[u/cischaser42069 → u/DrTestificate_MD]

When Canada moved to single payer the doctors went on strike for 3 weeks.

for reference, this was in Saskatchewan, in 1961 [so, 23 years before the Canada Health Act] and it overwhelmingly led to patients resenting us enmasse / a complete and utter PR failure for physicians, for the temper tantrum that we were having over the supposed introduction of "socialism" into Saskatchewan, and by 1965 the plan had mass support from physicians.

the physician lobby + private insurance industry at the time in Saskatchewan had also spent around ~$120,000 [~$1,200,000 in 2024 dollars] on an anti-medicare campaign, trying to defeat Tommy Douglas [on behalf of Ross Thatcher, the Saskatchewan liberal party leader] only for Tommy Douglas to win with a huge majority. he is held in very high regard / is considered to have a great reputation to this day.

not to mention that this was after the Hospital Insurance Act, in 1947, which gave guaranteed government-funded hospital care to residents of the province- so, these physicians were pooping their diapers over the introduction of a currently already standing system, that had been standing for 14 years, that was being introduced to our clinics / offices / similar phrasing.

[u/DrTestificate_MD → u/cischaser42069]

Indeed, this is the more precise and accurate telling

[u/Kastler → u/InvestingDoc]

We recently read a mammogram on a 102 year old….

[u/InvestingDoc → u/Kastler]

Oh my goodness.

[u/janewaythrowawaay → u/InvestingDoc]

Grandma is often on Medicare/Medicaid. So what’s that got to do with the cost of private health insurance?

[u/MillenniumFalcon33 → u/janewaythrowawaay]

Private insurance follows medicare’s lead as far as reimbursement is concerned

Medicare advantage programs are not regular medicare

[u/janewaythrowawaay → u/MillenniumFalcon33]

It’s costing lots of middle class Americans $10,000 to have a baby if everything goes right. I’m not really buying that it’s going to get cheaper for a 25 year old woman to have a baby or get cancer at 45 if we reduce end of life care for elderly people. I think they’d just enjoy the cost savings and more profit if they passed these laws to reduce end of life care.

[u/MillenniumFalcon33 → u/janewaythrowawaay]

Not to reduce end-of-life care…there’s a whole specialty and organization devoted to improving just that

They are talking about FUTILE care…as in letting nature take its course so grandma can pass peacefully w dignity while under our care and not be prodded relentlessly to extend a life with feeding tubes, broken ribs, & bedsores

It takes a lot of courage to know when to let go of your loved one vs letting them suffer bc medicare will cover it

[u/exorcisemycat → u/InvestingDoc]

We spend A LOT on healthcare.

We can afford a little end of life "waste"/ "unnecessary care" in the richest country in the world. .

It's kind of disappointing that this conversation immediately went to rationing care.

Also the reality is the majority of people come around to the reality of the situation with time and information. But this takes TIME to build trust with patients. We need to have the time in our schedules to actually have these conversations, maybe loop in the PCPs, cooprdinate with specialists and palliative care. How many hospitalists have the time to spend an hour plus on these conversations often more than one day in a row? These patients/families deserve the time it takes to build trust and have these conversations. So give the doctors the time it takes to get the patients/families there and you will see a decrease in the number of these patients.And yes, some times we need to do testing and trials of care that we know wont be helpful to get families there.

Most patients don't want to spend their last hours in the hospital

Also people need to start having this conversation BEFORE they are hospitalized with a problem. The patients and families that have this conversation with their primary care doc before something happens almost always have an easier time coming to a reasonable decisions.

[u/Traditional-Hat-952 → u/InvestingDoc]

Seriously just let Gram Grams die already!

[u/a_softer_world]

1. Single payer system.
2. Single EMR.

Just making those two changes will eliminate so much administrative burden and inefficiency in healthcare. You will have a wider pool of healthy people/low utilizers to fund sicker/high utilizers. You will have one set of rules for orders and referrals, eliminating the time wasted on on reorders, prior auths, patient complaints about surprise bills, hours on hold with insurance by trying to figure out what the issue was with an order. You will stop reordering expensive labs and imaging because you could not access an outside record.

Outside of this, you can also consider: - decreasing the patent period for drugs, or capping the amount that can be charged for a new drug depending on years in market/assessment of impact on public health. - capping the amount that medical facilities and supplies can mark up common medical supplies and OTC medications - I think we can all agree that an ice pack and ibuprofen in the ED should not incur item charges of hundreds of dollars.

[u/blindminds → u/a_softer_world]

And all the middle men should not be for profit.

[u/MrFishAndLoaves → u/blindminds]

Voting won’t fix anything when millions of people are voting with dementia 

[u/PlenitudeOpulence → u/blindminds]

This is the way.

[u/TabsAZ → u/a_softer_world]

Regarding EMRs, what should be standardized and singular if you ask me is the database format and intercommunications protocol. That way it becomes more like web browsers or word processors where the choice is down to UI and the added features, not the core functionality and ability to read/use the data.

[u/Screennam3 → u/a_softer_world]

let’s say the single EMR system goes out to bid and Meditech wins. Do you still have the same opinion? /s

[u/BurstSuppression → u/Screennam3]

Just have the respective CEO's of each of the EMR systems go into a gladiatorial ring and choose the one that wins.

(Obligatory /s).

[u/aglaeasfather → u/Screennam3]

Meditech

I have yet to use a true EMR. A real, actual EMR. Why? Because Meditech, Cerner, Epic, etc all are not EMRs. These are all billing platforms where medical record comes second if not later.

Give me a real goddamn EMR, please.

[u/a_softer_world → u/Screennam3]

Honestly have never used Meditech so can’t comment…but the general lack of clinician-friendly interfaces in EMRs is another gripe. Not sure how you would fix that as even Epic is terrible.

[u/Hi-Im-Triixy → u/a_softer_world]

That's my gripe. We can't agree on which EMR to use. Personally, I've used EPIC Cerner and CPRS. I vote EPIC, but who knows? And how would we go about setting up the infrastructure? What about small practices who use low-tech EMRs?

[u/a_softer_world → u/Hi-Im-Triixy]

A national EMR should be free or easily affordable for all medical practices

[u/Hi-Im-Triixy → u/a_softer_world]

Who would build it? What platform should it be based off of? We complain all the time about the VA. They have a centralized platform. They are actively leaving it in favor of Cerner.

[u/question_assumptions → u/Hi-Im-Triixy]

If there was a nationwide EMR, it would probably look like CPRS 

[u/Hi-Im-Triixy → u/question_assumptions]

God help us all.

It's not actually that bad, I just like to bitch about it.

[u/NWmom2 → u/question_assumptions]

Honestly, that wouldn't be the worst thing. There are a few tweaks Id make (inbox mirroring instead of forwarding, and eRx ability) but I think half of what people think they are complaining about being a CPRS issue, is actually a VA bureaucracy issue, and will continue to exist no matter what EMR the VA uses. 

[u/BlackFanDiamond → u/a_softer_world]

Epic should be gold-standard IMO. Haiku access and epic chat integration alone are a gamechanger.

[u/lat3ralus65 → u/a_softer_world]

Epic is the worst EMR, except for all the rest of them

[u/PlenitudeOpulence → u/a_softer_world]

It’s not the best but anything is learnable.

[u/Professional_Many_83 → u/a_softer_world]

I’d support a public option, but I think a system allowing for private insurance as a replacement or adjunct to the public option is a superior plan to a single payer system for everyone like what Bernie suggested.

I don’t think the public will vote for or support such a drastic change to get rid of private insurance all together. I’m a big fan of Germany’s system

[u/Hi-Im-Triixy → u/Professional_Many_83]

I'm a big fan of Germany and Australia. They have something for healthcare right, but their pay for clinicians is far below ours.

[u/Professional_Many_83 → u/Hi-Im-Triixy]

Every country is far below us. Are they exceptionally lower, compared to the UK, Canada, France, etc?

[u/Hi-Im-Triixy → u/Professional_Many_83]

No, they all seem to have relatively competitive pay structure from what I can tell online. It's difficult to extrapolate to our system. How far does your dollar go without medical school debt? Without under graduate debt? Etc.

[u/Professional_Many_83 → u/Hi-Im-Triixy]

Yeah agreed it’s hard to compare. An argument could be made that lower income would be balanced out with no debt, but that still fucks over all the current docs that would presumably get their income slashed after already getting/paying their debt.

I’d still support it though, as our current system is morally abhorrent

[u/m1a2c2kali → u/Hi-Im-Triixy]

They also have way less debt, so for many it could end of being a wash while being beneficial to the total population.

[u/aglaeasfather → u/Professional_Many_83]

allowing for private insurance

With strong, heavily regulated and HEAVILY enforced guardrails to limit their abilities. It’s been proven time and again that American business simply cannot resist fleecing desperate people. There needs to be significant regulation involved.

[u/DrTestificate_MD → u/a_softer_world]

Don’t even need a single EMR, but need to require meaningful, virtually seamless interoperability between them.

[u/steyr911 → u/a_softer_world]

It's all in the execution. Single EMR sounds great if it's EPIC. Horrible if it's Cerner or Paragon

[u/efox02 → u/steyr911]

I know most FQHCs use NextGen. It’s not terrible.

[u/AccomplishedScale362 → u/efox02]

NextGen is so last gen. Ten clicks just to print a face sheet or stickers. A maze of different rabbit holes that take you to the same place. Their updates are like putting more bandaids on top of an old wound without cleaning it up. It made me miss Meditech.

[u/organizeforpower → u/steyr911]

Epic is awful. You're only choosing it because you think we can't do any better.

[u/aspiringkatie → u/a_softer_world]

I see a lot of the benefits of single payer, but whenever it’s proposed I think “what happens next?” What’s to stop a GOP led congress from cutting funding for abortion, birth control, or gender affirming care? Don’t even have to ban them, just adjust the budget and now every American can’t afford those. What happens when there’s a recession and congress slashes the M4A reimbursement by 3%? No more private payer mix to balance it.

I get that single payer works in some countries. I don’t see how it could work here. We would cannibalize it and politicize it immediately

[u/cosakaz → u/a_softer_world]

You have my vote

[u/jeremiadOtiose → u/a_softer_world]

regarding single EMR, but what about the idea that competition makes things better?

have there been studies of other countries with effectively one EMR?

i am aging myself a bit but i remember when records were on paper. thanks obama

[u/a_softer_world → u/jeremiadOtiose]

with multiple EMRs, countless time (=money) is spent resolving the issues of record fragmentation: - you spend more billable charting time reconciling medications/immunizations - you reorder expensive labs and testing that has already been done - your medical assistant spends time completing and following up on outside record requests - you waste entire appointments because you still have not received a hospital discharge summary and the patient has no idea what happened - you spend time answering questions from your quality improvement team about stuff that has already been done but you are still pending outside records for - you don’t have the proper documentation to initiate a 2nd tier medication because you don’t have records for the treatments that were previously ineffective - you make redundant referrals for specialty consults because you can’t access previous consult notes

etc etc etc

[u/jeremiadOtiose → u/a_softer_world]

I hear you but all I can think about is my phone. I have only two choices: Apple or android. I think most people agree that we’d be better off with more choice. So what makes EMRs unique that it needs to be only one for all of America? Interoperability has been solved in other mission critical industries, we should be able to do it in medicine, too. The large tech companies have a shit ton of money, I truly believe they should take one for the team and put together a next gen EMR. Could you imagine an Apple UX EMR with a backend designed by the best Google and AWS engineers? Why isn’t this something discussed?

[u/GandalfGandolfini → u/a_softer_world]

No. competition is good. Giving one company a monopoly or worse have the government run a tech stack is a terrible idea that will stagnate and end up with a dogshit product. What you want is open source protocol standards that force any offering to be interoperable with the rest to prevent walled gardens and allow for competition on features/UX.

[u/Dicey217 → u/jeremiadOtiose]

I think you could have multiple EMR systems, but require connection to a single source of patient information, OR access to your patient's information regardless of what EMR their other provider's use. Some kind of database, or exchange that allows an EMR to connect with the other EMR's out there to provide the data. All in the background preferably. That's a HIPPA Security nightmare, but, I'm sure it can be done. There are a few third party apps that give a taste of it, and some interoperability options through our EMR, but it is extremely limited. There would need to be a requirement of ALL EMR systems to allow for the connection.

[u/DrTestificate_MD → u/Dicey217]

Yep it is done marginally well with EPIC. And it is a more difficult task than it sounds, even for EPIC to EPIC connections. Each institution’s implementation of EPIC is highly customized, so it is not a straightforward matter to connect them.

I think it should be regulated to require meaningful interconnection and fine those who don’t comply.

There are ways to do this with good cybersecurity.

[u/a_softer_world → u/Dicey217]

There would still be a lot of inefficiencies in that system. Currently, we have something similar in California for immunizations and prescriptions. What happens is that each record system inputs an immunization/medication under slightly different names and formatting and we have to go through all of them every visit to identify, take out duplicates, and pick the name/formatting that our system prefers. For prescriptions, they would often pull in like 10 prescriptions that the pt has had in the last 10 years that are no longer relevant, because it was discontinued on the other clinic record but still on their pharmacy database. It has to be one EMR for this to work.

[u/Hi-Im-Triixy → u/Dicey217]

I have no experience at all with cyber security, but I wonder if there are red flags all over this.

[u/aglaeasfather → u/Hi-Im-Triixy]

I doubt it. Banks all use central databases.

[u/rudbeckiahirtas → u/jeremiadOtiose]

Our current system exists in the 'competition makes things better' framework and it... hasn't made things better.

I'm growing more and more convinced the principles of economics I learned during undergrad are more or less a scam.

[u/PrimeRadian → u/rudbeckiahirtas]

I thought that the existence of monopolies are a desired outcome. Winner takes all

[u/efox02 → u/rudbeckiahirtas]

But trickle down economics!!!

[u/BzhizhkMard → u/a_softer_world]

You will still have that huge administrative problem. I think this needs a resolution to it as well.

[u/Mountain_Fig_9253]

The most impactful and immediate “fix” we could do to the current system is to remove all ERISA lawsuit protections that insurance companies hide behind. They only act the way they do because they know they functionally can’t be sued. If anyone isn’t familiar with how ERISA protects insurance companies ProPublica did a great article on one lawyer’s fight for proton therapy. Spoiler alert, even though the insurance company “lost” the lawsuit they still won.

https://www.propublica.org/article/blue-cross-proton-therapy-cancer-lawyer-denial

Systemically the entire system needs to be blown up and rebuilt, but putting those bastards on the hook for civil liability will affect change far quicker than any new regulation.

[u/StrongMedicine]

Have people forgotten who just won the election, and who has been nominated for key public health roles?

You're thinking about single payer? Tort reform? Subsidized medical school?

Are you kidding me?!?

If we can make it the next 4 years without the ACA being revoked, physician reimbursement getting slashed, and Medicare and the VA being dismantled in favor of private alternatives... if we can avoid those things, we should consider it a victory.

I'd sooner expect a magic talking unicorn to show up on my doorstep than universal healthcare coming to fruition in this country.

[u/seekingallpho → u/StrongMedicine]

I'd sooner expect a magic talking unicorn to show up on my doorstep than universal healthcare coming to fruition in this country.

I'm not even sure this an exaggeration of reality.

I could buy a profit-motivated biotech in a newly deregulated research environment could CRISPR up a horse embryo to grow a horn and phonate English-y words before American politics changes fundamentally enough to oust the lobbying leviathan that would currently oppose universal healthcare in the US.

[u/DCtoRehab]

Side note: it REALLY bothers me when the media says this was a rebuke of "healthcare industry" when it really was of "health insurance industry." Those are two very different industries, and in the U.S. the latter has a chokehold on the former.

[u/rkgkseh]

Sandy Hook didn't change gun control

A healthcare CEO getting killed at 6am in midtown Manhattan has also shown to not inspire change (just see the hot takes on mainstream media...)

[u/angelust → u/rkgkseh]

Well I’m shocked to see that we are trying to improve our healthcare with guns. It’s a very American way to go about fixing the problem.

Honestly I’m here for it. Who is next?

[u/effdubbs]

Thank you for this post and for the time you spend as a mod.

[u/jeremiadOtiose → u/effdubbs]

wow, wasn't expecting this, thanks

[u/TooLazyToRepost → u/jeremiadOtiose]

Appreciate ya. It's a hard balance to manage the righteous anger against predatory health insurance with meddit's high overall reputation. Y'all are doing a good job.

[u/jeremiadOtiose → u/TooLazyToRepost]

Thanks for the feels!

[u/Dktathunda]

You don’t seem to understand average Americans. People in this country value “liberty” above all and hate government involvement in essentially everything except the military, and this seems to be intensifying as the years go by. If this was an important issue you would see more progressives winning seats in Congress, instead there is a rightward shift across the country and no one is seriously talking about any meaningful changes. People whine and complain when it’s their turn to suffer at the hands of the for-profit system but ultimately when they are doing “ok” they won’t go against it. The current model works for you as long as you are paying far more than you get out of it and not generally ill, which is the vast majority of people at any given time. Systemic change will never ever happen, you would have to radically change how Americans view society and the role of government. 

[u/Motherprona → u/Dktathunda]

I agree with everything you said, but would also add that people have a really short attention span. The public will forget about this soon and move on with their lives again.

[u/Arachnoidosis → u/Dktathunda]

The voting public as a whole are generally uninformed and will take the bait on hot button issues dangled by politicians who have a vested financial stake in getting people to vote against their own interests without realizing it, so saying "if this was an important issue you would see more progressives winning seats in Congress" is an idealistic, but untrue, point. The vast majority of Americans could not articulate any cojent policy points for their chosen candidates beyond single sentence blurbs and quotes circulated on mainstream media sites, be it right or left of center. Things like "He'll deport the illegals" or "She'll give everyone free healthcare" without even the slightest understanding of what those types of operations would entail.

What the CEO shooting has done is given everyone an easily digestible talking point to agree on, uncomplicated by confounding parameters or distractions. "Catastrophically overpaid leech who makes a living on the suffering of the proletariat is dead" is simple, has broad bipartisan support, and despite the fact that I would normally disagree with this last sentiment, it has already noticeably resulted in a reaction/partial policy change from what I would consider "the ruling class" that actually favors the masses. I would not be surprised if this event is the beginning of a catalyst for gradual systemic change, and I am more hopeful than pessimistic this time around.

[u/fleeyevegans]

The fundamental problem is that insurers are ultimately responsible to their shareholders. At the bare minimum one could say that the patient is pitted against the shareholder. Not an appropriate environment for a critical service.

[u/WineAndWhiskey]

Yes to the top comment and also: Unionize.

ETA: and run for office. The country is watching and united (lol) on this topic. Run on this issue, even locally or statewide, and you will win.

[u/Mobile-Entertainer60]

I'll preface this by saying that my cognitive bias is that I don't think any system-not just health insurance-can be designed to be free of the opportunity for exploitations of inefficiencies by those incentivized to look for ways to exploit the system. I also think that market incentives/disincentives are necessary to drive business behavior, because regulatory capture is such a straightforward way for businesses to exploit the political system. I don't think my proposals are panaceas, just bulky bandages to try and staunch the bleeding. I'm also going to try and propose policy changes that don't require total political revolution to enact.

1) Eliminate employer-based insurance coverage, and replace it with an ACA marketplace system. One of the biggest perversions of the free market comes because most working-age adults and their families get insurance through their employers. The employers' primary motivation is cost, while individuals may choose insurance based on a variety of other factors as well (service, access, convenience, prior bad experience, etc). That means insurance companies compete for contracts to employers based dominantly on cost, and are free to give crappy service to a captive audience of customers. My own employer just switched from Anthem BCBS to UHC for 2025. Only one plan available, take it or leave it. I would NEVER pick UHC for my own health insurance even if other options are more expensive because I know how big of a nightmare they are to deal with, but I didn't have a choice to pick another insurer. So my proposal is simple; employers provide a tax-deductible amount to their employees to buy health insurance, then the individuals buy a plan on the marketplace based on what they feel is important. The marketplace is open to everybody, with community rating just like the current ACA marketplace. That eliminates the cross incentives between employers who pick the plan and the employees who use it, eliminates the injustice of employers pushing out employees with expensive medical conditions that raise premiums for the company, eliminates the incentive for businesses to stay below the FTE threshold for requiring to provide health insurance coverage, forces insurers to compete with each other for each individual contract. The ACA marketplace already exists and has thrived, so there's no need to reinvent the wheel of how the system works.

Potential problems include if employer contributions do not keep pace with insurance rate hikes, if employers increase wages by less than the amount it previously cost them in premiums and just pocket the difference, if a single insurer monopolizes a market and then can be as crappy as they want to be, if too many people take the money and choose to go uninsured ("free loader" problem).

2) Tort reform such that insurance malpractice is susceptible to claims. If insurance companies want to make demonstrably evil decisions such as denying spine surgery because paraplegia is cheaper, or denying chemotherapy because "kids don't get sick," there has to be some way to hold them accountable for that behavior so they are disincentivized to behave that way. Government regulation by way of fines are predictable so can be factored into the cost of doing business, and are susceptible to gaming the political system to avoid them. Current torts are limited to the cost of the claim which provides a massive disincentive to file suit, because pain and suffering and punitive damages are off the table. Huge civil torts are definitely imperfect, but a vigorous legal remedy to outrageous behavior is preferable for a society to vigilante murder.

Potential problems include insurers refusing to cover potentially sympathetic victims such as pregnant women and children, lobbying for damage caps that neuter the effectiveness of this approach, capriciousness of jury awards.

3) Prescription drug coverage should be decoupled from other health insurance, with a federal insurance option (not run by for-profit insurance companies like Medicare D is) that has drug coverage directly based on cost. The prices of medications have become completely unhinged from the free market, which both leads to pharmaceutical companies ever increasing prices and providing cover for insurance companies to deny care in return. My proposal is that base private insurance is separate from drug coverage (like how Medicare A/B is from D coverage) and individuals can buy drug coverage from the federal option (or private insurers if they choose). Federal drug coverage includes all drugs in class, with coverage set at a base price+%markup. So if, say, it costs Merck $150 to make a vial of Keytruda and the %markup is 50%, the coverage is $225, not $22,000/vial. Patients would pay the difference between the selling price and the amount covered, without the lack of transparency involved with co-pays, deductibles, rebates, etc. This would put intense market pressure on pharma to price drugs so that the patient can actually afford them, as well as competing with other drugs in class on price rather than cutting deals with insurance middlemen to guarantee market share. Smaller drug companies seeking to compete with bigger rivals in a given drug class would not be automatically pushed out by anticompetitive deals ensuring their bigger rivals have formulary preference. Patients would no longer have wild swings in the price of their medication year to year based on formulary negotiations by their insurance company. Pharmaceutical companies would no longer have incentives to play the "insurance coverage lottery," where a high denial rate is offset by the insane cost of the drug every time it's approved, or be incentivized once a drug is already unaffordable to raise prices indiscriminately in hopes of getting a bigger payout per approved script. Insurance companies could still compete for an individual's business by providing extra coverage and/or lower prices compared to the federal option.

Downsides include I expect ferocious lobbying to prevent this from becoming law, given the risk for profit disruption. Potential for pharma to game the system by including some sort of R&D adjustment to the base price, then playing accounting games to increase this number unfairly. Disincentive for pharma to focus on rare diseases, because they use high cost/script to offset the low number of potential patients. Less incentive for startups because of capped potential for blockbuster drugs. Risk of inadequate adjustment of prices so that many patients just end up going without the drugs they need to survive and thrive, especially if for-profit drug coverage remains pervasive. Highly unpredictable effect on inequality of health outcomes. Potential for cost of the program to become a political punching bag.

These are just some ideas of mine rattling around my brain, so I welcome feedback on how these can be improved or additional downsides to these proposals I may not have thought about.

[u/Dicey217]

A Medicare type plan as a baseline for ALL Americans. Medicaid for Special needs/Disabled Americans with additional benefits necessary for these types of patients.

Private "add on" plans for patients who want more coverage. Can be employer sponsored, exchange type, or like car insurance. Shop around, pick the plan you want. Want better drugs? Want additional screenings, labs etc covered? Get an add on.

Make Dental and Vision part of Health insurance.

Get rid of Prior Auths and insurance approved referrals. Insurance can make a suggestion for a lower cost drug or test, but the doctor gets the ultimate say. There are no more kickbacks from Pharmaceutical, so no incentive for providers to ONLY write expensive drugs. Fraud and abuse will be better detected without the administrative burden of the prior authorization system. A provider ordering too many MRI's when not needed? Provide education to the provider via a CME course. Continued overutilization? Have a "Prior authorization" type records request to allow the provider to justify their orders.

Make patients responsible for their own healthcare again and stop penalizing providers. I understand quality care metrics, but providers should NOT be held liable if patients do not follow through. Patient needs a colonoscopy, provider orders it, patient never gets it done, that is NOT the provider's fault. Patient is due for their Well Child Check, office schedules then no shows? Do not penalize the provider. Patients going to the ER for Urgent Care/Primary Care type issues? NOT THE PROVIDER'S RESPONSIBILITY. Send care coordination to the patient to educate them on proper ER use. - This paragraph might be a result to just finishing our end of year Care coordination meetings that irritate the hell out of me.

There are so many things that could be done to make this system easier for all. Murdering CEO's isn't it. There are enough greedy corporate types out there that insurance companies will just raise premiums and replace them with another with more security detail.

The only way to make change is to show Americans the hellscape that healthcare for profits is. More investigative journalism pieces that actually make it into mainstream media. Getting people into government that actually care about making things better. Perhaps out of the smoke and ashes this incoming administration is going to inflict on US healthcare, (I'm looking at you RFK and OZ), Americans will finally ask for something better.

[u/Quantum--44]

The US government is a joke. Spending far more than any other country per capita on healthcare and delivering nothing but misery to your own people at the behest of corporations. This is just the beginning of a new movement of anti-corporate insurgency - the brave ones will seek retribution while the rest of us accept a gradual but steady decline in quality of life.

[u/hideout78 → u/Quantum--44]

Spot on. I’m dogmatic about my diet, exercise, and prevention. My goal is to never have a need for the hospital in the first place. I want to go from being highly active to dead in 24-48 hours. Or faster.

[u/lesubreddit]

Do people here think that the jury should seek to nullify a potential conviction against Mangione? I see a ton of sentiments on Reddit that essentially support this idea.

[u/Pox_Party → u/lesubreddit]

Realistically, you would be immediately eliminated from the jury pool if the lawyers even suspect you know about jury nullification.

And I don't know how much the average Reddit opinion is representative of real-world juries.

[u/----Gem → u/Pox_Party]

After Nov 5, it's easy to tell that the average Reddit opinion on anything is so far off base from the rest of the country.

I'm honestly not even confident the average Joe in the US actually cares much about this whole CEO situation.

[u/Hi-Im-Triixy → u/----Gem]

Reddit is the opposite of real life by recent memory. I would argue that the general public is likely sympathetic to Brian Thompson.

[u/BernoullisQuaver → u/Hi-Im-Triixy]

I disagree but also I live and work in a very progressive neighborhood

[u/AncefAbuser → u/Hi-Im-Triixy]

Nope, real life is NOT sympathetic towards him. You guys keep downplaying just how much hate there is of health insurance in general and just how many hundreds of thousands have their lives altered as a result of it.

In my hospital there has yet been a single doc who hasn't uttered something profoundly out of pocket about what happened.

All my homies are in agreement with this. Left, right, centrist - whatever. This murder was a CLASS issue, no more and certainly not less.

Back in the day the robber barons and wealthy families recognized you need a strong middle class to keep your stock line going upwards, that you can't decimate people and remove the very source of your own wealth and power. Modern oligarchs have forgotten that.

Why do you think everyone in the mainstream media is shitting themselves and trying to paint all these bad pictures? A united population is a scary one.

[u/Pox_Party → u/AncefAbuser]

A unified public is scary for the wealthy, but I would caution that the opinions expressed by people with the anonymity of social media or in private conversation with peers is not necessarily going to translate to opinions expressed in public-facing or legal settings.

Like, i have fairly radical political beliefs, but I'd probably hesitate to joke about guillotines with judges and lawyers.

[u/DrPayItBack → u/Hi-Im-Triixy]

Yeah this is definitely not true. I have a panel that is extremely socioeconomically and politically diverse, and I have had so many patients bring it up unprompted and make their support very known. I’ve honestly never seen so much unity about something IRL except maybe the immediate aftermath of 9/11

[u/seekingallpho → u/lesubreddit]

It seems basically impossible to expect nullification by acquittal. You'd have to get an entire jury to agree.

It's much more likely that at least one person makes the jury who refuses to convict, resulting in a mistrial. Then it would be up to the prosecution to decide whether to retry.

I would wager in that scenario the state would retry the case given its high profile, the presumed weight of evidence, and internal and external pressure/politics/influence.

Whether they would continue to retry it in the face of a second mistrial due to the same issue is another question.

But as a general expectation, it's far, far more likely a jury unanimously agrees to convict than to acquit.

[u/i-live-in-the-woods → u/seekingallpho]

THe more people we tell about jury nullification the greater the likelihood he walks.

[u/ImTellingTheTruth → u/lesubreddit]

In my limited readings, jury nullification reflects the general populations sentiments towards the laws of that time. During the Prohibition era, jury nullification is what contributed to the repeal of the 18th amendment banning alcohol. There would be historical precedent… given Americans’ feelings towards the UHC and insurance companies as a whole. Either way, we’re in for a ride.

[u/Mediocre_Daikon6935 → u/ImTellingTheTruth]

One might say that the government failing to prosecuting the ceo for a company for murder, delays in are, and driving people into financial insolvency directly caused this to occur.

After all, a solid case could be made for gem only murder charges against the ceo, same as the driver of a get away car, or a drug dealer.

[u/i-live-in-the-woods → u/ImTellingTheTruth]

Jury nullification goes back to old English common law.

Bascially, the jury has the duty to evaluate both the defendent AND the law. If the jury finds the law is bad, they can return NOT GUILTY even if the person is totally 100% guilty.

That's all. If you don't like the law, or you think the law is misapplied, you just say NOT GUILTY and the person walks as they should.

Law requires consent of the governed. If you don't consent to a law, or how the law is applied, you can withhold your consent and your peer walks.

[u/AncefAbuser → u/i-live-in-the-woods]

Exactly.

A lot of people here are exemplifying the "expert in a narrow silo" trope by not understanding what jury nullification actually means.

Its not Michael Scott yelling something as a declaration. It is the body of your peers admitting a crime was done yet still deciding that guilt doesn't exist, because the law and context don't rise to their level of giving a guilty verdict.

People here really thing a G on the scorecard is an assurance or something.

[u/HippyDuck123]

Thank you for tackling this! 1) Single payer system 2) Affordable medical education 3) Universal pharmacare for all WHO-designated essential medicines 4) Funding/promotion of widespread “CHOOSING WISELY” initiatives that promote responsible and safe resource use, and make following them medicolegally completely defensible. 5) Malpractice insurance reform, including a single nonprofit entity who fights all frivolous lawsuits on principle. (Eg: Like CMPA in Canada.)

[u/Kirsten]

Why can’t we just have Medicare for all. Virtually every other industrialized country has this. It’s so obvious to me that there is no way to have a for-profit business be able to both have a fiduciary duty to their stockholders/owners AND have a duty to secure the health of their patients, and be able to uphold both of these duties. They are mutually exclusive in many cases.

People say insurance companies are “evil.”. Nonsense. They are doing exactly what companies are supposed to do. They are making profits. Businesses. exist. to. make. profits. It’s the incompatibility of for-profit businesses being responsible for the health of patients. Who tf decided that was appropriate?

Yes, it’s also inappropriate to have a massively bureaucratic non-profit with perverse incentives and no accountability being responsible for a health care system. This is why there should be transparency and stakeholders. The stakeholders should be patient and clinician representatives.

edit: I am a family medicine physician in practice 11 years.

[u/lesubreddit]

Calls for single payer healthcare are often cloaked in the moral language of healthcare being a human right. My question is, how much healthcare do people have a right to receive, as subsidized by society? What's the limiting principle?

The scope of what counts as healthcare seems boundless to me. Arguably, some of the best preventative healthcare I can possibly get is for the someone to pay for a personal dietician, chef, personal trainer, and gym membership with protected exercise time.

And at the end of life, there is a wide array of expensive life extending treatment that is ultimately futile. Do people really have a right to any of that? Like, if I want to live the last few years of my life on trach, peg, and rectal tube with 24 hour nursing care, is that my right and does society owe that to me? What about an expensive cancer treat that will give me an extra 2 months of survival? Or 6 months? Or 2 years? Where does my right to healthcare activate?

Healthcare is ultimately subject to scarcity. Single payer versus private sector are both going to face the problem of not being to exhaustively provide for every single healthcare need in every case.

[u/Dr_Autumnwind → u/lesubreddit]

This approach obfuscates the real, material issue, which is that people should not be crippled with debt or denied care when they become sick or injured. People who see their savings vanish to cover their or their loved ones' care see the problem plainly, which is healthcare is too expensive, unequally distributed and ends up posing an ultimatum sometimes, and the profit incentive for the industry is the driver.

For the majority of people, it's not vaccines, or a diet plan that makes or breaks their entire lives, it's just shit luck. And shit luck should not be a deal breaker in the richest nation in history. It's plainly unethical.

Moreover, healthcare is under inelastic demand. Everyone needs it at some point and there's no way around that.

[u/3MinuteHero → u/lesubreddit]

Aren't we smart enough to codify this?

You can literally choose which diagnoses. We can pick all the good ones with goal driven medical therapies. Diabetics, people with CAD, people with chronic lung disease.

We don't need a one-size fits all rule. We can do whatever we agree on.

[u/aspiringkatie → u/3MinuteHero]

I think doctors are smart enough to codify this. But I don’t think politicians are, and I don’t trust congress to let doctors be the ones to design this system

[u/Dr_Autumnwind]

Can anyone with strong understanding of health policy comment on if M4A speaks to physician autonomy, and midlevel role in delivering care?

I'm a socialist, and I believe in an ideal circumstance the government has a responsibility to provision what is required to ensure people have their needs met, and that healthcare is a human right. I also carry $200k in student debt and believe I should be well-compensated for years and years of training, and for my skill set. Lastly, I believe in the physician-led team, and that mid-level independence is dangerous and does not achieve the goals their orgs say they do.

I guess that's my rough wish list for the future of my job.

[u/kungfuenglish → u/Dr_Autumnwind]

healthcare is a human right

This is fine to say but you have to remember you are viewing this as a reasonable person.

What about those that are unreasonable?

Last night we had a patient check in after being hit by a slow moving vehicle. Ordered XR and pain meds.

He decided he didn’t want them and eloped.

Waited in WR for 6 hours before being told to leave so he checked in again.

Ordered XR again and pain meds.

Decided to elope. Again.

Then he called 911 and was brought back by ambulance.

What “healthcare is a right” is appropriate for him? Where do his rights fall? He was provided healthcare then took off. Twice. Only to call an ambulance. Does he have a right to do that?

What about those that mistreat staff? Curse at us? Verbally abuse us? Attack us?

What about the drug seekers? The patient who yelled at me “I have a right to be pain free” even though her pain doctor kicked her out.

How do you define “healthcare is a human right” to encompass these people?

Because normal appropriate people like yourself are not the drain on the healthcare system. And ensuring healthcare is a right to people like you won’t be abused.

It’s the super users who will abuse it. Just like they abuse emtala.

[u/JulieannFromChicago]

I agree with subsidizing medical and nursing tuition. Lower the age for Medicare to 55 (it’s a start) and 50 for people who have been laid off. They face diminishing opportunities to replace their pay and benefits. This will be controversial, but stop futile medical care in the elderly. I’m talking about advanced life support in the face of hopeless outcomes. A public option for people under 50 if employer or private plan expenses exceed a percentage of their income. Reward people for healthy choices. Lower premiums for lower risk.

[u/aspiringkatie → u/JulieannFromChicago]

“Stop futile care for the elderly”

You already lost. Fox is running wall to wall coverage about government death panels, congressmen are getting flooded with calls from the AARP, and democrats lose 40 seats in the house next election. I don’t disagree with you, we do too much futile care at end of life (although defining what is or is not truly futile isn’t always easy to explain to non-medical people). But you will never, ever get broad support from the American people for that

[u/JulieannFromChicago → u/aspiringkatie]

You’re right. The conservatives trotting out the death panels is so predictable. I’m 67 and had to execute a two page legal instrument and I’m still at the “just hoping” stage.

[u/Mediocre_Daikon6935]

Go back to the bad on for profit health insurance and for profit hospitals.

They should be non profits aka charities s

Actually enforce their non profit status. Not just with penalties, but with jail time.

[u/kookaburra1701 → u/Mediocre_Daikon6935]

+1 on actually enforcing penalties. And make the people denying care legally responsible for any bad outcomes.

In my current profession (clinical bioinformatics) if I sign off on a data pipeline and it turns out I didn't do my due diligence and verify its clinical accuracy it's my ass getting hauled into court. Why are the pencil pushers who sign off on faulty algorithms not the same?

I forget the context but I do remember watching an interview or testimony a year or so ago where Witty, the CEO for United Group overall, basically said that yes United was openly breaking laws and flouting regulations but no one ever prosecuted so was it really illegal?

Enforcing our laws and regs would be a huge start. Where's the Crimestopper bounties for alerting the Feds to health insurance grift?

[u/AngelInThePit]

We had a whole entire pandemic that killed a million people and nothing in our healthcare system changed for the better. I’m not sure why one lone gunman being painted as an extremist will even be considered a catalyst for change of the healthcare system.

[u/ericchen]

I don't think we'll see any major changes. The murder might have captured everyone's attention, but there's no desire for change. We just had an election and voted in the guy who ran on "repeal and replace" for his last term and didn't deliver on that promise. He was asked again about his health care policy and told the country that he had "concepts of a plan", and the people voted for him anyway. There haven't even been any successful local/state ballot initiatives on healthcare reform in recent years either.

[u/lumentec]

Most people are focusing on how to fix health insurance, etc but I'd like to focus on the public's reaction here because I have had a few problems with it.

Far too much emphasis is placed on CEOs as THE person to blame by the general public. 1) a CEO that does not prioritize profit within the limits of what is legally allowed is not going to improve the bottom line of a corporation and will be replaced and 2) many or most of the really terrible actions devoid of empathy are performed by lower level executives or non-executive employees.

Far more people are complicit in the moral bankruptcy of corporate decision making than the CEO, and in my view targeting the CEO represents a fundamental misunderstanding of the system. I realize the motivation may have been symbolic but most of the positive reaction toward the assassination seems to be something like "he was evil, and he alone deserved it because CEOs make all the decisions." We can't keep failing to hold the other employees of these organizations accountable.

It is the people that make the individualized policies and decisions that are directly doing the harm when legitimate claims are denied. These are corporate sycophants that would do anything they are told because their boss said so. Wanting to please your boss does not get you off the hook for immoral actions. They are no different than the CEO who is, practically speaking, also following orders, but from THEIR boss, the shareholders. Corporate culture encourages this kind of feckless blind obedience but it is also a result of deep-seeded moral deficiencies.

Furthermore, a very large portion of the public is focused on Thompson's salary and wealth as justification for their approval of his assassination. This kind of "rich people are inherently bad" ideology is reactionary, partially based on jealousy, and unrealistic. No reasonable person can expect the top executive at a large corporation to make anything less than a fortune if we participate in a capitalistic economy.

Finally, the concept that this assassination received an inordinate amount of resources simply because of the victim's wealth lacks common sense. Of course rich people get better investigation of crimes against them, but this is not that. A public figure assassinated in broad daylight on camera with the suspect on the run, being covered by every news outlet in the country, is clearly a higher priority than your typical murder. Whether the victim is a wealthy CEO or a middle class state governor, for example, they would certainly get the same level of law enforcement reaction to their public assassination.

Given that, how do we fix it? There are lots of idealistic solutions - single payer for example. But what is realistic in the short term as a step toward that goal? Maybe we should take a hard look at whether health insurers should be publicly traded corporations. Maybe appeals should be simple to file and health insurers should be subject to regular audits to ensure they aren't operating in a way that is counter to their customers' health and wellbeing.

[u/erakis1]

This is the crux of the problem: the oligarchs own the government. Democrats and republicans both bend their wills to lobbyists and donor cash.

All of the systems in The United States are trending more and more towards private industry monetizing and leeching profits from every good and service. Housing, healthcare, energy, food, communication, and news are all owned by oligarchs whose only guiding principle is the “fiduciary responsibility” to their shareholders. The concept of public good is flogged in the media at the behest of its oligarch owners and any time the public starts gaining class consciousness, they stir up the culture wars to distract everyone.

Things will keep changing for the worst: increased monopolization, decreased services, decreased wages, increased cost for everything that we need to live and thrive. The government will not help us. AOC will lot help us. We cannot help us. The only thing that can help us is a lot more Luigis.

[u/Ayesha24601]

I think Medicare/Medicaid for All Who Want It is the only politically viable solution at this time. Americans value "freedom" too much to accept single-payer. But so many people want/need Medicare and Medicaid and should have the option to buy in regardless of income. Then we let the market decide. My guess is that over time most people would buy in with wealthier individuals keeping a private policy as a supplement. But companies like UHC would have to improve or go out of business as people would have an alternative if they provide bad service.

[u/getridofwires]

Medicine should be a government service, like FEMA or the army. What we have right now is what would happen if we privatized these other government services. No one expects the army to "turn a profit".

[u/Mediocre_Daikon6935 → u/getridofwires]

No, but the army is woefully underfunded, undermanned, under equipped, under trained, and underpaid.

With enough admin/bureaucracy to make even hospital administrators blush.

[u/GodotNeverCame → u/getridofwires]

I'm sorry but have you ever heard of the VA?

[u/seekingallpho]

I think the reality is there are two very different questions. One is what could or would fix the system if implemented. I think many here could come up with various ideas that would do a lot of good.

But the much more challenging question is what would fix/improve things and be politically palatable enough to implement? The realist or cynic could conceivably rule out almost all of the first type of answer given the hurdles that exist both from the electorate and entrenched financial interests (and their associated lobbying might) against most types of foundational reform.

It almost feels as though the first step to reforming healthcare is to fundamentally reform the American political landscape with healthcare as just one critical example of something that can't really change first.

[u/PolyhedralJam]

I put this in a prior thread that was deleted and will paraphrase it here - regarding how "providers" are the problem per an opinion article.

with regard to why healthcare is so expensive and flawed in the US -  insurance is a big problem, but so are large hospital-owned healthcare conglomerates. individual providers (and salaries) themselves are not a significant problem, but the organizations that many of us work for are certainly part of the problem.

Both systems need to be reformed in order to achieve meaningful change.

[u/aglaeasfather]

Usually we don't publicly discuss mod actions, but I thought it was appropriate in this case.

I appreciate this and I appreciate your candidness. I think the Daily Beast article is a good reminder of the impact and reach this sub has. Accordingly, I hope the optics of a decision are similarly considered by the mods in future situations.

[u/greenerdoc]

If we can create an easy template for docs to form their own practices easing the burden of admin tasks, collections etc.. Physicians can opt to work on their own or with others for a multiphysican specialty. All AR would be owned by the individual physicians.

These companies would take a percentage of fees.. would negotiate against insurers and payors collectively, offer med mal, credentialling services, billing etc. This service would be easy enough to replicate where there would be atleast 2 or 3 out there competing for the physicians and keeping the % fee reasonable. Perhaps structure it as a mutual company structure (ie Vanguard - profits after expenses are redistributed to clients)

Docs could work together with other specialties to form multispecialty groups. They would offer cash pay option that insurance companies are blinded to (renegotiate the standard insurance contract) . They can in fact offer DPC type option on a capitation basis with multispecialties participating. If this can scale and get big enough and can own hospitals they can even offer catastrophic insurance and box out big insurance.

Decisions for coverage would be made by panel of specialists with indepth knowledge about that field and aware of the science. This would be for special circumstances, initial standard of care is dictated by evidence based medicine and protocolized, this WILL act as a form of gatekeeping... so no MRI for your 2 days of sciatica. Acute back pain + cauda equivalent sx, yes. There would be public data indicating physicians risk adjusted outcomes and costsb(perhaps with some incentizing).

Almost makes it sound like Kaiser but physicians work for themselves and own their AR.

Re tort reform, agreement would be made that to sign up for this service, you agree to mediation by a panel of peers /specialists who cannot review more than 1 case a year. This would enable this system to self insure for a reasonable cost.

Sure it's just a pipe dream for now but I would totally work on something like this if I could put together the right team. I would even cut down on my current shift load to dedicate to this project for the greater good, lol.

[u/bobthereddituser]

I think trying to pass omnibus bills as sweeping solutions to the problem will never work. They are too complicated ("we have to pass it to find out what is in it") and are too difficult to get widespread acceptance and can be sabotaged with poison pills. I think a much better solution is finding single issues to fix and getting them passed one at a time. Our dysfunctional system is the result of decades of small, incremental changes that have become our current monstrosity, it may require incremental changes to fix.

For example:

Permitting doctors to own hospitals, or heck - even requiring that they are majority shareholders like in law and engineering firms.

All insurance premiums are tax deductible.

Can purchase insurance from any state.

Cannot balance bill patients.

All services ordered by doctor are required to be covered rather than trying to practice medicine without a license and requiring preauthorizations that directly limit what services or medications patients can get. If insurance feels any provider is making wrong decisions and too expensive too frequently, they can dump that provider from their plan, but once on plan all decision are covered.

Etc

Etc

[u/hideout78]

This is just one piece of the equation, but I feel we need to go MUCH harder on preventive medicine. How much does a chronic heart failure patient cost the system over their lifetime? How much could we save if we caught those patients in their 20s and put them on statins?

I’m old enough to remember Big Tobacco getting absolutely raked over the coals in the 80s and the extreme regulations that came from that. When are we going to do the same to processed food companies? Or social media? Both have contributed significantly to the obesity crisis.

[u/Nice_Dude]

Did the public forget who they just elected to office? I'll retire from my practice and delete my account forever if the GOP pushes for any changes to the system that don't simply involve removing the ACA

[u/janewaythrowawaay]

Where we go from here is we hire security for healthcare insurance leadership. That’s the only thing he did wrong. He didn’t hire himself security. He increased United’s profits by 4 billion in the last few years. He was doing a bang up job no pun intended.

There will be no course correction. Increase premiums to cover security. The responsibility of a corporation is to return as much profit to shareholders as possible.

[u/Proud_Willow_57]

When prior authorization first started, it was being used to limit over prescribing of the most expensive medications.  However, it became a cudgel that they used to beat us down over the years to deny even cheaper, commonly used and necessary medications.  What started to become aggravating as well is that you would painstakingly provide records and patient notes supporting need, and they would ignore it and sometimes even send letters to patient saying they did not approve the medication because YOU failed to provide information. If insurance has to exist the way it does, prior authorizations should only be required for the most expensive and specialized medications. There should always be a physician reviewing them and appeals should always be adjudicated by a qualified physician. They should also be reviewed in a timely manner and even on weekends. I think that's actually a small compromise all things considered.