The steady, inexorable bureaucratization of health care in the USA has been visible for many years. As a partly disabled person who relies on permanent medications to function, and has more routine contact with the medical profession than I'd like, I've watched it happen. However, over the past two to three years (post-COVID, to be precise) the process appears to have accelerated alarmingly, to the point where I feel more like an unwanted annoyance to many medical practitioners rather than their bread and butter, paying their salaries. They've become fully invested in the medical system, rather than their patients. In just the past six months I've experienced:
- Nurses and nurse practitioners standing in for specialist doctors, interviewing patients and drawing up case studies for the specialists to use in making care decisions, but doing so inaccurately, not recording everything the patient tells them, and brushing off patient concerns with "We'll deal with that later".
- Medical insurance companies denying most prescription requests at a bureaucratic level, so that specialists must argue with clerks over why they ordered a particular medication and why they consider it necessary. They don't always win the argument, either - despite the clerks and their administrative systems having no medical qualifications whatsoever.
- Legal restrictions are also complicating treatment, particularly when it comes to pain management. The War On Some Drugs means that narcotic pain relief is regarded with suspicion, and prescriptions for serious pain management medications are often very hard to get. I'm fortunate that my prescriptions have been in effect for literally decades, so to a certain extent I'm grandfathered in to the system; but new patients needing anything stronger than NSAIDs are finding it very hard to get them approved. The fact that they're suffering while fighting the bureaucrats and drug enforcement agents doesn't seem to bother anyone except them and their families. Some turn to illicit substances as being the only thing they can get that helps . . . but then they face prosecution. Some days you just can't win.
- New, automated artificial intelligence (AI) "front ends" answering patient calls to medication providers and other medical services companies, trying to force every query into their pre-programmed "boxes" and balking when the patient has a problem that they aren't addressing. It may take a dozen tries to get the system to refer the caller to a human respondent, and sometimes it doesn't work at all. The latter appears to be a feature, not a bug, because if patients complain about these systems, the response is always along the lines of "You have to work with our system to streamline our operations. Everyone else is - what makes you special?"
- A lack of information about procedures and tests that are requested. I have one coming up on Friday that was described solely and simply as a "scan", without mentioning that it will involve a spinal injection of contrast fluid, and be done in an operating room with anesthesia available in case I can't hold still for long enough in an awkward position with a needle in my spine. I had to figure out the details for myself, with help from my wife looking things up on various Web sites. Do I feel like a soulless digit in the system, treated like a mushroom - kept in the dark and fed on manure? Why, yes, now that you mention it, I do . . .
- My primary care resource, a nurse practitioner whom I like and respect highly, said to me a short while ago that she would never have dreamed that the practice of medicine in a rural area like ours could become so bureaucratic and soulless. She has to spend hours every day doing nothing but fill in forms, update records, justify the treatments and medications she authorizes, and so on. It's soul-destroying for her as much as her patients.
- More and more doctors and medical practices appear to be refusing to accept Medicare and/or Medicaid patients, because they claim the reimbursements no longer cover the cost of treatment. I can't speak to this, but if true, I suspect the Canadian approach - encouraging patients to die, and actively helping them to do so - can't be long delayed in this country, purely on economic grounds. It's cheaper for the bureaucrats to kill their problems rather than treat them.
Another part of the problem appears to be bureaucracies arguing with each other over who should pay for a particular treatment. I'm experiencing this in connection with a decades-old work-related injury. Some of my current problems may be related to that injury, but it's hard (almost to the point of impossibility) to directly prove a relationship between them. In the absence of such proof, workers compensation won't re-open the case and won't pay for treatment. On the other hand, regular medical insurance sees that the old injury took place and immediately says, "You claim that the problem is age-related deterioration, but it's in the same area as your old injury. That means it must be work-related; therefore, we're not paying." It's going to take lawyers to sort this one out . . . but that'll take years, and meanwhile I need to find a solution before I'm forced into a wheelchair for the rest of my life. Neither bureaucracy cares about me (or any other patient) as a person. They're just ticking off the boxes on their forms, checking their reams of regulations, and putting their organizations' interests ahead of anything and anyone else.
It's immensely depressing to have gone through this bureaucratic conflict for so long and be no nearer to a resolution; and I'm watching friends and acquaintances deal with the other problems I mentioned above and become equally frustrated and disillusioned. I'm sure some of you, dear readers, can tell us your own horror stories in Comments. Please do - we need to raise awareness of this problem.
I guess the real issue is that there are too many of us. We've overwhelmed the simpler systems of the past, and forced the medical care industry to automate and computerize as much as possible merely to cope with caring for well over 300 million people. Tight budgets don't help, particularly because so much taxpayer money is wasted on non-essential expenditure. The medical "industry" is trying to cut its coat according to an ever-diminishing amount of cloth . . . and there isn't much room left for us, the patients, after they've done so.
Peter
32 comments:
It's simple.
They hate us, and want us dead.
No more.
No less.
19% of GDP goes to healthcare. Follow the money, who benefits? It is not the patients. RFKjr said recently in one of his videos that we all must become experts in our own healthcare. Sadly, this is true. Years ago, researching on the internet, my wife diagnosed the issues faced by her mother and, later, her father. In the current system, doctors are not invested in your health. And it will only get worse until the system breaks, which will be even worse. Karl Denninger covers this in great and gory detail.
I fell at work and fractured my wrist. A few years later, I needed carpal surgery on that wrist. They wouldn't touch it because of the worker's comp claim. I called the company insurance, and got a nasty clerk. I finally told her to "give me back my wrist so I can fix it." Might have been a veiled promise to help her understand the pain I was in if she didn't. I got a letter in short order releasing ownership of my body part to my personal oversight.
Getting pre-authorization is a mess, too. I credit it all to the lack of competence that we have institutionally rewarded.
Unfortunately you are correct. I noticed it after the Affordable Care Act went into effect.
I seen how my wife was treated before it happened and after it happened. The medical community has a corporate ideology.
No compassion. No empathy.
Just shut up and pay me. Nobody should be treated like a $$ sign, but they are.
I understand completely. I pay a PT out of pocket because Medicare only covered my wife's physical therapy for 30 days after her release from the hospital. It's worth the money in my mind but I don't know what people would do without the disposable income.
Thank you very much for taking the time to enucleate (the original archaic definition) the problem so emphatically and succinctly.
Unfortunately, I'm going to agree with your missive. Can't really add to it.
I'm wondering if we aren't seeing the "demincrat playbook" working it's way through society. The demoncrats don't give a fig about the common man. Just look at how they stole the common man's social security money.
Yeah, what i see is a socialist malaise wafting through society.
The big question is: how long will it linger.
Decades ago I had to undergo a liver biopsy and I was admonished to "hold still" or I would cause an internal laceration. I so wanted to scream "stop impaling my viscera with a foreign object and I will be glad to oblige" but I figured that would equally deleterious as squirming would be to my innards. So I can certainly empathize about the spinal procedure and measures taken to immobilize "just in case". Honestly, I do not see how medicine is any different than any other human-contrived system. It must adapt or die, right? If it makes itself irrelevant and unsustainable, then let _it_ be euthanized.
We have overpopulation due to immigration. Everyone realizes at some level that traffic, line lines at stores, depressed wages, etc is caused by this and lower population would be better.
And every individual of each race (except white women and gays) intiitively believes lessening the numbers of the other other races will benefit them. Therefore Shaniqua and Maria are gonna try to deny medical care to Whites.
I get medical care through the VA. I see the same thing and almost all my doctors, PA's, Nurses.. whatever they are agree off the record. If your illness/injury etc.. fits in a common known category, their treatment and care in my area is actually rather smooth and fast. However half my stuff wrong with me is not diagnosable with the standard common tools and methodology and they just give up at that point. Also it is very noticeable that they are not my doctors, they are the VA's doctors and I am a client/patient/service unit? that the VA is obligated to treat within its established bureaucracy.
To be fair it seems as they are modifying the bureaucracy at a fairly fast rate as I can now get chiropractic and acupuncture treatments. Electro Stim muscle treatment devices that help with pain and rehabilitation of muscle condition. plus a few other for them unorthodox treatments. The flip side is that the acupuncture is not an on demand service but a limited course of treatment. The chiropractic when outsourced to community care is the same. They did get a chiropractor at my local va facility and he is a nice guy that I don't want to adjust me after the first time. He will see me on demand or make a reservation anytime but he can only treat my lower back as that is what I was having issues with when I got refereed to him. He is not allowed to actually adjust your whole back. I've been going to chiropractors on my own dime for 30+ years and can't even imagine one of them only adjusting on part of my back unless I actually told them to don't touch the rest of it. I would have heard a lecture about the back needing to be fully adjusted as issues in one area will cause issues in others that if not caught early will become problems of their own. Which very much seems spot on given my 30 years of experience.
anyways the point is that all my doctors and specialists have to stay very much in their VA bureaucracy approved lanes regardless of the wider picture of my individual health needs. Even with common issues that they have no issues with, they are for the most part, tunnel visioned on bog standard treatments that were cutting edge 20 years ago.
With my cardiologist I asked him about several drugs that are in development or even being sold overseas that are supposed to reduce plaque blockages in your arteries. not stop it from maybe happen but roll back existing ones. Not drugs you go on for years but just for a few weeks or small amount of months and then treatment is done. These are things that have been in journals and even the media for 3 to 15 years. He was total unaware of them, wasn't interested, and dismissed it without pause as quack medicine. He isn't a bad guy but he also doesn't give me the warm and fuzzies that he is up on anything new in his own field. Not to pick him out special. I have had the same conversation with at least 3 other cardiologists both in the VA and outside and got pretty much the same reaction.
another comment:
it's not just medical; it's almost everything
"Let me put on hold while I look into this..."
two hours later (if you haven't hung up or they haven't disconnected you): I'm terribly sorry, but we can't find any record of ..."
Educated people are out of work, the educated elderly, who want to work, are subsisting on whatever the agencies decide to dole out to them - - and we still can't get any service - - in this day of easily accessed, computerized data
Y' gotta be kiddin' me
I fear, so long as the bureaucrats are trying to get the lowest-bidder to do medical anything, and the government (at any level) is the customer, patients will have a hard time of it. I managed to slide past a lot of that, partly through luck, partly because I am in a mutual-assurance pool. The down side is I have to pay cash up front, then I get reimbursed. When I turn 65, well, I'm stuck.
The computerization and coding requirements from the feds (that other insurance providers latched on to), are another problem - too much time spent entering data into the system, not enough time to gather the data and analyze it.
TXRed
As a doc (most of my time past 20 years in rural ER) I want to defend myself, but in reality most of what you have written is perfectly true. What audeojude wrote about if your illness fits in a common known category treatments are available and can be performed in a reasonable time period.
Insurers limiting pharmacy benefits has been going on since the 90's. Right now it is placing different meds on different tiers of cost. $10/month vs 50-100 is a big burden for most.
Making APRN's do the work of MD/DO's is the new normal. In the 90's it was making FP/IM do the work of specialists.
In regard to chronic opioids the pendulum has really swung. In the early 2000's all pain was to be treated with opioids per government directives and if I didn't their was threat against my license. Now docs have not only had their licenses suspended for over prescribing but some have gone to jail for manslaughter when their patient combined the opioid with alcohol and died. Most docs don't want to be involved in pain rx unless for a very short course and for very measurable reasons such as recent major surgery or a broken bone.
As for drugs in development: there are always new drugs in development. Just a few years ago a very promising disease preventative drug was in the news - the mRNA "vaccine"!! There is a lot of snake oil out there. Not every treatment is a good idea. When someone brings up a treatment I'm unfamiliar with I usually don't have time to do a proper literature search. A proper literature search involves using PUBMED or NIH database. Figuring out the right search terms. Rejecting most of the results based on flawed methodology (such as small sample size, unapplicable demographics, retrospective review, non-blinding, case control errors, and other fallacies. Many studies are helpful in the sense of making a case to study an intervention further. But to use those studies for treatment decisions puts people in danger.). Then there is the NNT and NNH. NNT means number needed to treat over a time period to help ONE patient. NNH is the harm side. How many do I need to give this intervention to harm(or kill!) ONE person. As an example - Statins in coronary artery disease prevention the NNT changes depending on age, blood pressure control, gender, if diabetic and if previous vascular event has happened. I'm not going to have time in a 30-40 min visit to determine your NNT and NNH on a therapy I had never heard of before and may not be available in my country.
The AI stuff concerns me two ways: It might work great. It might be complete BS, and I may not be able to tell which. If it works well I may be out of a job. But if it is BS people may be hurt. You do know the current AI's if you ask it to suggest good reading material sometimes just makes up books that don't exist? Extrapolate that to medical care...
The lack of description of a "scan" seems really inexcusable.
Their were doc's in the 90's who were dropping people on medicare /medicaid. I thought they were crazy then. Now? Oklahoma medicaid paid half of commercial (years ago when I knew the numbers). My overhead was half of what I took in. So when I saw medicaid the reimbursement paid the overhead (office rent, staff salaries, malpractice insurance) but I got nothing. I was volunteering my time. Same as if I was working the free clinic on the poor side of town. Most docs saw their share of medicaid but nobody could afford to make medicaid the totality of their practice.
Overall Peter I think you are spot on , but there is nuance to these issues.
If doctors stop taking Medicare then we old people are toast because we will not be able to afford health insurance due to our comorbidities. If you can make it to 65 without a few problems then you are fairly rare in my experience.
I’m 70 this October. I see chiropractors fairly often and so far that and activity have kept me out of the medical system.
I will not willing go see an MD unless if HAVE TO. If the ambulance takes me there. I try not to do much that would require an ambulance but you never know with all the people on the road that should not be allowed out.
It will probably get better but I’m thinking I won’t see it.
Let's add, on top of this, the decline in medical education, coupled with the increase in DEI rules for acceptance into a pre-med program. I shudder at the thought of what level of expertise I"m going to encounter when I start seeing physicians as I get older.
And today's nifty headline is that the use of AI is actually eroding diagnostic skills among oncologists.
- jed
The decline in healthcare absolutely tracks with the bureaucracy expansion. Take a look at a spine surgeon's summary: https://youtu.be/fteNl6aJJDs?si=Y2OVotEelVfq9veZ
"Why, yes, now that you mention it, I do . . ."
ROFL!
Concur on the chiro... I will say the VA 'seems' to be getting better.
The entry of private equity (baby boomer Drs cashing out their practices) and consolidation of hospitals, Drs, pharmacies, insurance companies under one umbrella (insurance cos increasingly own drs and facilities) are the crux of the problem -- profit before care/patient outcomes.
We've gone to high deductible hmo plus hsa for our needs. No longer made sense to go w/ more expensive ppos when everyone who's good is increasingly out of network. At least we get a tax write-off for that hsa amount without needing to reach specific % of income thresholds... (we're self-employed so can switch between a handful of plans we authorize annually if we need a more expensive ppo for any reason.)
For anyone not wanting churn and burn patients under very strict treatment parameters dictated by medical bureaucrats and lawyers, I think that's unfortunately the best way forward.
Gee, what could possibly be the root of this problem child? Hmm, let me think for half a nanosecond…oh yeah, government getting their grubby regulatory and thievery hands on healthcare, forcing the slow creep to socialized medicine…which took a huge leap into that abyss with the so-called Affordable Care Act. Private, across state lines, healthcare is the answer.
Essentially, it's too many people fighting over the money that represents your medical costs. All of them experts in rent seeking, none of them qualified in medical care.
Free Luigi.
The increase in doctors attitude of "I don't GAF...." started with all of the nonsense of having to treat patients without health insurance. IE: illegals. California and Texas have long suffered under this ruling, since probably the early 1980s. At first, everybody got the same treatment, then suddenly the illegals were taken to the top. Taxpayers were paying the freight costs and we continue to be fleeced. It is simply a nightmare. I have medicare plus a great supplemental-not all of my friends are so fortunate. And I have to continue to work to keep paying for that supplement. Everyone hates the elderly; we cost money, we aren't smart, and we take too much. The fact that we sent people to the moon, developed computers and cell phones doesn't mean a damned thing to anyone under 30. If you can afford it, I would advise anyone to go Concierge Medicine. Doctors are freed from the medical system and the healthcare is personal, professional, and competent.
I know of more than a few doctors at my wife's church that are opting out and starting or joining concierge practices. We can't afford to use such services sadly.. on or two are still taking insurance from people that are friends or members of the church but I don't think that will last much longer. to much infrastructure needed to comply with insurance billing practices for just a few people.
A BIL began his medical practice in '88, as a solo doctor. By the mid 90's he had a clinic with about six doctors and maybe twenty paper shufflers for support. Those office workers spent most of their time dealing with insurance companies and searching for the correct charge code for the work the docs were doing. Couple of nurses in the mix.
He recently had to sell his TWO clinics as he never recovered from the effects of getting the covid wonder drug he was required to get to retain his hospital access. Each facility had about 25 employees, not counting the doctors, as they are not part of the employee group for federal requirements.
During the covid panic, the feds made great effort to close down independent medical offices to try to force the public into the hospital system for medical care.
More than 50 employees puts you in a different category of business, and gets expensive to run because of different rules. You need to get much bigger to reach economy of scale. That is for all US businesses.
Fifty years ago, your doctor was focused on fixing your medical problem. Now, they are focused on figuring out which drug(s) they can prescribe for your symptoms, instead of addressing the underlying problem. It also seems that doctors don't bother to do any continuing schooling to expand their knowledge base. Whatever they learned in med school is all then can be bothered with. They also can't be bothered to keep your records up to date. Point out a mistake, and you find the bad data is still there the next time you go in.
You are more right than you can know. I am no longer a doctor, I am a cog in the medical industry. And you are not a patient, just a potential profit center.
Will send you my email if you want to discuss further.
You were warned about this when government got into the health care business in 1965.
People tried to tell you it was a mistake, and have repeated it many times since.
The chickens have come home to roost.
Get government out of health care, and instead use it to police insurance company fraud, and you'll return to fee-for-service, getting what you paid for, and doctors making house calls, in about 20 minutes.
But poor people, crazy people, waste-of-skin-and-oxygen addicts, and illegal aliens will stop getting Cadillac care for free, and middle-class and rich people will stop paying for that.
TANSTAAFL
"The government powerful enough to give you everything you want, is also powerful enough to take away everything you've got."
Never are those words truer than when you entrust them with the care of your health.
Peter, as a 25yr veteran of the Healthcare business, I am as burned out and frustrated as you are. What a mess.
~Skean
FWIW - Canada but in keeping
"The Doctor Will Kill You Now"
https://www.theatlantic.com/magazine/archive/2025/09/canada-euthanasia-demand-maid-policy/683562/
"The euthanasia conference was held at a Sheraton. Some 300 Canadian professionals, most of them clinicians, had arrived for the annual event. There were lunch buffets and complimentary tote bags; attendees could look forward to a Friday-night social outing, with a DJ, at an event space above Par-Tee Putt in downtown Vancouver. “The most important thing,” one doctor told me, “is the networking.”
Which is to say that it might have been any other convention in Canada. Over the past decade, practitioners of euthanasia have become as familiar as orthodontists or plastic surgeons are with the mundane rituals of lanyards and drink tickets and It’s been so long s outside the ballroom of a four-star hotel. The difference is that, 10 years ago, what many of the attendees here do for work would have been considered homicide."
Via https://www.smalldeadanimals.com/2025/08/15/the-doctor-will-kill-you-now-22/
Although I have seen much of this I see it far less now that I have a deep understanding of one thing, doctors are huge! What I mean is, having a good doctor literally makes or breaks your care. I doctor hunt. I will not move despite hating the climate here because I have a phenomenal set of doctors where I live. One of my doctors tried 5 times with surgery to get an issue resolved (lest you think this doctor is bad, he's not, I'm just an extremely rare and complicated case and feel incredibly blessed to have found this doctor because my two previous couldn't even tell me what my issue was and one, due to their ignorance, almost cost me my life). A good doctor and his good staff will fight the fight for you. Plus getting good care from knowledgeable doctors who only do the absolutely necessary things and don't try to patch you with meds... big difference from pill pushers.
> "The Doctor Will Kill You Now"
You have got to be kidding me.
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