Medicare's new plan to reduce hospital overcrowding

Brandon Lopez6 said:I was half-listening (and half-reading 😬) all this talk about the new medical law—or whatever it is—saying that primary care doctors will be running the show for chronic patients now. It’s got me wondering where I actually fit into this whole mess.

My GP is a sweetheart, really, but whenever I brought up any kind of mental health stuff, he’d immediately tell me to head over to Washington, D.C. to see a psychiatrist. How am I supposed to trust that he'll make the right call for me when he's already admitted he doesn't know enough to even tweak my meds?

* I think I saw someone mention somewhere that a GP can prescribe a new antidepressant if the current one isn't working, as long as it's in the same class. Dammit, I can't remember the specifics right now. 🙂

Also, word is we won't get to "pick" our hospitals anymore; everything is being assigned based on where you live. The closest hospital to me (Sisak) has a nine-month waiting list just for psychotherapy.
Basically, I need to know: do I still have the right to go to a major center like Mayo Clinic, or am I just stuck waiting to drop dead at home as far as they're concerned?

melloworca6 said:Here’s the article: and I made sure to give them a piece of my mind yesterday, item by item.

Long story short: doctors are going to be prescribing the cheapest options available, and if you want the premium stuff, you’re paying out of pocket. From what I can gather, specialists won't be calling the shots on therapy or tests anymore either; they’ll just make recommendations while Medicare makes the final call on everything. There’s also talk that we won't be able to seek treatment anywhere except at their specific hospitals and such.

I am not a fan of this at all, and I’ll get into why in a bit. It’s infuriating. Between health insurance and supplemental coverage, even as someone who's unemployed, I’m going to have to pay for my own meds if I don't want the cheap junk they’re pushing—and let's be real, the cheapest version isn't always the best one with that same formula. Meanwhile, you've got politicians getting whatever procedures they need treated abroad on Medicare's dime.

melloworca6 said:Here’s the article: and I made sure to give them a piece of my mind yesterday, item by item.

Long story short: doctors are going to be prescribing the cheapest options available, and if you want the premium stuff, you’re paying out of pocket. From what I can gather, specialists won't be calling the shots on therapy or tests anymore either; they’ll just make recommendations while Medicare makes the final call on everything. There’s also talk that we won't be able to seek treatment anywhere except at their specific hospitals and such.

I am not a fan of this at all, and I’ll get into why in a bit. It’s infuriating. Between health insurance and supplemental coverage, even as someone who's unemployed, I’m going to have to pay for my own meds if I don't want the cheap junk they’re pushing—and let's be real, the cheapest version isn't always the best one with that same formula. Meanwhile, you've got politicians getting whatever procedures they need treated abroad on Medicare's dime.

melloworca6 kaže:

The referral system is getting a complete overhaul. They’re rolling out a new encryption method for all incoming referrals, and it’s going to be categorized based on where the patient is actually headed: whether they're being sent for a multidisciplinary consultation at the hospital (A), direct inpatient care (B), specialized outpatient services (C), or standard ambulatory treatment (D).
Under this new directive, the specialist's role covers the initial consultation and all those necessary diagnostic tests. They’re also cleared to suggest follow-up screenings, specific medications, or specialized therapies—though, let's be clear, the family doctor still holds the final say on any of that. But here is where I get frustrated: the specialist's hands are tied when it comes to actual follow-through. They can't refer a patient for further hospital treatment, they can't schedule follow-up appointments, and they certainly can't issue any official opinions regarding a patient's ability to work. It’s a massive gap in the process!

vividsailor7, I’m genuinely terrified that I might be misinterpreting this, so please, read these specific excerpts I’ve pulled from the text. Honestly, I am praying to God that I’ve just gotten everything wrong. Look, I have a wonderful primary care physician—really, she's great—but I refuse to let her play judge and jury on whether my immunologist prescribed the right treatment or which additional tests I need to undergo. She couldn't even fully explain my own lab results to me! How on earth is she qualified to dictate my medical regimen when she can't even provide a detailed breakdown of my findings? I don't expect my GP to be an encyclopedia or to interpret every single nuance of my data, but that is exactly why we have specialists who have actually completed their advanced fellowships and subspecialties.

Look, I couldn't disagree with you more if we’re pretending it doesn't matter which medication we take just because the active ingredients are technically the same. Let’s talk about antibiotics—and don't even get me started on things like chemotherapy, where you absolutely *do* care about the specific brand and wouldn't dream of settling for the cheapest option available. Take penicillin, for instance. There are tons of different brands prescribed under various names. Suppose I wake up with a nasty sore throat, head to my doctor, and she prescribes me Silapen simply because it’s the cheapest one on the list. Honestly, I have no clue why they always push Silapen on us whenever they prescribe a penicillin-based antibiotic, but that's usually what I end up with. Now, here's the problem: what if my friend and I both have terrible side effects from Silapen? We're talking debilitating diarrhea and insane stomach cramps—the kind of reaction I personally get from Erythromycin. It is infuriating that we’re forced to choke down medications that clearly don't agree with our bodies just because they happen to be the budget option. If you want the more expensive version from the same class of drugs, fine—pay the extra money yourself. But don't act like it's all the same.

Look, I honestly don’t give a damn how they plan to reorganize the system or whether they start slapping fines on doctors just because they keep prescribing the most expensive drugs on the market. My priority is simple: I want to be able to get the medication that actually works for me—the one that doesn't make me feel like death or wreck my body with side effects. I don't care about the price tag, provided it’s on the approved list and covered by Medicare. Instead of actually doing their jobs and monitoring who is prescribing what—and maybe earning those ridiculous salaries instead of sitting around in offices doing absolutely nothing—they’ve chosen the easiest, laziest way out. They're basically saying, "Fine, pay the premium, we don't care." It’s a joke. If you have money, great, you get the top-tier meds. If you don't? Well, tough luck. When we politicians inevitably fall ill with some kind of tumor or need major surgery, we won't be stuck in this mess. We’ll be using Medicare to fly straight to Germany for surgeries or heading to the States for experimental treatments that cost an absolute fortune. Meanwhile, little Nora will be left begging for scraps on the news just to get some basic help. 🤮

Regarding the medical care in your neck of the woods—honestly, that sounds great. Why bother with actual treatment when we could just pass around a handful of pills and end up dead instead? It’s much more efficient, right? I can't speak for hospitals in other parts of the country since I don't know what they're dealing with elsewhere, but where I'm at? You're better off avoiding certain wards entirely. It’s just one "expert" after another, all pretending to know what they're doing. Absolute nonsense. Don't even get me started. Are you seriously telling me that in your hospital there isn't an entire ward where most of your colleagues—to put it mildly—don't have the slightest clue what they're doing? We’re talking about people who wouldn't know how to actually treat a patient if their lives depended on it, let alone someone working there without even holding a degree! It's absolutely infuriating.
Look, in my experience, there are certain departments where it’s just better to head straight to a major medical hub like Washington, D.C. immediately—unless you actually want some amateur poking around inside you without having a clue what they're doing.

Angela Wright said:It looks like these new regulations are going to hit family practitioners and their patients the hardest. I have a family doctor in my own family, and what they’re putting them through right now is pure torture—let alone dumping this extra load on them. This is a calculated move to shift the entire burden of deciding on the most appropriate therapies—which used to be the responsibility of hospital specialists—straight onto the shoulders of primary care. So, go ahead, be a hero and reject a specialist's opinion. Tell an oncology patient with PTSD that you won't prescribe the new line of Avastin that the hospital oncologists correctly recommended, all while Medicare is breathing down your neck, threatening to hang you out to dry for exceeding referral or prescription limits. If the mess they made with antibiotics was any indication, I can only imagine the disaster coming our way.

I honestly think it's high time the medical profession finally unified, dropped the ego and the massive doses of vanity, and actually stood its ground. Taking a once-solid, reliable system and degrading the American healthcare system to the level of Albanian healthcare is nothing short of criminal.
They aren't approving new specializations, residencies, or continuing education, yet practicing doctors are forced to play games with various pharmaceutical reps just to scrape together enough funds for the very conferences and training sessions they are mandated to attend from their first day on the job until retirement.

vividsailor7 said:I have no idea what kind of "torture" by the medical board you're talking about. Up until now, everything revolved around issuing medications and referrals, which was clearly too much for some people. Let me repeat: there were cases where my colleagues or I had to call out "the gentlemen" in charge because they refused to issue medications that were clearly indicated. Every single one of those conversations ended with them nodding along while they spewed nonsense about guidelines that make zero sense professionally.
If a patient is indicated for Avastin, they will get it, just like they always have.

Angela Wright said:Look at what’s highlighted here—it says everything you need to know. We’re talking about guidelines that are so incredibly vague that even the bureaucrats at Medicare can't make sense of them half the time. It’s all just a mess of conflicting limits. Here’s the kicker: if a Medicare auditor decides they don't like how a prescription was handled, they don't just ask questions; they go straight for the doctor's paycheck. They dock the physician's salary to cover the cost of the medication or the travel voucher, and there is zero recourse. No chance to appeal, no chance to explain the medical necessity. You prescribe Avastin for something outside of the one specific line item Medicare has authorized, and suddenly the doctor is paying for it out of pocket. It makes me wonder: what kind of cheap generic are they going to force you to prescribe just to stay in their good graces? 😍

Nicholas Myers said:Angela Wright, a family practitioner isn't going to write you a prescription for Avastin. They don't handle that, nor do they deal with Sutent or anything else in that category.

When it comes to specialist-recommended medications prescribed by your primary care doctor, the rules are pretty black and white. There are very specific guidelines determining which drugs Medicare will cover and which ones you're stuck paying for out of pocket.

vividsailor7 said:I have no idea what kind of "torture" by the medical board you're talking about. Up until now, everything revolved around issuing medications and referrals, which was clearly too much for some people. Let me repeat: there were cases where my colleagues or I had to call out "the gentlemen" in charge because they refused to issue medications that were clearly indicated. Every single one of those conversations ended with them nodding along while they spewed nonsense about guidelines that make zero sense professionally.
If a patient is indicated for Avastin, they will get it, just like they always have.

Angela Wright said:Well, based on this new update, it looks like those rules might be out the window. At least, it’s certainly not laid out clearly—I know for one I can't find it anywhere. 🤷

vividsailor7 said:

melloworca6 kaže:

The referral system is getting a complete overhaul. They’re rolling out a new encryption method for all incoming referrals, and it’s going to be categorized based on where the patient is actually headed: whether they're being sent for a multidisciplinary consultation at the hospital (A), direct inpatient care (B), specialized outpatient services (C), or standard ambulatory treatment (D).
Under this new directive, the specialist's role covers the initial consultation and all those necessary diagnostic tests. They’re also cleared to suggest follow-up screenings, specific medications, or specialized therapies—though, let's be clear, the family doctor still holds the final say on any of that. But here is where I get frustrated: the specialist's hands are tied when it comes to actual follow-through. They can't refer a patient for further hospital treatment, they can't schedule follow-up appointments, and they certainly can't issue any official opinions regarding a patient's ability to work. It’s a massive gap in the process!

vividsailor7, I’m genuinely terrified that I might be misinterpreting this, so please, read these specific excerpts I’ve pulled from the text. Honestly, I am praying to God that I’ve just gotten everything wrong. Look, I have a wonderful primary care physician—really, she's great—but I refuse to let her play judge and jury on whether my immunologist prescribed the right treatment or which additional tests I need to undergo. She couldn't even fully explain my own lab results to me! How on earth is she qualified to dictate my medical regimen when she can't even provide a detailed breakdown of my findings? I don't expect my GP to be an encyclopedia or to interpret every single nuance of my data, but that is exactly why we have specialists who have actually completed their advanced fellowships and subspecialties.

Look, I couldn't disagree with you more if we’re pretending it doesn't matter which medication we take just because the active ingredients are technically the same. Let’s talk about antibiotics—and don't even get me started on things like chemotherapy, where you absolutely *do* care about the specific brand and wouldn't dream of settling for the cheapest option available. Take penicillin, for instance. There are tons of different brands prescribed under various names. Suppose I wake up with a nasty sore throat, head to my doctor, and she prescribes me Silapen simply because it’s the cheapest one on the list. Honestly, I have no clue why they always push Silapen on us whenever they prescribe a penicillin-based antibiotic, but that's usually what I end up with. Now, here's the problem: what if my friend and I both have terrible side effects from Silapen? We're talking debilitating diarrhea and insane stomach cramps—the kind of reaction I personally get from Erythromycin. It is infuriating that we’re forced to choke down medications that clearly don't agree with our bodies just because they happen to be the budget option. If you want the more expensive version from the same class of drugs, fine—pay the extra money yourself. But don't act like it's all the same.

Look, I honestly don’t give a damn how they plan to reorganize the system or whether they start slapping fines on doctors just because they keep prescribing the most expensive drugs on the market. My priority is simple: I want to be able to get the medication that actually works for me—the one that doesn't make me feel like death or wreck my body with side effects. I don't care about the price tag, provided it’s on the approved list and covered by Medicare. Instead of actually doing their jobs and monitoring who is prescribing what—and maybe earning those ridiculous salaries instead of sitting around in offices doing absolutely nothing—they’ve chosen the easiest, laziest way out. They're basically saying, "Fine, pay the premium, we don't care." It’s a joke. If you have money, great, you get the top-tier meds. If you don't? Well, tough luck. When we politicians inevitably fall ill with some kind of tumor or need major surgery, we won't be stuck in this mess. We’ll be using Medicare to fly straight to Germany for surgeries or heading to the States for experimental treatments that cost an absolute fortune. Meanwhile, little Nora will be left begging for scraps on the news just to get some basic help. 🤮

Regarding the medical care in your neck of the woods—honestly, that sounds great. Why bother with actual treatment when we could just pass around a handful of pills and end up dead instead? It’s much more efficient, right? I can't speak for hospitals in other parts of the country since I don't know what they're dealing with elsewhere, but where I'm at? You're better off avoiding certain wards entirely. It’s just one "expert" after another, all pretending to know what they're doing. Absolute nonsense. Don't even get me started. Are you seriously telling me that in your hospital there isn't an entire ward where most of your colleagues—to put it mildly—don't have the slightest clue what they're doing? We’re talking about people who wouldn't know how to actually treat a patient if their lives depended on it, let alone someone working there without even holding a degree! It's absolutely infuriating.
Look, in my experience, there are certain departments where it’s just better to head straight to a major medical hub like Washington, D.C. immediately—unless you actually want some amateur poking around inside you without having a clue what they're doing.

Let’s take this one step at a time.
1. We're talking about Code A versus Code C; we already settled that part.
2. This isn't anything new; they've been doing this forever. In some cases, we even had to call people on the phone just to have them hang up on us while rambling about "guidelines" and other absolute nonsense.
3. Good grief, you completely missed the point! You didn't even read my example regarding esomeprazole. Both Emaner and Nexium 40 mg are absolutely identical; they just come from different manufacturers. That is what I am talking about. It’s not even about different drug classes; it's about the originator versus the generic. Your example doesn't work because Silapen is a penicillin and doesn't have a generic equivalent, whereas Erythromycin is a macrolide (a completely different class from Abbott Laboratories).
So, with all due respect, please don't lecture me about things you clearly don't understand with such intensity. I’m not attacking you personally, but rather speaking generally about the North American regiment.
It is standard practice worldwide (take Abbott Laboratories as an example again) that if you want the brand-name version, say Sumamed, you pay extra, whereas insurance might cover something like Belupo Azithromycin. At the end of the day, it's all just azithromycin.
4. Let me clarify this once more. Say you have a urinary tract infection. You get a urine culture back, and it shows, for instance, *Pseudomonas aeruginosa* which is sensitive to ciprofloxacin. This means you will receive ciprofloxacin, but instead of the expensive Ciprinol, you might get Cipromed. Either way, you got the correct therapy, not some cheap Amoxicillin.
Honestly, I don't see why patients should care which manufacturer produced their meds. If ciprofloxacin is indicated, it shouldn't matter who made it.
5. As for the pointed comment regarding this: Well, if that were the case, you'd be heading straight to Washington, D.C. too.
We need to distinguish between primary, secondary, and tertiary healthcare.
If it's a complex case, then there's no issue with traveling to a major city like D.C. The problem is when people with trivial issues—like allergic rhinitis, gallstones, or a million other minor things—flood the big city hospitals, instead of saving those resources for someone dealing with a brain tumor or a rare disease.

melloworca6 said:Regarding Code A. As far as I know, a consultation is when a group of doctors gathers to discuss a case. At our hospital, this usually happens between 8 and 9 AM before they head down to the wards and clinics. So, if I'm wrong about what that code refers to, fine, my mistake.
My doctor referred me to a consultation, where a panel of doctors discusses my case, suggests therapy, tests, and medication, and then my GP decides how to proceed and what I'll be taking. If I understood this code correctly, the whole system is a total comedy. I honestly wonder how long it will take before we start reading in the news that people have started murdering their GPs—especially if they end up with incompetent doctors like the one I had.☕

For heaven's sake, I know Silapen and Erythromycin are different antibiotic classes. I wasn't comparing them against each other; I was comparing the side effects that both my friend and I experienced from those two drugs.
Since you brought up Sumamed, let me explain my point better. Why do you think there are people for whom Sumamed works perfectly, but the Belupo version doesn't? And vice versa. I'm not going to sit here and study the chemical composition of every pill to see if they are identical, but the physical makeup of a tablet isn't always the same (and when I say "makeup," I mean the inactive ingredients, not the active drug). I have family members who are sensitive to certain fillers used in tablets and have huge issues swallowing any kind of pill. Those people won't have a choice; they'll have to pay out of pocket if the cheapest option makes them sick. These people pay for health insurance, they pay for supplemental insurance—they should have the right to get a medicine that doesn't make them ill or cause massive side effects. People with lactose intolerance know they can get diarrhea from meds containing lactose. I know people who had terrible digestive issues with Euthyrox, but were fine with Letrox, even though they contain the exact same active ingredient. The tablet composition just isn't identical, but go ahead and try explaining that to them. If Euthyrox is the cheaper option, then sorry, folks—either buy the Letrox or take the Euthyrox and deal with the cramps and diarrhea.

Should we talk about the heavy hitters? Things like corticosteroids, antimalarials, or cytostatics—medications where it actually matters which brand you’re taking. Should I mention that people have tried different manufacturers of steroids and found that the side effects weren't the same across the board? Same ingredients, same dosage, yet different results. How do you explain that? 🤷 Maybe it's time to realize the human body isn't some math equation you can just solve. Every organism is its own unique story, and life isn't always black and white; it's mostly gray.

vividsailor7, if we're restricted to only getting treatment in our own backyard, that won't just apply to allergies or minor stuff—it applies to everything. If I want to see the top immunologist in the entire US because my local doctors are basically stumbling around in the dark with no clue what's actually happening to me (I might be exaggerating, but I'm not far off), why should that be blocked? 🤷 And it's not just me. It's anyone else being bounced from ward to ward without a single concrete answer. Look, we have hospitals, we have specialists, but just because half of them don't have a clue doesn't mean we should just shrug and say, "Oh well, we're lucky we don't live somewhere else." Honestly, it's more likely that we're all just unlucky to live in a country where we can't even tell if our healthcare system is supposed to be social or private. This messed-up hybrid we've got here isn't even funny anymore; it's pathetic.