Hi Reddit,

My name is Nelson A Paguyo, and I am a retired physician. I have worked in medicine here in the US since emigrating from the Philippines in 1963. I specialized in Pulmonology and practiced internal medicine and have twenty years in solo practice and thirteen years as a member of an HMO. Through my career, I have first-handedly witnessed the evolution of healthcare from the ART & SCIENCE OF MEDICINE to the BUSINESS OF MEDICINE where, unfortunately, money and profits are more valued than patient care. I am joined today by my granddaughters who have tried to explain to me what reddit is and encouraged me to try an AMA. They will be helping me with the technology and will type my responses out for me. Proof that it is me.

Originally written in 2007, I have recently republished the 4th edition of my book, "Healthcare for All Americans" this year. It's a comprehensive universal healthcare plan that covers details on how we can implement and finance a truly universal healthcare for America. The plan is a hybrid approach of Medicare for All, combining government and the nature of the free-market to reduce and control the cost of insurance.

The COVID-19 Pandemic has significantly shed a light on the circumstances of the United States' broken healthcare system. Many Americans are more aware of the rising costs of healthcare in this country and are wondering why there isn't universal coverage like many other countries around the world. Ask me anything about my book, my experiences as an immigrant doctor, the evolution of healthcare in America, and my ideas for Universal Healthcare/Medicare for All!

More Links:
Healthcare for All Americans: Health Crisis USA--A Comprehensive Solution on GoodReads

Doxomity Profile

EDIT: Thank you so much for all the questions! That's all the time we have for today, so I'll be ending things here. If you have any further questions, feel free to contact me.

Comments: 82 • Responses: 20  • Date: 

Muscle_Doc12 karma

Hi Dr. Paguyo, my uncles are MDs who also came to the US from the Philippines after graduating UST and Far Eastern University in the late 50s, early 60s. Coming to America in the 60s, why did you choose Minnesota over more popular places for Filipino physicians like Albany, NY?

paguyomd15 karma

Coming to America in the 60s, why did you choose Minnesota over more popular places for Filipino physicians like Albany, NY?

When I first moved to the US, I was in New York for two years on internship. I applied to various Ivy League institutions for residency. However, Minnesota was the first institution that accepted me before my deadline as a resident physician, so I signed and mailed the contract. 24 hours later, the other institutions I applied to also accepted me!

paladine17 karma

I'll try to make this short and may be more of a statement than a question. I know stuff has to cost, but why does it cost SO much? Medicare is the most efficient system in the United States today (and the VA is very efficient as well) so why doesn't our government care about the well being of its citizens? Why isn't Medicare an option for any citizen? I think I know the answer and it is all about money, but I would like to hear you experienced take. Thanks

paguyomd20 karma

I know stuff has to cost, but why does it cost SO much?

Healthcare in the US is twice as much as it is in other countries. The reason why this is is because everyone is gaming the system, for example, insurance companies, health industries, businesses, lobbyists, government officials, even the public at times, everyone. This created the 13 major problems that has led to the crisis in our healthcare system. These 13 major problems are 1) abuses by patients, 2) over utilization by healthcare professionals, 3) profit motivated companies (this includes both for-profit and non-profit), 4) malpractice and litigation, 5) defensive medicine, 6) new technological advances in healthcare, 7) illegal immigrants and non-permanent residence, 8) capping and limitation of medical benefits, 9) fraudulent claims, 10) lobbying and politics, 11) isolating the public from the actual cost of their care, 12) health attitude of Americans (though changing), 13) cumbersome paperwork.

Medicare is the most efficient system in the United States today (and the VA is very efficient as well) so why doesn't our government care about the well being of its citizens? Why isn't Medicare an option for any citizen?

Medicare is working fairly well for only a limited number of our population. The way it is set up now is not through a single-payer unlike those of Canada, United Kingdom, and other countries. The ones who are implementing our current system are only looking for their own advantage. My proposal is basically expanding Medicare for all, but set up in a way that eliminates all the problems with our present healthcare.

nuclearswan2 karma

New technology is a problem?

paguyomd6 karma

While new technological advances are good, it also adds to the increasing and uncontrollable cost of healthcare. Physicians and patients move to the new technology. As those technologies become more standard, the cost of that technology will go down, but it is still something to consider when looking at why healthcare has become more expensive.

herbwannabe7 karma

Thank you for doing this ama. Do you think the US will see universal healthcare in the next generation or so?

paguyomd13 karma

Yes, if majority of US citizens call their state representatives, senators, governors, etc. and advocate strongly for it. Politicians will only listen to the constituents that interact with them. Therefore, we all need to flood them with emails and phone calls of what we want. This is why lobbyist have so much power.

brosbe4gnomes5 karma

What do you think about the ever increasing bread trail of requirements that incoming students transitioning to doctors face, as it relates to the increasing “doctor shortages” we keep hearing about?

The same doctor shortages that are allowed encroachment by Physicians assistants. Seems like an intentional divide for lucrative purposes, making more requirements constantly that cost more and more, increasing the time And hoops to jump through to become a physician, while simultaneously creating a new job pool by increasing the potential; I.E allowing PA’s to open clinics and operate independently in some states etc.

paguyomd5 karma

What do you think about the ever increasing bread trail of requirements that incoming students transitioning to doctors face, as it relates to the increasing “doctor shortages” we keep hearing about?

It has to do with people wanting to make a lot of money. The increased requirements for students is directly related to the institutions wanting to profit in educating doctors. Current physicians need to advocate and define what their proper roles are in order to help the younger generation of doctors. It's a multi-factorial issue, government requires the physicians to do a lot of non-medical issues. Going to school nowadays is too expensive and too long. This leads to the loss of freedom to practice medicine, and so on.

scJazz5 karma

I worked in IT providing onsite support for many Doctor's offices. A few things always struck me as worrisome in these small practices.

HIPAA required a significant change in the way the IT infrastructure operated in these small offices. Yet, practically no office I ever worked in was fully compliant when I started there and many were still not fully compliant when I stopped. This despite tens of thousands of dollars worth of billed hours and equipment over the course of say a single year. What are your thoughts regarding HIPAA?

Regarding HIPAA and market forces there are very few vendors, of for lack of a better term, "Medical Practice Management" software. The few that exist are incredibly expensive, require extensive training to use, ongoing support contracts that are also expensive and despite the promise of compatibility for Personal Electronic Medical Records never actually deliver. Have you any thoughts about the Software end of HIPAA as it applies to a practice?

In every office there were one or more staff dedicated to the task of working with Billing. By which I mean their job was to interact with Insurance companies or state Medicare. In one practice that was notable, there were 2 full time and
2 part time employees for 4 full time Doctors and 3 part time. This even though they had a contract with a Medical Billing Contractor whose job it was to handle this workload. Can you comment on how this affects the practice of medicine?

I have more questions along this line of thought but I'll stop here and await your answers.

paguyomd6 karma

What are your thoughts regarding HIPAA?

HIPAA is good because it protects the patient. To implement it, like you mentioned, is very expensive. The smaller practices may have trouble implementing all of the requirements regarding HIPPA. This was one reason why I moved from private practice to HMO.

Have you any thoughts about the Software end of HIPAA as it applies to a practice?

If the HIPAA software is more affordable and user-friendly, it could be applied well to practices. I personally didn't have any problems with HIPAA, but I understand the technology around it has transformed since I have retired.

Can you comment on how this affects the practice of medicine?

Expensive and very time consuming. A universal healthcare plan would eliminate this.

scJazz1 karma

Follow Up: So you moved from private practice to HMO specifically to avoid this cost which thus reinforced the issues with HMOs and pricing in regards to Health Insurance? Is this not a kind of Negative Feedback Loop?

"The law says I must do this which is too expensive so instead I will join a group which profits because of the law?"

paguyomd5 karma

The main reason that prompted me to move to HMO was that I was losing patients. At that time, HMO and other managed care institutions became dominant players in healthcare and required their policy holders to see physicians in their network. They negotiated coverage for their employees' healthcare and employers would provide health insurance only within those networks. Patients who had previously come to me no longer were able to because I was not in network. In a way, moving to HMO was a matter of financial survival.

JayCroghan5 karma

Hi there. Thanks for doing this AMA. I’ve lived on 4 continents and I’ve encountered my fair share of amazing doctors and awful doctors and being honest there seems to be a lot more awful doctors out there than good ones. The good ones though are absolute gems.

I could list examples of things bad doctors have said and done to make me just walk away but I’m sure with 40 years experience you know already how awful some can be. And I don’t mean personally, I mean strictly professionally.

Do you have any tips for figuring out if a doctor is useless or good early on rather than having to experience them making some insane diagnosis/give insane advice/say something awful?

Edit: Some examples. Misdiagnose genital warts as herpes (!!!!) Misdiagnose costochondritis as a heart problem. Prescribe ear drops which said “do not use with any ear drum perforation” for a perforated eardrum. I could go on but this is the gist of what I mean when I say a bad doctor.

paguyomd8 karma

Do you have any tips for figuring out if a doctor is useless or good early on rather than having to experience them making some insane diagnosis/give insane advice/say something awful?

In this day and age, we really have to advocate for ourselves to find good care. Always have a primary doctor or family doctor that you can go back to. If your first encounter with your doctor isn't good, it's okay to change them. Ask your peers who their primary doctors are, or call clinics or hospitals to see who they would recommend. Your primary physician can help you navigate and recommend specialists to help you. Unfortunately, insurance companies have networks that prevent you from going out of network and limits your choice of physician. I believe that we should be able to choose our own physicians regardless of networks!

Anoncat35 karma

What are boomer physicans doing to protect the next generation of physicans from mid level creep? I've heard stories of new doctors being laid off to be replaced by an NP, what can older docs do to help the young ones out? Currently, most people are tackling cheaper healthcare or universal healthcare but trying to replace doctors with midlevels yet patients still pay the same amount whether a doctor or nurse or PA sees them.

paguyomd14 karma

What are boomer physicians doing to protect the next generation of physicians from mid level creep? I've heard stories of new doctors being laid off to be replaced by an NP, what can older docs do to help the young ones out?

I believe that the best way for older physicians to help the younger physicians is by becoming politically active alongside the younger physicians and advocating for the proper roles of the physician and other healthcare providers.

During my time, before the emergence of doctor's assistants, there was a lot of demand to save money for medical services. Initially, mid-level health providers were allowed to do some physicians work in order to save money. Over the years, more mid-level health providers became politically active and asked for higher wages. This has evolved into the current situation, and a lot of the older physicians believe that they have lost their freedom to practice medicine and that everything is overly controlled by the business of insurance.

beachnerdlife3 karma

Hello Dr. Paguyo! First, thank you for doing this AMA! I have two totally different questions, is that allowed? If not, please feel free to answer whatever one you’d like.

  1. A lot of different diets and “eating styles”, for lack of a better phrase, have gotten popular in recent years... intermittent fasting, keto, paleo, plant-based, etc. In your opinion, is there any particular diet you think is more beneficial as a whole to the human body, in general?

  2. I’m thinking about applying to a chiropractor program, maybe in the next year or two... but I’m in my early 30s. I’ve know there’s a lot of time and study involved in any graduate health program, but...do you think I’m too old to start down this path?

Thank you!

paguyomd4 karma

1) My opinion of the best diet is a balanced diet that consists of all food groups. I believe a balanced diet has to be based on a person's individual calorie needs. The food should consist of 60% carbohydrates, 25% fat, and 15% protein. A rule of thumb to calculate your calorie requirement for a sedentary person is to allow 12 calories per 1 pound. For a moderately active person 14 - 15 calories per 1 pound, and a very active person 20 calories per 1 pound. This estimate is based on a person who is age 25. The calorie requirements decrease about 5% every decade.

2) You're never too old to pursue what you desire in life! So go for it!

Corka3 karma

Commonly American politicians will cut expenditure towards public services, or they will fail to increase funding at all over decades despite increasing costs, all in the name of delivering more tax cuts. Even when this inevitably happens, will your proposal likely still leave better with better health outcomes than they do currently?

paguyomd3 karma

The basis of my proposal to financing universal healthcare involves three possible options: 1) pooling all money earmarked from private and government health programs and creating a Healthcare Superfund that delegates and redistributes the money on a per capita basis to each state, 2) increasing the Medicare part of FICA to 3%, this will raise money sufficient to cover Medicare and Medicaid expenses, or 3) increasing the Medicare part of FICA to 8%-9%. This will raise enough money to cover everyone, though many politicians may feel this is too big of a tax to consider. Any additional savings would go into each state's "healthcare safety fund"--this will allow for financing future healthcare needs in the event of economic downturn or pandemics like Covid-19.

lotusblossom603 karma

It just took me a year to get diagnosed with MALS after doing my own research and finding my own vascular surgeon. This is the third time in my life I have suffered and had to find my own diagnosis and treatment. What can I do different? Why don’t doctors know more about rare diseases in their specialty areas?

paguyomd4 karma

What can I do different? Why don’t doctors know more about rare diseases in their specialty areas?

If you went your primary doctor, they should be able to refer you to the right specialist. If your not satisfied with their diagnosis, it would be best to ask your primary to refer you to another specialist for a second opinion. Unfortunately, the system right now is such that it gives a lot of obstacles for patients to find adequate care.

grovelmd2 karma

Would a person with a rare condition be able to choose his or her MD? Even if it is out of state? What would happen to the salaries of the medical practitioners?

paguyomd3 karma

Yes, in my proposed plan. A truly universal plan would give each person a Healthcare ID (similar to a driver's license) that will allow the freedom to choose one's physician anywhere in the country, and possibly in the word. I do not believe salaries would be affected.

shmoe7272 karma

I am Canadian and I’m curious what your opinion is of our health care system. Personally, I really like it. I never have to think about paying for medical care and the level of care is excellent.

Do you think it would work to implement the same style of system in America?

The one negative of our system is the longer wait times. This could be partly due to many of our grads going to the US to work to make more money. So my question to you is: Does the doctor who drives a sports car provide better care than one who drives a family sedan? Would evening out the playing field in terms of doctors salaries result in any negatives for Americans?

paguyomd3 karma

I am Canadian and I’m curious what your opinion is of our health care system.

The Canadian healthcare system is good because if provides healthcare for majority of Canadians. It is bad because services are limited and the wait is too long. Physician compensations are also not competitive to the US which is why some may migrate, as you mentioned. Unfortunately, I do not think that it would work to implement the same style in America because I feel that many Americans would not accept it. Every state is different because they each have their own state constitutions and state laws.

Does the doctor who drives a sports car provide better care than one who drives a family sedan? Would evening out the playing field in terms of doctors’ salaries result in any negatives for Americans?

Doctors who drive a sports car probably are in higher paying specialties. As for "evening out the playing field" in terms of salary, applying Relative Value Principles is the fairest way of compensating doctors and healthcare services. Relative Value is calculated through time the doctors spend, specialty, and operation expenses.

__DazedandConfused__1 karma

Do you think there is a way to implement free or affordable healthcare without insurance agencies feeling threatened and lobbying against it?

paguyomd7 karma

Do you think there is a way to implement free or affordable healthcare without insurance agencies feeling threatened and lobbying against it?

Yes, there is a way to implement free/affordable healthcare, however insurance companies will always lobby against it since they will be losing profit.

By partnering the government and private enterprises, the way to free/affordable care would utilize free market principles (which is nonexistent in today’s healthcare systems). There's three ways this could potentially happen:

  1. The government AND the people need to agree to healthcare for all with no exceptions. This is key. Everyone needs to be covered by the same comprehensive healthcare.
  2. The government and private institutions (insurance companies) need to partner to implement the healthcare for all.
  3. Implement free-market principles, such as a bidding system. The calculated per-capita healthcare expense currently in the United States is about $14,000 per person. How it will be conducted is by dividing the population based on segments, for example a city of 10,000 people. The budget for this segment is $140,000,000. Then the state government would have to offer this to insurance companies for bidding. An example: BCBS offers to cover $12,000 per person, Humana offers to cover $10,000 per person. Humana wins the bid because they offered the lowest amount and then provides insurance for that city of 10,000 people. Humana now has $1,000,000 to cover all 10,000 people in this city.

All insurance companies agreeing to participate in the bidding need to have a reinsurance policy. In our example, if Humana spends over $1,000,000 for that city, they are required to have a reinsurance policy. That way they are always financially liquid, and no American would have to pay out-of-pocket.

I go into more detail in my book, but please feel free to ask more clarifying questions!

Storyteller_Of_Unn1 karma

I personally feel as it the legalization of all drugs, and the relegation of doctors to advisors and surgeons exclusively, would benefit the healthcare market immensely.

What do you say to the charge that doctors gatekeeping prescription drugs is the major reason why many poor people cannot access the medications they need to survive or stay healthy?

paguyomd1 karma

What do you say to the charge that doctors gatekeeping prescription drugs is the major reason why many poor people cannot access the medications they need to survive or stay healthy?

Doctors are not the problem when it comes to access to prescription medication. We just prescribe, we cannot determine the price of drugs. Whatever the drug companies feel they can charge is what people pay in the United States. In other countries, this works differently. This is why Americans pay so much more for prescription drugs compared to those in Canada or Europe. The government doesn't negotiate the price of medication, therefore the drug companies are free to charge whatever the market can bare.

Simmering_Beagle1 karma

Where I'm from (Developing Country) it's common for Doctors to both recommend treatment and "alternative medicine".

For example, I've had Doctors treat me for an infection with Antibiotics, but also recommend all manner of herbal teas (Not for soothing, but as an actual agent to help cure me)

I know that the Antibiotics are Science based, but the effectiveness of "alternative medicine" is mostly based on rumor and third party experience.

What can I do in these situations where I can't really even trust half the things the Doctors are saying? (Other than get a second opinion which here is somewhat difficult to obtain)
Do I just trust my BS alert and focus on applying the scientifically validated recommendations they give?

paguyomd4 karma

Medical science is effective in many human diseases, however not everyone will respond to such treatment. Alternative medicines, though they are not scientifically proven, have been practiced for centuries. The observation is, in some cases, very effective. Presently, there are a lot of doctors that believe in complimentary or alternative medicine (such as chiropractor, acupuncture, herbal medicine etc.) however it is up to you to decide and consult with your doctor about these methods.

Gwiz841 karma

Why do you think it's so hard for politicians like Bernie Sanders to persuade voters that universal healthcare is a benefit for all? Why are people so sceptical of these ideas in the US?

I'm from Denmark and people can't even imagine what it's like not to just have healthcare from birth here.

paguyomd5 karma

Why do you think it's so hard for politicians like Bernie Sanders to persuade voters that universal healthcare is a benefit for all? Why are people so sceptical of these ideas in the US?

A lot of politicians believe that universal healthcare should be financed and administered by the government, however a lot of people don't believe that the government can implement it effectively and efficiently. Americans look at other government programs and facilities and assume that the government's implementation could have a similar result. I believe that for it to be implemented effectively and efficiently, it needs to be a hybrid plan the incorporates both government and private entities. The amount we spend now is coming from the American people's pockets. A universal plan would still be coming from the pockets of the American people.

felixthekat0070 karma

How do you foresee physician salaries changing in a universal healthcare system? I’ve still got plenty of loans to deal with...

paguyomd2 karma

In a universal healthcare system, the salary should be based on Relative Value Principles. In the past, doctors would independently charge for their services based on the complexity and length of service. In many universal healthcare plans around the world, the government sets the salary. I personally believe this is bad. The government should work with healthcare practitioners in order to standardize the Relative Value Principles. This would be determined on the service, operation expenses, and specialty.

NorthernLight_0 karma

1.) If people are forced (by taxes, at gunpoint/threat of imprisonment) to pay for their neighbor's basic healthcare, do you feel that would lead to more food/smoking/exercise shaming and consequently more regulations on unhealthy drinks/food?

2.) Government systems have repeatedly shown to be less efficient than free market solutions pretty much across the board (with the 'wealthy' of the world traveling to the US for healthcare because it's undeniably the best)-- do you genuinely believe the government would actually competently and successfully provide the best system for healthcare?

4 Ways of Spending Money

https://i.imgur.com/jKxtWxN.jpg

paguyomd2 karma

1) If the healthcare system is truly universal where everyone is covered without exception, and the payment of the system does not directly involve the individual, I don't believe there would be more regulations on unhealthy practices.

2) If it is solely the government providing a plan for healthcare, no I do not believe it would be successfully implemented. However, if it is jointed with the government and the private enterprises (such as Germany and Switzerland's healthcare systems), it can be implemented well. The government should play a very limited but important role. With a truly universal plan, we have to remember that only Americans would be covered. If someone is flying from a different country to receive care, they will have to pay out-of-pocket depending on their country's health insurance.