In my humble opinion, hospitals are the most evil organizations around. The avoidance of the bureaucratic bullshit associated with working in a hospital and the headaches of dealing with third-party payers are key reasons why I'll be starting a solo, cash-based practice when I finish my training. In order to keep in touch with what I see as a real social responsibility to provide care to those who need it regardless of ability to pay, I'll simply institute my own sliding-scale payment scheme to make my care as affordable as possible (interest fact: it's illegal for physicians to charge different copays to patients covered by identical insurance plans administered by the same insurer; even if a physician wanted to, he/she couldn't charge one Medicare beneficiary $0 if they have no ability to pay while charging another the standard copay allowed under their association agreements). Physicians really are becoming little more than highly paid corporate drones. These trends are resulting in a complete deprofessionalization of medicine and the surrender of key clinical decision making responsibility to administrators and third-party payers from physicians. This all the while physicians are portrayed in the public as greedy and money-hungry with no real care for patients - most prominently by President Obama. Oh, the cost of healthcare is going up? BETTER CUT PHYSICIAN REIMBURSEMENT - WHICH, AT MOST, ACCOUNTS FOR 10-15% OF OVERALL HEALTHCARE COSTS. Don't worry, that won't demoralize a profession that is already overworked and under-appreciated if not outright villanized from all sides. That's not to say that physician reimbursement shouldn't be included in the discussion of cost reduction. But you'll have to forgive us for resisting these cuts so ardently when pharm, medical device, and insurance companies posting billion dollar profits every quarter somehow remain immune from attack. Practicing medicine is nothing like what it used to be. The avoidance of primary care specialties by the next generation of physicians thanks to ever increasing costs of education (the average indebtedness is now north of $150k and continuing to go up) and ever diminishing reimbursements to control costs (despite going after the real costs of the healthcare system, i.e., administrative costs, pharmaceutical companies, and medical device companies; as an example, there as an ever-hanging threat of a ~25% cut across the board to physician reimbursement that is very graciously averted by our Congress each year - often corrected in a retroactive way months after the reduced reimbursement has already been in place) will, unfortunately, result in substandard care to patients. As midlevel providers come in to fill in this need (e.g., our good friends at the AANP which, as I mentioned in another comment, vehemently denies the need for more rigorous clinical training for their independently practicing NPs despite the fact that their training is both shorter, less extensive, and more variable in quality than that of the typical graduating medical student), the result will be less rigorously trained providers managing a population with increasingly complex and chronic disease. Remember that before crucifying us when these issues come up in politics. The overwhelming majority of physicians want little more than to do what's best for their patients. Political influences, however, are making it more and more difficult for physicians to do what they need to do in order to make that possible, and it's easy to create a strawman of the Porsche-driving physician making millions of dollars a year that "clearly" is making too much money. Change we can believe in?
The ACA has many faults. I won't enumerate all of them that I'm aware of. Consolidation is part of its design to minimize cost by economies of scale. I'm not convinced of the wisdom of this yet, but pretty much everyone can see that the name of the game is go big or go home. This may work in the non-profit sector, but I think that it's going to make the for profit hospitals even more shameless.
The big secret on non-profit hospitals is that they are nothing of the sort. There's all kinds of waste that goes on in hospitals. Look at how much administrative costs have increased (see table 2 here: http://www.nejm.org/doi/full/10.1056/NEJMsa022033). Notably, this excludes administrative costs related to insurance plans. Given that roughly 2/3 of US hospitals are supposedly non-profit (http://www.aha.org/research/rc/stat-studies/fast-facts.shtml), what would've otherwise been profit is instead squandered in hugely wasteful and totally unnecessary ways. Non-profit hospitals are just as shameless as the for-profits. They actually have the gall to run development offices dedicated to raising donations while simultaneously charging uninsured patients huge sums of money that they know are totally divorced from reality. They create aesthetically beautiful hospitals at a cost of tens to hundreds of millions of dollars while waxing poetic about the single-digit millions they devote to charity care. They engage in billing practices that are questionable at best and leave the patients with unnecessarily large bills. My institution, for example, knowingly keeps patients in the ICU longer than is medically necessary in order to preserve beds for the particular service we receive patients from (there are a handful of patients on our census that could've left the ICU and gone to the general floor days ago - I'm sure the cost difference between an ICU and standard bed is not inconsequential). They claim medical residents are a financial drain on their system - despite giving only half of the roughly $100k provided to them by the government per year per resident to the residents themselves - failing to take into account that residents, rather than attending physicians, are almost single-handedly responsible for the day-to-day work of delivering healthcare (and, interestingly, pay midlevels that perform the exact same role roughly double what they pay their residents). In short: fuck hospitals (except, perhaps, St. Jude's in Tennessee and the Shiners Hospitals).
Depends on the hospital. There are good ones and bad, just like other sectors. The one for which I work has an annual loss from uncompensated care of around $200,000,000. That's not chump change. Sure they have waste, but they also have a mission. That's not super atypical for a large, urban institution. The ACA does disincentivize doctors from practicing in poor areas however, so to me that's a huge negative.
I've enjoyed your insight into the medical world. That said, where are you in your training? I'm curious to know if/how some of your perceptions have changed as you moved throughout your training. Full disclosure, my wife is a physician and I've been tangentially related to some eye opening revelations over the years.
I want to preserve some degree of anonymity, so I will simply say that I'm in residency. My perspective has absolutely changed over time. I think that sort of change is inevitable if you pay attention as a medical trainee. The clinical years of medical school were, to say the least, an eye-opening experience. Medicine lost its mystique and prestige. Instead, it was replaced with an understanding that makes medicine much less scientific, precise, and - dare I say it - helpful than I thought beforehand. I still believe in medicine as an institution and believe that, ultimately, we do a bunch of good, but seeing how the sausage is made, so to speak, fundamentally changed how I understand what being a physician is and how we practice in this crazy ass system of healthcare. What field is your wife in?