Why the debt ceiling deal is a horrific outcome for physicians

Why the debt ceiling deal is a horrific outcome for physiciansIf you’re a physician or hospital that relies on Medicare payments, grim times are ahead.  Yes, even worse than the scheduled 29% payment cut that’s scheduled to go into effect in 2013.  Emergency physician Shadowfax calls the debt deal “a terrible deal for health care providers.”

Under the contentious debt ceiling agreement, significant cuts in Medicare dollars will be made.  But beneficiaries are mostly protected.  Instead, it’s the physicians and hospitals who will be affected the most.

According to Politico,

Under terms of the hurried deal, the 12-member joint committee would be charged with crafting proposals that trim at least $1.2 trillion in federal spending over the next decade. Those savings could be found in a number of programs, including Medicare and especially Medicaid, which the White House has signaled it would be open to.”

If the panel can’t come up with enough savings, automatic cuts would go into effect. Medicaid, Social Security and veterans’ benefits would be protected. But providers could see a 2 percent cut in Medicare reimbursement.

Worse, if the Congressional super committee cannot come to an agreement, a “trigger” will automatically make draconian Medicare cuts.  And, yes, those cuts will specifically target provider payments.

The trigger is meant to be unappealing to both political parties, in order to incentivize them to come to a deal.  For conservatives, that means deep cuts in military spending.

But for Democrats, the cuts in Medicare primarily targets providers and hospitals, and leaves beneficiaries mostly untouched.  That doesn’t seem too unappealing for progressives, as most believe physicians are overpaid anyways.  That’s why some are saying Democrats may even prefer the trigger to a deal.

Furthermore, Politico also notes that the decision whether to “trigger” deep provider Medicare payments come at the same time as extending the doc fix.

To put it in plain terms, I wouldn’t be surprised to see deep cuts in provider and hospital Medicare payments, on top of the previously scheduled 29% cut sans doc fix.  We’re talking a combined 30-40% cut or more.  So, if Medicare patients are having a hard time finding a doctor now, it’s nothing compared to the shortages that will come soon.

Recently, Michael Zhuang wrote that the physician lobby was suspiciouly quiet during the debt ceiling debate:

Compared to lawyers, the insurance industry, and even seniors, time and time again physicians have failed to make their voices heard. No wonder their interests get sacrificed in every political turn of events.

Now that we know the outcome, and the horrific impact on Medicare providers, it’s clear that we’ve paid a steep price for our silence.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

     
    I will agree, Kevin, with your assertion that physicians don’t lobby as vigorously as other
    special interest groups. This points to an even larger problem. Is
    the solution in life truly to fight harder politically, so that physicians
    can get more at the cost of “lawyers, insurance and seniors”
    getting less? How did our country degrade into a zero-sum game?
    What
    do I mean? Well, in a NON-zerosum world, everybody tries to produce
    more value so that the quality of life for others is lifted and in
    return, the value-producer earns money that he can, in return,
    spend to pay others for improving his own quality of life. Everybody
    wins because everybody is working to create even more wealth and value for the world. In a
    zerosum world, people fight for their slice of a limited pie so that
    if they lobby their politicians harder it will “successfully”
    gain for them and take away from some other person’s pie slice.

    As physicians, our world view of the
    value of our work has changed over the past few decades. How many
    doctors today still believe “The hard work I do gives value to the
    lives of other people, so much so, that patients are willing to allocate
    a portion of their own earnings in order to exchange with me in
    return for my work and time.”?There’s a huge difference
    between believing A: “Medical care should be given charitably to
    those who are utterly unable to afford it” and B: “Medical care
    should be given away for free”. And by the way, is something truly free if a huge
    chunk of your earnings is forcibly taken from you in order to give
    you back something “free”?

    Belief in A is a fantastically generous
    and moral worldview. Belief in B distorts the value of what doctors
    do and becomes a self-fulfilling prophecy that will further degrade
    the quality of care. When you start to believe that something should
    come with no monetary payment or little monetary payment, it slowly
    changes to have the quality of something that has no monetary value or little
    monetary value.

    Granted it is difficult for physicians
    to adopt a strategy of “I am going to improve the quality of my
    product so much that people are going to be willing to pay enough to
    support me and my family”. The reason this is difficult because you
    are being forced to compete with other providers who have bought into
    the system of seeing patients who pay a reduced rate due to
    third-party subsidization. It’s difficult, but not impossible, as
    many concierge physicians are proving.

    • Anonymous

      “When you start to believe that something should come with no monetary payment or little monetary payment, it slowly changes to have the quality of something that has no monetary value or little monetary value.”
      Are you saying that only value of medical care is monetary?

      • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

        No. I’m not saying that at all.

        • Anonymous

          “The hard work I do gives value to the lives of other people, so much so, that patients are willing to allocate a portion of their own earnings in order to exchange with me in return for my work and time.”?

          I pay premiums for my health insurance. Does that mean I allocate a portion of my own earnings to exchange for a doctor’s work and time.  Does that have any value?

          The insurance industry was formed in response to market demands.  When you say third party, do you mean Medicare only?

          • http://twitter.com/drpauldorio PAUL DORIO

            Here’s another take:

            When we value a product, such as health care delivery, it has a monetary implication. In order for that product to be delivered reliably, that monetary value should be stable and relied upon. What we see happening in this country is the inexorable decline, through government intervention, in the value of health care services. That decline puts you, me and everyone else at risk of not being able to obtain those services in the future.

            Everything has a monetary value.

          • Anonymous

            “What we see happening in this country is the inexorable decline, through government intervention,”

            Of course you blame government…and nobody else.

            Life for Seniors before government intervention-I don’t see this as reliable healthcare…

            “We retired workers are very proud of being citizens of the greatest country in the world, but … we cannot think it is the greatest possible country when about 65 percent of the aged do not have any insurance to deal with their needs for hospitalization and medical care. Without such insurance, the retired person must pretty much exhaust any savings he has before he can get free hospitalization. This is a constant source of worry. Many of my acquaintances will not visit a doctor for minor illness because they have no money to pay for drugs. After they exhaust their savings they go on welfare to get medical aid, but then, in many cases, it is too late.”

            -John Barclay-Retired autoworker testifying before congress 1959.

          • http://twitter.com/drpauldorio PAUL DORIO

            I’m not sure of your point: “Of course you blame government…” — Who else would you blame for the declining reimbursement rates, besides maybe the for-profit insurance companies? I suppose one might suggest that doctors could simply work for free, but clearly that’s not a practical or realistic solution.

            I thank you for the 1959 quote from the retiree. As we know, Medicare was subsequently signed into law by LBJ in 1965. However, you are also hopefully aware of a significant issue regarding life expectancies: In 1965, the average life expectancy was 68 for a male. It is now 78. For females, the ages are slightly higher.

            Medicare eligibility age and retirement age have never been indexed to increasing life expectancies. Instead, the finite products and services of the healthcare system are increasingly taxed by the ballooning numbers of our aging population. What used to be health care coverage for a retiree for 10-20 years is now coverage and care for 20-40 years. I am certainly not advocating that we stop caring for our beloved seniors.

            I am advocating that we start caring for everyone intelligently, judiciously, and realistically. Behavior and expectation moderation will have to occur among all populations, seniors, youths, doctors, patients, government workers and private citizens. To continue to point fingers instead of trying to solve the problems only perpetuates the issues and makes them worse. (look at the deficit/debt/economic issues at play currently – deal with it now or we’ll deal with a bigger problem later)

          • Anonymous

            “To continue to point fingers instead of trying to solve the problems only perpetuates the issues and makes them worse.”

            Like blaming the government?

          • http://twitter.com/drpauldorio PAUL DORIO

            lol! I figured you’d quote that and ignore the rest. Do you have any productive comments to add? If not, I’ll stop here and thanks for the discussion. If nothing else, I hope that people reading these comments realize that there is a whole lot at stake every time the government (yes, the government) cuts Medicare reimbursement rates.

          • Anonymous

            If I suggested we should pay more taxes to get Medicare reimbursement out of the dark ages. I am sure I certainly would be labeled a socialist…

          • Anonymous

            WHO should pay more taxes?  Therein lays the trap.  This nation is already at the point that about 50% of citizens don’t pay any income taxes.  Make it greater than that, and all hope is gone for restraint.

          • Anonymous

            The complaints begin…

          • Anonymous

            I’m still waiting for the answer.  Can we stick with the issue rather than starting a labeling game?  Who should be liable to pay these taxes that would be needed? 

          • http://www.facebook.com/rick.zynda Rick Zynda

            Close the tax loopholes for the wealthy, tax the corporations who outsource, and reform the health care system using the Medicare model (catch up to the rest of the world) to assure that all people have access.  In order to do so, campaign finance reform needs to take place to rid DC of the lobbiests.

          • Anonymous

            Everyone except the poorest in our nation.

          • Anonymous

            We have a doctor who is worth more than he is paid….he gave us something priceless. Now the doctor who was negligent and allowed cancer to spread in my daughter’s lymphs…I feel sick even thinking about his name…feel weak even entering the office he works at (he was cited)…I pray protection on his patients.

            I think doctors are paid less than your predecessors…who did your very career perception almost irreparable harm with their greed….but I think doctors are worth what they earn…now tests…they are outrageously expensive.

          • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

            e_patient: “I pay premiums for my health insurance. Does that mean I allocate a portion of my own earnings to exchange for a doctor’s work and time. Does that have any value?

            The insurance industry was formed in response to market demands. When you say third party, do you mean Medicare only?”

            Yes, paying insurance premiums allocates a portion of your earnings in exchange for a doctor’s work and time. In addition, along the way there is a third party (and often 4th and 5th parties) interfering so that you are not getting nearly as much consumer empowerment with your doctor as there would be in a direct interaction.

            When I spoke of third parties, I include Medicare as well as insurance carriers.

          • Anonymous

            Well, those 4th or 5th parties include the government.  Because the government interfered, I now have coverage I didn’t have before the interference.  I feel more empowered.

          • http://profiles.google.com/reesie22 Reesie 22

            Yes. You are taking a service from someone and not paying for it. The interferers are not paying for it either. It’s called stealing.  Physicians spend decades sacrificing their personal family time getting educated and putting in long, hard hours on call…and they go into great debt to do it…all so other people like you can take their services from them and not pay.  How is that right?  What if you were a baker, and people in your surrounding area felt like it was their right to eat and not pay, came and took your bread without paying you for it, or only paid a small fraction of the cost you incurred to make the bread?  How is that right?  And a lot of these people who say they can’t afford to pay for their bread, instead pay for extra luxuries like cable TV, big screen TVs, movies, manicures and pedicures, hair extensions, alcohol, cigarettes, cell phones, ipads, ipods, cameras, computers, internet, etc.  What do you do for a living e_patient? Do you work hard so you can give away your product or service for free or for much less than it costs you to provide it?  It won’t be long and the “baker” is going to go out of business and just spend his time with his family.

          • Anonymous

            I would suggest if you don’t like what my insurance company pays for your product, don’t sign a contract.  If the baker signed a contract that didn’t cover his expenses, why is the customers fault?

            How is it right that I pay $10,000 a year in insurance premiums for my family (not including employer contributions and copays) and I am stealing?  If Medicare or an insurance company doesn’t pay you enough, then don’t sign the contract.  Sixteen percent of the population is uninsured…a huge market share.  

            I you don’t want to be a doctor then quit.  No one is forcing you to practice medicine.

          • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

            There is absolutely nothing wrong with you paying a third party which in return pays doctors to care for you as long as participation is voluntary and not forced in any way. You are free to participate. The third party is free to participate. The providers are free to participate. What’s wrong is FORCING others to participate, primarily by confiscating and looting a portion of what they earn in order to subsidize the very plans that you are benefiting from at the cost of people who wish NOT to be a part of it. If it weren’t for that aspect, there would be nothing bad about you choosing to go with whichever plan works best for you. Agreed?

          • Anonymous

            “The third party is free to participate. The providers are free to participate. What’s wrong is FORCING others to participate, primarily by confiscating and looting a portion of what they earn in order to subsidize the very plans that you are benefiting from at the cost of people who wish NOT to be a part of it.”

            I get my insurance through my spouse’s employer.  This employer is forced to offer this insurance to us because of government regulation.  I am free not accept this insurance.  I am forced to pay for Medicare and Medicaid.  I don’t benefit personally from these programs.  If Medicare still exists when I reach 65, then I will benefit from it.  With my pre-existing conditions, no insurance company would offer me coverage-now or when I retire-without government regulation.  Perhaps you can accuse me of being selfish because without government interventions, I would not have meaningful healthcare.  I will not bankrupt my family, even if it means I have a shorter life.  I doubt charity care would make a difference.

            So am I morally entitled to healthcare?  If healthcare is optional, can I pray for my type 1 diabetic child instead of getting medical care?  Can I refuse medical care if my only reason for doing so is to commit suicide?

            Both doctors and patients have the right to enter into an mutually voluntary agreement.   I could find a cash only practice to receive care.  I chose to use my insurance for my medical expenses.  My doctor chooses to accept my insurance.  The only entity in this relationship that doesn’t have a choice is the employer that provides the insurance.  We made a market based decision to work for this employer based on the fact they provide insurance.  My spouse turned down a job because they didn’t provide insurance and  we can’t get insurance on our own in the independent insurance market.

            In 1959 charity didn’t work.  What makes you believe it will work now?

          • Anonymous

            But what if this exact government that you say empowered you disempowers about a third of the people currently insured? Maybe less…maybe more..dunno…do we? I just know the formula gave employers an out…pay the fine…cheaper than the insurance premiums the government just made go up for tons of individuals.

            That said…capitalists need some regulating…but I will take private, regulated companies over government.

          • Anonymous

            “capitalists need some regulating”
            Your regulations are my intrusive government.  

          • Anonymous

            Wait a minute….you said you felt empowered by gov’t. So you like outta control capitalists? Just sayin’!

            Reading threads like this….. I see a real problem with ignorance of history these days…people have little understanding of economics…socialism…and why are we willing to jump off the same cliff countries like Scandinavia, etc. are clawing their way back up from? It’s just raw emotions set loose…

          • Anonymous

            Where did my response to this go?

          • Anonymous

            E-patient says: Well, those 4th or 5th parties include the government.  Because the government interfered, I now have coverage I didn’t have before the interference.  I feel more empowered.>>>>

            You said this but do not like regulation? Only when it benefits you?

    • Anonymous

      Terence…you make valid points…but, ultimately, the patient will get less care…a necessary victim of budgeting. But I blame a political system that allows unions or AARP types to actually sway elections. We have elected pawns….officials voting with their eye on being reelected…not what is right and good…or even Constitutional…the “What is in it for me” mindset that ruins both the republic and democracy because overall if the people had voted it seems Obamacare would not have democratic muster…so our elected officials are failing to vote in that direction…and it is really bothersome when they use taxpayer funding (case in point teacher’s unions) to seek election. I understand that type of thought, but it seems to be in direct conflict with their very position…yet…doctors deal with this exact dilemma….oaths or career are a conflict for them to at times. I share with my daughter’s doctors that I have more freedom of thought and expression than they do….yet, ultimately, they have the power to change lives.

      Oh yes, I so admire doctors like you and Paul here…you put a face to your words…sad, that you are what oftens seems like a minority…you are willing to be held accountability…you stand for something beyond a mere rant. Good on you!

  • Anonymous

    Third party payments are like crack. Maybe now that the product has been cut and stepped on so many times, doctors will eagerly sign on tor a much-needed intervention.

  • Todd Yecies

    Another win:  The subsidized stafford loan program is eliminated, which will lead to around 6k higher debt for all medical school graduates that used said program (almost all of them).  

  • http://thehappyhospitalist.blogspot.com happyhospitalist

    Physicians have a choice.  If they don’t like the terms of Medicare, simply stop accepting Medicare.

    • http://profiles.google.com/dr4roots Robert Frank

      How profound!!  Did you make it through kindergarden??

      • http://pulse.yahoo.com/_Z57TQOUASZJZZON7H72TKU7HFA Dr. B

        That is the extent of your argument?  Name calling means that you have nothing intelligent to add to the conversation, so please let the adults handle this.  

    • http://www.facebook.com/people/Ardella-Eagle/840440226 Ardella Eagle

      Granted, physicians have families to feed and overhead to pay, but one can only hope that the reason why a person goes into medicine is to HELP PEOPLE.  How much help can a doctor do if they refuse to accept Medicare and Medicaid if the recipients can’t afford a cash only situation?  Accepting insurance is more than a way to get patients into your door.  As afprovenzano stated up there, worrying is bad for your health.  Worrying how you’re going to pay your medical bills will kill you if not completely bankrupt you.Everyone has a choice.  Let’s not ask the physicians to make a bad one.

      • http://thehappyhospitalist.blogspot.com happyhospitalist

        Everyone has a duty to help people.  Being a physician does not magically mean they do it for free.  If physicians decide not to accept Medicare or Medicaid and the person cannot afford cash, that is the time for the lay public to contact their representatives and ask them why the support a program that doctors don’t.  Physicians have an obligation to refuse Medicare, Medicare and all other third parties they feel are not fairly compensating.  If they don’t, they have, by default, accepted the rules and have no reason to complain about what they are paid.

  • http://twitter.com/eddunkle Keith Alt

    It’s important that medical insurance providers make money.  Physicians not so much.

  • John Henry

    I don’t think that even with vocal and effective lobbying that there would have been any hope of using the debt limit legislation as a platform to eliminate the SGR or to make any meaningful reform to Medicare. There doesn’t appear to be any interested constituency beyond beneficiaries who demand in the most general way that Medicare benefits not be cut.

    Of course, by enabling across-the board reductions to occur, or even by targeting selected specialties for substantial reductions (radiology is about to be cut to the bone), it is foolish and wishful thinking to believe there won’t be significant access issues forthcoming for Medicare patients. Many practices will simply stop accepting new Medicare patients. Some will decide the entire billing and payment-in-arrears practice common now is unworkable, and will go cash-pay only with minimum staffing, and opt out. What is at stake is not merely the viability of Medicare, but really the future of third-party mediated payments. Some correctly believe that is not necessarily a bad thing, and that it is time to end what has become unaffordable and unworkable. I guess we will see. I do not think patients will enjoy dealing with either CMS or their insurance companies any more than their doctors do now.

    And what of the opt-out option? I think it works for CMS as they expect only as long as the numbers of doctors opting out are relatively few. If done on a mass scale, where it would effectively represent a wholesale repudiation of CMS and its policies by the professional community, the threat is more that of a paper tiger. There would be outrage, and I think it would be directed more at the federal government than the medical practice community, who would rightly be seen under those circumstances as choosing the unpleasant route of opting out only because it was necessary for practice business survival.

  • Anonymous

    Not to worry. With the shortage of physicians currently and projected to get worse over the next few decades, the public will have to deal with the same access issues that European countries have faced for years. The government never learned that before the sword of Damocles is wielded a thorough analysis must be made of the potential collateral damage that will invariably occur. I as a baby boomer physician of 61 will sit back in a few years and deal with all the head hunters who will be trying to persuade retired physicians to come out of retirement as different regions face catastrophic shortages even after attempts are made to offer inducements to highly experienced and knowledgeable clinicians who just couldn’t take it anymore. And furthermore, I said “not to worry” because worrying is bad for your health and there won’t be anyone around to listen…

    • Anonymous

      Do you think USA citizens have greater access to medical services than Europeans? I think many more are excluded in the USA than in many other countries.

      • Anonymous

        you are right. but our system isn’t a single payer one and so we have to deal with this legislation and how it will affect the current broken one. that’s why the analogy to damocles… people who need the system fixed the most will suffer the most…

        • Anonymous

          This isn’t true. Even Canada has people who cannot get a doctor. They are trying to fix that. France had to raise copays, etc. VAT’s are really expensive, etc. Liberal and conservatives figures do not match….Obamacare did little to alleviate what is a universal problem…money….too bad it is limited. Having lived in the UK…had two kids with cancer…do not like waiting lists….nope…I will take privatized care over the government running the show (a study of single payer needs broken down into public vs private and the authority vested in these arms). I guess…I am frustrated at fairy tale medicine tales….doctors who want single payer because they desire civil servant status…easier money…knowing full well that some will be helped…harder cases will be harmed…yeah…it is better than nothing…great care for those without major problems…which is really the gist isn’t it? The others will usually get better on their own….the healthy will use the system like a smorgasbord….proclaiming it U’s wonderful they can eat so crap cheaply…so, indeed, better than nothing.

          • Anonymous

            i started as a solo practitioner in business for myself 1981 as an oncologist and developed a flourishing practice where i delivered evidence medicine based quality care for 30 yrs. i did this in private practice the best way i could as i reimbursements, expenses and regulatory mayhem almost drove me into bankruptcy. and so my hospital threw me a lifeline and i am now an employee at my hospital who is highly regarded for what uncompensated work i did for them the past 30 yrs. this is how i will finish my career. i brought intense passion and skill into my practice (you just have to take my word) and what i see now is an EHR, abstract benchmark driven practice that the government wants so it can ‘measure quality’. so it is not that i advocate a single payer system because it is better but rather i do not want my children to bear the burden of a healthcare system that will bankrupt the country (which is much worse than bankrupting ~500,000 doctors who have no political clout anyway). so what is the solution? read the special article in the Journal of Oncology Practice Sept 2010 on ‘A Paleontology Primer for the Oncologist’ i attempt to offer some solutions….

          • Anonymous

            I will read the article you suggested…but I fear some are playing Chicken Little with their profession and vision. Indeed, the sky may or may be falling, but if the government takes full control (and at this point we are somewhere between the 50 – 70 % depending on who and how the estimates are done) the sky will fall sooner than later.

            Are you saying you want VA care for all because you feel it is best for your children’s future care? If your child had cancer like my child would you want VA or private care?

          • Anonymous

            don’t get me wrong. the government cannot legislate quality. we had our chance at trying to be both entrepreneurs and responsible health care providers. something went wrong. technology and unbridled access (for those who have insurance) in a fee for service environment outpaced funding and health care spending grew faster as a percentage of GDP than any other sector of the economy. all attempts at reining in those costs have failed miserably. the best doctors delivered the best care in that environment and now we are so restricted we can’t stay in business. we are either joining ACO’s, medical homes or hospital based practices. i am pessimistic that they will succeed because they create winners and losers in the consumer market. i wish i knew the answer…read my article

          • Anonymous

            You did a very good job with this article. On a personal note…my child receives care at Cleveland Clinic…the land where a private practice is either bought or extinguished. I think, overall, the doctors there do a better job…but it is like corporate medicine…they answer to a Chair (who usually will lie in a peer review for those he covers…at least that is my experience), the docs clamor for importance with the boss….donations given for prestige…..same ole…same ole…yet, that same management promises World Class Care….tells doctors to tune in emotionally to heal physically. The doctors are salaried, but get bonuses….maybe a few aspects of single payer in play in corporate medicine…but as an ex-civil servant I can say with assurance it is quite different….much better that government as king…and with so many relatives in the UK dead at very young ages from waiting lists and what we consider casualties of socialized medicine (i.e. single payer via government dispensing) I have seen too much misery to ever endorse the government in charge over such an important private enterprise.

            I thought new legislation forced insurers to spend more on the patient? So it is not just solo practices in jeopardy…it is small insurers too…..and on, and on, and on…..socialized medicine wipes out solo patients…we become faceless….it is so limiting without the private sector involved.

          • http://www.facebook.com/people/Rick-Stephenson/1485415034 Rick Stephenson

            I don’t want civil servant status, and sure you’ll take privatized care since you have access to it. What about those who have no access to it? Send them to the local public hospital with its excessively long waits for routine care? How is that paid for? With the taxes that the richest 1% and the corporations don’t want to pay? By the poor whose tax dollars amount to …..well 20 percent of nothing is nothing? No by taxing a middle class who is increasingly stretched thin, unemployed, underemployed, uninsured(no privatized care). Medicare is a model, albeit not perfect for a type of single payor. Covers renal failure, most patients requiring cardiac interventions……..

          • Anonymous

             Oh boy….previously you rallied on about doctor’s debt..yet doctor’s earnings will be taxed higher if this administration gets it’s way.  I don’t want anyone taxed higher.  I can’t remember if it was here or elsewhere I pointed to the Camden Project.  They find that 10% of those receiving Medicaid use up most of the resources.  We have the money….70 million now qualify for Medicaid.  We just need more accountability…which is progressive….you sound like a progressive….but this project is progressiveness without asking for more money…just more accountability with the eye on helping people with the resources we have.

            Of course, I defend private insurance…I have no problem contributing to those who need help.  Didn’t I share that government is already paying for the vast majority of health care?  But history does not show your solution as one that is good for the economy….granted corporate tax may need some tweaking…but even then I hesitate.  Just look to Europe…your suggestion doesn’t work.

            How can we defend doctors and their income only to have higher earners point to those making more money as some kind of villians?   We need private enterprise…surely Cuba and Europe have shown us that?  Even Castro doesn’t want his countries health care….nor Michael Moore who is stupidly calling for the arrest of the S&P head.  Yech!

  • Anonymous

    Another Kevinmd poster (sorry I can’t remember who it was) commented on a previous Medicare post that the federal government is simply no longer a reliable business customer. I think this is exactly the right way to think about it.  If you allow your practice to evolve such that you must depend on Medicare to keep the doors open, you are risking your business.  Sad that it has come to this.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      How long do you think before the other “reliable business customer[s]” cut their payments to physicians to match what Medicare does? Not so reliable either…..

  • http://twitter.com/whatscorrect don peterson

    29 percent is the accumulated series of cuts extending from the Deficit Reduction Act of 2005 (insert group laugh here). The cuts were meant to be implemented 4 percent per year over the past 7 years but Congress found ways to table the cuts before they could take effect. 
    Where did the problems start? Hospitals and their lobby, the AHA, have convinced CMS that they deserve reimbursements significantly higher than what the same procedure would fetch if billed by an independent physician. The AHA contends that all healthcare should be delivered by healthcare corporations because they have economies of scale no physician of group practice can achieve. Yet, because they hide behind the obligation to serve indigents, they expect and receive significantly more money for what they do…and they love it when CMS cuts reimbursements in the PFS (Physician Fee Schedule) because they know this hurts the independents.  Sadly, the shenanigans of the AHA are mainly in response to the Stark laws. Hospital used to exist by referrals. They would entice, encourage and punish to achieve the referrals that kept them going.  Stark put a halt to most of that. To circumvent Stark, hospital corporations have been buying up physician practices across the spectrum of services.  They move the ancillary services that were performed by these practice into the imaging and diagnostic centers in the hospital so that they can now bill for the same exact services at the higher OPPS price.  For example: a transthoracic echocardiogram CPT93306 fetches a private practitioner using the PFS a global amount of $232.74; while the hospital using the OPPS reimbursement fetches nearly double, a global of $469.89.Unless we are ready to have corporate administrative types telling doctors and patients what they can have or when they can have it, and unless we want to see every healthcare procedure cost skyrocket, independent physicians MUST be heard and the sanctity of the private, independent practice must be preserved.

  • Anonymous

    We need to begin to understand that the best and most advanced health care in the world is not affordable. Employers are refusing to pay for the ever increasing costs and they are passing these costs on to their employees or they are dropping coverage and no longer offering employee health care benefits. The simple fact is, many people don’t continue their coverage once they have been dropped. Unless we change health care delivery, the 50 million plus that are currently uninsured and the 25 million more that are currently underinsured with grow exponentially. It’s great to hear our health care providers defend the status quo delivery model and brag about offering the world’s most advanced methods and procedures, but they are speaking to a growing number of middle-class Americans that increasingly can’t afford space-age health care!

  • Anonymous

    We need to begin to understand that the best and most advanced health care in the world is not affordable. Employers are refusing to pay for the ever increasing costs and they are passing these costs on to their employees or they are dropping coverage and no longer offering employee health care benefits. The simple fact is, many people don’t continue their coverage once they have been dropped. Unless we change health care delivery, the 50 million plus that are currently uninsured and the 25 million more that are currently underinsured with grow exponentially. It’s great to hear our health care providers defend the status quo delivery model and brag about offering the world’s most advanced methods and procedures, but they are speaking to a growing number of middle-class Americans that increasingly can’t afford space-age health care!

  • Anonymous

    Not all primary care requires the services of a doctor. Estimates say that about 85 percent of primary care is “routine” care that can be done easily by a nurse practitioner (NP). Why can’t providers begin to understand that patients should be seeing a NP as their initial contact? Most stuff like flu shots and cuts and bruises and coughs and colds can be handled at the NP level. A Primary Care Physician should be level two, just like referrals are done today. An NP can determine if it’s an eye problem and refer to an eye specialist, right? An NP can determine if it’s a skin problem and refer to a dermatologist, right? An NP can determine if it’s a urology problem or a breathing problem or a foot problem and refer to those specialties, right? If the NP gets stumped with not being able to determine a specialty, they can refer to a Primary Care Specialist for further evaluation, right? If most primary care gets stopped at level one, costs will be reduced!

  • http://thehappyhospitalist.blogspot.com happyhospitalist

    Why do you need an NP as a patient to decide what kind of actual doctor needs to be consulted. Why not just self refer to a sub specialist? That model of thought makes all pcps irrelevant. Why not just have all specialists for all problems, all the time and get your shots at walmart by an RN not sn aprn? And why do you need to see anyone for cuts and bruises. Call your grandma. She’ll give you some good medical advice.

  • Anonymous

    If a root cause analysis was done on WHY the US is in such a mess in healthcare it would go back 100 yrs.  It has always been a free market vs what is good for the health of the country.  Corporations aren’t moral.  The only concern is profits irrespective of public health.  The AMA and AHA functioned as Corporations in 1965 when Medicare and Medicaid were implemented.   

    55 yrs later we have an unsustainable hodgepodge of care, most of the healthcare $$ going to preventable chronic diseases with a great percentage of America’s feeling entitled to get this care at some point or another regardless of what they put in their mouths that leads to the need.   THIS IS the biggest problem with the debt. 

    We will never bend the healthcare cost curve, regardless of all the reform, until we get tough on the so-called American diet.  If we all ate to feed our DNA there would be 50 to 80% decrease in need for all the healthcare we receive. 

    It is not a shortage of doctors that is the real problem but rather an excess of cheap unhealthy subsidized food that no politician will touch because Big Food and Big Pharma stay rich by supporting politicians and keeping people sick!

     
    It is a travesty!

          

    • Anonymous

      Have you seen the Frontline special on the Camden Project with New Yorker writer Dr. Atul Gawande? He goes to the poorest area of the US, used number crunching for identifying hot spots…amazing the money to be saved when there is a desire….this is why the foundation of the ideology against big government only serving a few well is worth dwelling upon. The video is on YouTube…sure there is progressiveness involved….and as Dr. Gawande points out the real problem is that success of patients not using the ER or medical services is a plus for taxpayers and patient….but the bottom-line…we will need less doctors…and you hit on that…accountability. Florida just instituted accountability for those who accept government aid…private insurers are working in that direction and fining patients who cannot meet three of the five criterias.

      So if Americans get healthy…we stop the fraud…stop using the ER like a pitstop, stop filling prescriptions we do not plan on taking but can’t resist if they are no to low cost….or on the taxpayer’s dime….hospitals and most doctors will not like it…we will need less of their services…..but we can help heal ourselves.

      • http://www.facebook.com/people/Rick-Stephenson/1485415034 Rick Stephenson

        Unlikely. Adding millions of presently uninsured to the insurance rolls will increase the demand for physicians. Especially primary care physicians but specialists also. You ever see arthroscopic knee surgery or total joint replacement in uninsured patients. These patients simply tough it out as it’s very difficult to get specialists to care for them. Likewise with patients who have disk herniations, diabetic retinopathy, chronic pain syndromes.Maybe if demand is great enough there’ll be a way to forgive some of the debt our med students are incurring. The amounts are staggering. We have residents who are $250,000 or more in debt……..

        • Anonymous

          Where I live they can get it if they need it.  Look into Cleveland Clinic….they work out financial help for those making six figures.

          Why loan forgiveness when they will make on average five times what their average patient makes?  Doctors make a good living and they deserve it…they worked hard for it….they knew they were going into debt….same as teachers…but they get loan forgiveness if they work in the ghetto…there are programs for loan forgiveness for doctors already.

    • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

      I agree with the implied statement that the shift towards corporate power is causing many of the problems today, in healthcare and in many other things. But what is the solution? More government? I would argue that the solution is LESS government.

      In a free market, the competition bewteen large corporations and small mom-and-pop businesses is in dynamic balance as there are some things that are better done by corporations due to economy of scale and some things that are done better by the little guy due to the advantages of flexibility, personalized care and carving out a niche market. The customer gets to decide: Today I’ll eat at the chain franchise restaurant. Tomorrow I’ll eat at the friendly diner.

      This is fine, because it gives all businesses the incentive to provide the best product and compete for the consumer dollar. The consumers get to voice their opinions by voting with their wallets. However, when politicians interfere in the corporate vs small biz competition, they often shift the playing field to greatly favor one over the other. Which one gets the unfair favoritism? I’ll give you a hint. Which one donates more to the politicians – corporations or the little guy?

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