What good is Medicaid expansion if no doctor sees Medicaid patients?

With its expansion of Medicaid eligibility, the Affordable Care Act (a.k.a. Obamacare) was supposed to go a long way towards providing healthcare coverage to millions of uninsured Americans. That accomplishment was dealt a large blow by the Supreme Court, when it forbade the federal government from requiring states to expand Medicaid coverage. Nevertheless, many states plan to offer Medicaid to anyone with incomes at or below 138% of the Federal Poverty Limit (FPL). And more states might follow suit over time, under pressure from the healthcare industry, which likes its customers to be paying customers.

However, even if Medicaid coverage expands under Obamacare, a big potential problem remains — many physicians will be unwilling to care for Medicaid patients. But how many physicians and which ones?

July study in Health Affairs estimated the percent of physicians from a wide range of specialties who were unwilling to take on new Medicaid patients in 2011 and 2012. What specialty would you guess was least likely to accept new Medicaid patients?

If you are like me, you guessed some high-paying procedural subspecialty, like orthopedic surgery or ophthalmology, where the physicians are accustomed to high fees and well-paying patients. In the case of orthopedic surgery, you would not have been too far off—40% of these physicians were unwilling to make new patient visits available to Medicaid recipients. On the other hand, only 18% of ophthalmologists were unwilling to see Medicaid patients.

The “winner” was a surprise to me however: it was psychiatrists. A full 56% of them were not open to seeing new Medicaid patients. I don’t know why this is such a high number. Perhaps Medicaid enrollees have a higher than average rate of mental illness, and thus account for a disproportionate number of psychiatric patients, maxing out their ability to care for those patients. Or perhaps Medicaid fees are particularly low for psychiatric care, relative to other forms of care. I’d be curious to see if any of you readers have any other ideas.

Which doctors do you think were most likely to accept new Medicaid enrollees? Once again, I was surprised by the answer: it was cardiologists. Only 9% were unwilling to take on new Medicaid patients.

I am not knowledgeable enough about Medicaid to understand what is going on here. I would love to hear ideas from all of you.

But meanwhile, I leave you with a simple take home point: healthcare coverage does not equate with access to healthcare. Physicians have to be willing to see patients. And if Medicaid does not pay well enough to incentivize physicians to see Medicaid patients, or if it is too slow to pay off claims, or if some other barrier stands in the way of helping these patients receive needed medical care—then we need to address those barriers. It is no use to obtain healthcare coverage that doesn’t get you healthcare!

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together

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  • Catherine Marie

    Psychiatry & mental health care are the “ugly stepchild” of medicine already. As a patient with a disabling, chronic, incurable disease on Disability, I have been in therapy for about 6 years now. But since being diagnosed, I have also become a very active patient advocate for others with my illness. I can tell you – anecdotally – that a large number of patients that I talk to – are very low income, can’t afford insurance, have no income but still can’t get approved for Medicaid, or can’t even find a psychiatrist/psychologist that is accepting new patients even WITH insurance! I have known people with serious mental health issues requiring both medication and talk therapy that could NOT find a doctor in their insurance from work that would accept new patients! So this dilemma with Medicaid does not surprise me! It already existed before passage of the Affordable Care Act and it seems, sadly, is only going to get worse!

  • guest

    The typical Medicaid payment for psychiatric services averages about $80/hour. I am not in private practice, but I would guess that at that rate, after paying for office space, malpractice insurance, and office staff to deal with complex Medicaid-associated billing and compliance requirements, the doctor would end up losing money. Even before he or she tried to pay the premiums on health insurance for him/herself and family. Although none of us go into psychiatry to become rich, we do have an obligation to pay our own bills and support our children through the work we do.
    Parenthetically, why is someone who blogs about healthcare not able to easily find for himself on the internet an answer to a relatively straightforward question about Medicaid reimbursments? Is it possibly evidence that CMS is just way too cumbersome for everyone to deal with efficiently? Perhaps another good reason docs don’t accept it…

  • betsynicoletti

    Most practices lose money on Medicaid reimbursements. And, state Medicaid programs aren’t required to follow CPT rules, and can be slow payers. Some groups don’t accept new Medicaid patients or limit the number of slots they make available to Medicaid patients. Physicians who are regularly called to the ED in the middle of the night (general surgeons, interventional cardiology) often do accept Medicaid, in the belief that some reimbursement is better than none.
    Access to non-emergency specialty care (and primary care in many markets) is limited.
    Psychiatry needs higher reimbursements from all payers.
    Your point is well taken: having Medicaid does not equate with access to needed healthcare services.

    • beautyis everywhere

      I narrowly escaped being ARRESTED after keeping an appointment with a primary MD here in Oklahoma….and then showing my Medicaid card (she was supposedly accepting Medicaid…I always would ask before requesting an appointment) When I was told there was no appointment I smelled a rat and insisted she check again. So the police were called out on me. When I escaped before they arrived, I ended up in another doctor’s office down the row…& told the receptionist what was happening and SHE called the cops out on me too and then I used the magic words “no I certainly do not want to “hurt” anyone” to be let go.
      This is what coverage for the poor looks like…..UNTIL we get single pay for everyone.
      And I’m tired of hardly anyone else understanding this stuff. Maybe as long as there are people MORE poor than us, its all still ok????

  • Anthony D

    Still no mention of the American Medical Association and its hundred
    year embargo on the supply of physicians? It wasn’t until a few years
    ago that the AMA stopped preaching about a future physician surplus and
    finally admitted that a physician shortage was on the horizon. Also,
    last I checked, the Federal Reserve does little to determine the
    interest rate on student loans, that would be Sallie Mae. While the
    interest on a secured loan for something like a home might be less than
    5%, student loans for tuition purposes are closer to 8%. Absurdly low
    interest rates aren’t driving increases in medical school tuition – it’s
    the fact that schools do not have to compete for students because of
    the large availability of loan money, regardless of interest rate, and
    the fact that there are 45,000 medical school applicants for something
    like 18,000 seats.

    • guest

      Actually the number of medical school seats has been expanded, to the point where there are no longer enough residency training programs spaces to accomodate them. Residency training spaces are controlled by CMS (Medicare and Medicaid), not the AMA. The AMA and every other medical organization I know is involved in actively lobbying to increase residency spaces.
      If you want to gripe about the undersupply of doctors in the US, gripe about the US taxpayer who doesn’t want to see his tax bill increased to provide funding for Medicare to fund graduate medical education. The claim that the AMA is controlling the physican supply is a fallacious one at this point.
      And really, we could have millions more doctors in the country, and not one of them would be able to choose a medical job in which they lost money rather than making it.

      • Tiredoc

        Residencies used to be the exception rather than the rule. The AMA was instrumental in requiring years of residency prior to licensure, which forces students with enormous debt to make a choice about their profession with a couple of months’ worth of experience. The AMA is a union. Keeps the supply down and the price up.

        • Cyndee Malowitz

          I know many physicians who never completed a residency – just the one year, which is required to practice as a general practitioner. I don’t understand why so many people assume that every physician actually completed a residency and is board certified. That is not a requirement to practice as a physician.

          • Tiredoc

            You are correct in part. My state only requires an internship to practice. States do not require completion of a residency, but completion of years in a residency. Many states require more than one year. Besides, good luck getting priveledges at a hospital for all the things GPs used to do. I agree with you, more doctors should spend time as GPs before going to residencies. The cost of medical school compels too many to seek income over job satisfaction.

          • Jason Simpson

            Cyndee you have no clue what you are talking about.

            Hospitals wont credential MDs without a full blown residency.

            Insurance companies wont credential MDs without a full residency.

            Hospitals require you to become board certified in 3 years or you lose credentialing.

            Unlike your cracker jack box “certifications” that dont mean anything, physicians actually have to complete significant training in order to practice.

          • Guest

            Correct. Maybe deep in BFE someone with only an internship might be able to practice, but anywhere else a residency is required. In most urban areas board certification is a requirement.

          • Cyndee Malowitz

            That is totally untrue! I know many physicians who completed a one year residency and they have contracted with the major insurance carriers. They also have hospital privileges. Although, most physicians I know use hospitalists.

            Cigna has even jumped on board. They wouldn’t credential NPs (who owned businesses) or non-board certified physicians 2 years ago, but that has changed.

  • pbat

    Hey Peter, maybe you can pay my 200k in med school loans so that I can see Medicaid patients for (practically) no reimbursement?? Thanks!

  • Tiredoc

    Psychiatrists historically have been reimbursed at 50% of the regular reimbursement rate for an office visit by all insurances. The ACA mandated parity, which goes to the “even a blind dog finds a bone every now and then” school of legislation. Prior to the ACA, the Medicaid reimbursement for a 300 code visit was under $30. The only psychiatrists that accept Medicaid work for nursing homes.

    It’s not that complicated. Doctors that receive the majority of their patients from ERs accept Medicaid. The more independent a doctor is from a rotation that assigns patients, the less likely they are to take Medicaid.

  • ninguem

    The reason Medicaid participation is low in primary care, and high for cardiologists, should be rather obvious to anyone actually practicing medicine outside of academia.

  • guest

    Point well taken. In your article, I was not clear if you were referring to private practice MD’s or just overall specialties in any setting. I am a psychiatrist and NO ONE takes medi-cal let alone medicare in private practice. But In all the county kinds of programs where psychiatrists are paid by the facility, all of them take medi-cal. I don’t know of any private practice that takes these. Once when I was on call at a local hospital I was forced to take whatever insurance came along when i was on call. And the payment from medi-cal was so low I felt like I was forced to work for free when I saw the medi-cal patients. It was absurd.

    • Noni

      Around here it’s so bad that even the university hospital is trying its hardest to turn away Medi-cal patients. I work in a hospital that serves a lower income population. Only the very new junior physicians accept Medi-cal. Everyone else has stopped, and most have stopped taking Medicare as well.

      Meanwhile the hospitals are expanding and growing and advertise like crazy. Beautiful big facilities that the poor live adjacent to but can’t get in. It’s quite depressing, really.

      • guest

        that is very depressing. Just curious Noni. How do they turn away medi-cal pts? You mean with poor access to care or flat out refuse to treat? It’s interesting that all the focus is on medicare problems but it is true that medi-cal is actually worse!

        I live very close to a well known academic institution with brand new beautiful buildings and have insurance. But anytime I have had a medical problem their access to care is so abysmal that I can’t get in for an appt anyway for months so it also has little value to me.

        • Noni

          Of course there is no overt refusal to treat; I think that’s illegal. However, they make access difficult, stabilize and transfer, delay access to care whenever possible. One surgeon there told me (privately, of course) that his office tells the Medi-cal patients that his next available appointment is in 6 weeks. The private pay patients can see him within 24-48 hours.

          You touch on a good point. Even with insurance AND proximity to tremendous medical centers patients often get good value out of the American medical system. It took me long enough to figure out to just avoid them as much as I can!

          • guest

            6-8 weeks for an appt is actually not bad. Over here at an academic center many PCP’s practices are closed and the ones that have openings it can be several months for an appt. Specialists the wait is usually several months(2-3) as well and this is with good insurance.
            The problem with giving a medi-cal pt an appt in 6 weeks is if they take it, they will likely be a no show and waste the physicians time that could have been given to someone else. But maybe that’s the idea hoping they don’t show and they are busy enough that the no show is a relief.

          • Noni

            Gah, 6 weeks isn’t bad? Maybe I’m spoiled and entitled but I wouldn’t wait 6 weeks to see someone (unless I had some very rare disorder and they were a super specialist). Do you live in an underserved area?

            I live in a super saturated area with tons of competition (at least for the patients with private insurance!). One of our older docs on staff recently had surgery himself and had a hard time finding someone who would take Medicare.

          • guest

            I don’t mean it’s not bad to wait 6 weeks. But that is how long the wait can be and no i don’t live in a rural area. Far from it. That’s the point. Even people that have insurance can have long waits for an appt. at this well known academic institution.

          • beautyis everywhere

            I have Medicare and couldn’t get treated properly for an orthopedic crisis (hip locked so severely I couldn’t stand up after sitting), and finally after much fighting and trying to limit the abuse coming from the med. racket, I saw the corruption like a riveting indie movie….and decided to heal myself. So now I am better and not perfect, but I considered the hundreds I DID spend….as a kind of “tuition” in self-care. PS: keep your body alkalized and your orthopedic problems will lessen considerably, maybe allowing you to avoid an unaffordable surgery…

  • guest

    it is clear that what drives the growth of certain medical specialties is NOT the needs of the patient but rather how powerful are the lobbyists in that particular segment of medicine.
    So for example, front page NY Times today is that dialysis centers are booming. Even though a law was passed to decrease funding recently, lobbyists have been busy bees this summer and seem to be successfully working on Congress to overturn the recent law they just passed. Even those in Congress from both parties that worked to pass the bill are spending their energies now undoing it. It is clear who is running the country now–and its not Congress….

  • Ron Smith

    Medicaid payments not enough! How about getting paid by Medicaid AT ALL! I dropped Wellcare and Peachstate CMOs (?collective management organization) in Georgia because of the repeated refillings and ignorance of my claims. At one point they had claims that were 9 months out with repeated fillings and repeated stalling. I stopped taking any new Medicaid patients though I still take current patient’s Amerigroup. That CMO has proven, at least for me in Pediatrics where I am in McDonough, Georgia, that they are consistent and pay me on time like non-Medicaid insurers.

    Our Medicaid percentage is less that 15% and dropping. We provide quality service, high technology in the office, and well-trained, incentivized staff. The experience is good for everyone in my office, providers, staff, patients and parents.

    I love taking care of kids! I’m not in practice to fleece patients or insurers. I don’t see dollar signs when I see patients. I drive a Mini Cooper. I pay market rates for all the expenses pertaining to the practice. I want to do a good job and be reimbursed a market rate for my services. My services are offered and not a creator-endowed right or government-defined entitlement of the citizenry.

    Here is my glove on ground. I will not work FOR the government. I reject the meaningful use nose ring. I will NOT be run over by insurers, Medicaid or otherwise. I will NOT work for nothing. I am not a commodity…I’m a person and I deserve as much respect as my patients.

    Ron Smith, MD
    www (dot) ronsmithmd (dot) com

    • Guest

      Right on the money! I work with many practitioners in different fields who openly describe Medicaid’s practices as fraud. They don’t reimburse and trying to collect reimbursement is near impossible. I don’t blame practitioners for refusing to take new Medicaid patients.

    • Robert Steed

      I’m also in Georgia and no longer participate in Medicaid (endocrinologist). Besides the lower rates than other payers, their bureaucracy was incredible. Every minute spent on the phone with an insurer is a minute not spent with a patient.

      One day, I was on the phone with a Medicaid reviewer trying to get an approval. I presented the case, and then the conversation went like this:

      “You’ll have to tell me more, this doesn’t meet our criteria.”

      “Well, what are your criteria?”

      “I can’t tell your.”

      “Why not?”

      “Because then you’d know.”

      • T H

        Heaven forbid you know the rules of the game before you play…. if you did, they’d just change them anyway.

  • NewMexicoRam

    Eventually, it’s going to be single payor, probably at Medicaid rates for all. Guess we better get used to it.
    At least the attorneys will only have dry pockets to pick at that point.

    • Guest

      What part of the state do you practice in? Just curious – I went to medical school at UNM.

      • NewMexicoRam

        ABQ

    • beautyis everywhere

      The sooner the better…..

      • Guest

        That “free healthcare for all” that you’re pining for, will be worth every penny you (don’t) pay for it.

        • beautyis everywhere

          In the European states taxes are higher than ours so they can cover everyone medically…. it keeps costs down too, for obvious reasons. No insurance sharks. No ghetto-ization of care depending on income. People are not made homeless because of unpaid astronomical medical bills. Get sick, you get cared for, period. No forms to fill out. No screening for income. No outrageous questions at the door. That’s the “single payer” plan everyone here is so terrified of. And we will have it here, eventually, after everyone is milked to death and racketeered to death and all the poor have been offed…..that’s when we’ll get it. But we COULD have it now, yes we could, yes we can. But we might have to MAKE some politicians sit up and take notice…..and assure them we don’t buy into this divide-and-conquer idiocy that rules America. I won’t hold my breath waiting though.

          • Guest

            I think the 85% of Americans who were happy with their healthcare before Obama came along, would revolt before they’d put up with 75% taxes and mandatory “death pathways”, let alone the rest of the downside of government healthcare.

          • https://www.facebook.com/arobert6 Alice Robertson

            Yes look at France. Right away before the other taxes you pay a quarter to your healthcare. So if you make $60,000 right away that’s $15,000 to healthcare THEN you pay your other taxes and in Europe taxes are high. I think just the VAT in the UK is around 18% and going out to eat in Canada we paid 22% taxes but I can’t remember how much was VAT. It’s not the fairytale the media keeps promoting.

          • beautyis everywhere

            If you look at the OTHER media you will find that most Europeans AND Canadians cherish their single payer health coverage AND their HUMANE employment policies and PAY. We Americans have been so brainwashed about death panels and unaffordable taxes (worse than unaffordable health care dudes?) that nobody knows who’s really talking when this nonsense starts spewing again……please!
            And also if it is getting a bit harder over “:there” look to policies re: globalization…ie: screwing everyone in order to screw some people even MORE.
            So u want what u have now….keep flaming and fighting one another and forget what’s really important…the right to get sick and better and go on living. People who rely on their single-payer STILL appreciate those things. OVER AND OUT.

          • https://www.facebook.com/arobert6 Alice Robertson

            Well now here is the problem. I have lived there. You are believing the liberal media while also spewing bollocks. You are believing the media that spins the old WHO stats that were so slanted WHO won’t even publish them again. Here’s the bottomline. I have a child with cancer and I can get free care in the UK (my husband is a citizen there). Now if you had a child with cancer where in the world would you get treatment? In a country with a waiting list? Or here? The answer is very clear. I sit with Canadians at the Cleveland Clinic.

            I tire of the false altruism from those who really prefer fairytale medicine over the reality of care across the pond or further.

            And where do you think American reporters and journalists get their care (yes, there is a difference)? Right here, and European correspondents come here when it’s beyond nominal care.

            And sometimes it reminds me of the people who want more and more entitlements and when questions you find out they pay little to no federal income tax, many are getting EIC, many are getting checks from the government but it never seems to be enough. That’s the result of socialism. A Golden Corral banquet and the liberals rah rah it.

            And about death panels. Go read up on what liberal Nobel prize winner Paul Krugman says about the necessity of death panels and VAT to pay for even the most basic of Obamacare implementation.

            Sometimes you just wonder what’s going on in the universities where liberal teachers getting excellent healthcare and other benefits sit and spin shite all day long.

          • Mengles

            Wait a minute, I thought healthcare was a right? So doesn’t that mean it’s automatically free?

          • https://www.facebook.com/arobert6 Alice Robertson

            If you could read as well as you criticize we would have a winner here:) Go back and read more thoroughly. I said catastrophic care can be a right, but if you read my posts overall I believe healthcare is a responsibility of society but I have said ad nauseam that I don’t believe mundane care is a right. You are a whole lot of upkeep Mengles!

          • guest

            Socialised healthcare in the US would be like the worst of the worst HMO, administered with all the efficiency and caring of the DMV.

          • ninguem

            I could almost kinda sorta maybe live with the systems in Canada, UK, wherever, if accompanied by the more realistic expectations of the people covered by those systems.

            “guest” has a point. I can see it becoming the worst of all possible worlds. The worst of a private HMO, the attitude of the DMV (I say TSA is far worse)…..with the unrealistic inflated expectations of the USA……and enforced by the USA trial bar, which is severely limited in those countries.

          • https://www.facebook.com/arobert6 Alice Robertson

            I lived in the UK and when my family is visiting there (my husband is a Brit) we are absolutely terrified one of us will get hurt and need care. We don’t worry about mundane stuff like an ear infection or cold…you know the stuff that usually gets better on it’s own. They excel at that. But anything else is absolutely terrifying. It’s why 60% of doctors there have private insurance. They know what they provide is slop.

          • Mengles

            It must get very lonely living in your utopia.

          • beautyis everywhere

            It must get lonely being such an unhelpful snide so and so, who can’t address the real issue.

          • Tiredoc

            If we made one simple change in the Medicaid system, we would cut 30% from the budget and reach parity with France’s per capita health expenditure.

            The rule is quite simple. If you’re over the age of 65 and don’t work, you don’t get dialysis. This is the rule in your socialist European utopia.

            In about a month, our Medicaid budget would plummet. No nursing homes for dialysis patients. No transportation. No expensive hospitalizations. Just a lot of dead patients with uremic crusting.

            Since dialysis is technically life support, it isn’t even a violation of medical ethics.

            Remember that next time you talk up the European system. Cheaper means less. In medicine, less most of the time means dead.

          • beautyis everywhere

            OK here we go again. This is FASCISM make no mistake, and YES it is creeping in to the European system too, thanks to machinations of the New World Order, headed up chiefly by the good old U S of A.
            What did ja think would happen if none of the other FASCIST features of this entirely corrupt modern America corporatocracy….were NOT held in check?
            Think “GESTALT”!!

          • Anne

            You were institutionalized at one point, yes?

          • beautyis everywhere

            If you mean that to imply I was crazy therefore I somehow deserved it…I say…ummmmm…nope.
            It was the corrupt system in all it’s florid grotesqueness (the system all of you love so much right now) that locked me up instead of the dude who attacked me, and if you can manage to ask me respectfully I MIGHT tell what actually happened.

          • T H

            The 65 year old cutoff in dialysis is an urban myth. Just like people older than 59 not getting heart procedures in England.

          • https://www.facebook.com/arobert6 Alice Robertson

            But it is not a myth that England denies for far less than a heart procedure. They deny medicines and the papers covered a young woman who had a denial letter. The cost to keep her alive was too much and it was about $40,000. She didn’t have long to live so her parents went on a campaign. It’s such a mess there a move to get privatized involved is launched.

          • Tiredoc

            I accept your correction. I meant rule in the statistical sense. The proportion of people over the age of 65 receiving dialysis in the U.K. is half that of America. In addition, the capacity for dialysis in the U.K. is half of the amount needed to actually fully treat the number of people with ESRD in the U.K. Someone over the age of 65 can get dialysis in the U.K. If they are otherwise healthy. There isn’t a written rule, but if you don’t budget the service, then the service doesn’t happen.

            2/3 of the dialysis patients in the U.S. can’t pass a mini-mental status examination. That we warehouse our demented elderly for the financial benefit of nursing home corporations, dialysis corporations and transport corporations isn’t a plus in my book.

            In the U.K. the doctors just don’t offer the service to sickly, demented patients who reside at nursing homes.

          • T H

            Well, I see that we’re going to have to agree:

            Dialysis in the U.S. is one of the biggest schemes modern medicine has to harvest money from the Insurance Industry and Gov’t.

            And the UK priorities seem to be ok when you present your side: of course, being on ‘forever dialysis’ is one of my (many) medical nightmares, right up there with becoming locked-in because of injury/ALS,

            @ Alice Roberton: cite your case, please. Names/dates/etc.

          • Tiredoc

            I’m OK with forever dialysis. I’d get the machine and do it at home. It’s the “kept alive but with no brain” I have a problem with. I’ve got the “no brain, no vent, no feeding tube, no dialysis” in my living will. I’m OK up to a point with the U.K. priorities. I do think their “we do everything” but “only if we have the money” is politics as usual. I’d rather have a firm rule, or at least a discount for taking myself off of the useless procedure list.

          • Frank Lyons

            don’t want it.

          • https://www.facebook.com/arobert6 Alice Robertson

            Me either, and didn’t this poster admit to using a Medicaid card for care? Our Medicaid is better than universal care (because we still have the capitalistic aspect) unless this poster is willing to pay some co-pays or private insurance in the socialized wonderland, but I am sure they want socialized care for the good of mankind? Because in that world the cancer victims who die waiting don’t even get to become a statistic because you weren’t completely or correctly diagnosed. You are just dead!

      • https://www.facebook.com/arobert6 Alice Robertson

        If we get single payer you will need to change your posting name because there sure won’t be “Beautyis everywhere” there will be “Horror stories are everywhere”!:)

        • beautyis everywhere

          we get what we expect AND work for in this world.

          • https://www.facebook.com/arobert6 Alice Robertson

            That’s a great story starter….but if you think just work and expectations are getting you through then where does that leave your liberal leanings for the sick and helpless? Did they get what they expected or deserved?

          • beautyis everywhere

            always with the epithets when we can’t address the real issue, and btw, isn’t it typical of people like you to shoot yourself in both feet and expect people like me to craft your crutches.

          • https://www.facebook.com/arobert6 Alice Robertson

            You know….Obamacare is here because of naive youth. Your slip is showing:)

          • beautyis everywhere

            Learn to respect your elders missie.

          • https://www.facebook.com/arobert6 Alice Robertson

            Well excuse me Queenie!: Ha!

          • Mengles

            Except for doctors apparently.

  • Richard Willner

    The Medicaid Fraud Control Units well funded by Obama are quite a competent group to deal with if a Physician takes Medicaid. It is my opinion that this is the single best reason for a doctor not to accept Medicaid.

    Richard Willner
    The Center for Peer Review Justice.

  • Anthony D

    Here’s the thing.

    The problem with PPACA (ObamaCare’s real acronym) is that is fails
    completely to understand the real problem or deal with it. The primary
    reason that medical prices have been growing faster than inflation for
    many decades in a row without end is because of Third Party Payment. TPP
    break the market’s natural cost control mechanism…which is prices
    being paid by the consumer.

    In a HEALTHY market, a consumer pays for goods and services and
    therefore has incentive to seek the best total value he can. he
    prioritizes from himself what is important, and what is worthwhile. The
    provider is always under pressure because of this to innvoate, be
    efficient and meet the consumer’s expectations and desires at a price
    point that both can live with.

    But in the medical market in America, the consumer doesn’t pay. About
    90% of all medical dollars are spent by someone OTHER than the patient
    (insurer or government usually). But wait, it’s worse! because not only
    do most people not pay for 90% of their bill themselves, but their
    insurance isn’t even paid for by them directly. Either their employer or
    the taxpayer pays. So you really have 4th party payment MOST OF THE
    TIME.

    The effects of this are a classic Moral Hazard (if you don’t know
    what that is, look it up, it’s an important economics term that every
    American should know). The consumer, because he doesn’t pay for
    anything, is incentivized to overconsume medical services. The provider,
    because the consumer doesn’t worry about costs, is incentivized to
    overprovide.

    Thus unnecessary tests are prescribed, unnecessary procedures, new
    expensive drugs are prescribed when an older cheaper one could solve the
    problem almost as well., etc. This overconsumption is an increase in
    demand. If you know ANYTHING about economics you know that when demand
    rises, prices rise.

    In a normal market, when prices rise, suppliers have incentive to
    increase supply to capture profit which then brings prices down.
    However, medical markets have two problems. One is that training doctors
    is REALLY hard and expensive. Only so many people have the capacity to
    be doctors and it takes more than a decade of schooling and interning to
    make more, not to mention hundreds of thousands in debt. This is a
    naturally inelastic supply (another economics term you should know).

    But in addition to natural inelasticity, our licensing system has
    turned the AMA into a medieval guild that suppresses competition. The
    AMA takes steps to ensure that only a small number of medical colleges
    exist, and that those colleges keep from expanding their production of
    new doctors. The AMA has this power because it writes the licensing
    rules to restrict doctors to having come from AMA approved medical
    schools
    rather than using skills tests. The result is to give the AMA the power
    to control the supply. And no such group will ever voluntarily expand
    competition so as to lower their own compensation. So we have natural
    and artificial limits on supply.

    These are the challenges. PPACA does NOTHING to reduce them. It does a
    GREAT DEAL to make Third Party Payment worse. Independent industry
    analysts are predicting 33-169% premium rises over the next few years
    after PPACA comes online. These are not conservative interest groups.
    These
    are group paid by businesses to give them the most accurate forecasts
    they can so that businesses can plan for the future. They have every
    incentive to be as accurate as they can without political bias because
    the degree to which they are right determines if they get their next
    contract.

    PPACA is going to to substantial damage to our health industry. Ten
    years from now, I GUARANTEE, the situation will be SO much worse than
    today, and I also guarantee that no one on the left will admit that
    PPACA made it worse. They will instead call for more solutions that fail
    to recognize the problem.

    I can’t add anymore. Its too long to be posted!

    • meyati

      I like hearing about running every test known to man, whether the patient needs it or not. I’m taking antibiotics for a strep throat that I’ve had for almost 3 months. I’ve been saying and writing-yes, I am guilty of harassing my PCP electronically, sore throat, fatigue, etc.

      I’ve been tested twice by the military to see if I’m a strep carrier, because my throat usually doesn’t get red or inflamed and I don’t run fevers. Like it’s my fault that I was born this way. The doctor that ran the strep test told me that it would take 20 minutes to get results. Then the nurse knocked on the door- because the strep was so hot. The military and most of my doctors gave me records to back up my strep symptoms, and some other problems-or outcomes-like a dirty break healing in four weeks. They said that it would take about 8 months or more. Now the problem is getting a modern doctor to just glance at one strep note- atypical strep.

      Anyway, I found a doctor that would run a strep test on me.

      • beautyis everywhere

        laboratory-manufactured antibiotics are designed to create more problems than they alleviate. Use natural products for the strep…info is all over the internet.

        • Frank Lyons

          I would not take that as good advice.

          • Anne

            Your advice not to take the advice of ubiquitous pulchritude up there there is good advice.

          • ninguem

            Your advice to take Frank Lyons advice to not take the advice of omnipresent comeliness is good advice.

          • beautyis everywhere

            and what is with you whoever u are??????

          • beautyis everywhere

            what is with you lady????? ;=(

  • Sherry R

    If you had asked “how many are unwilling to take insurance of any kind” you would have gotten similar results – P-docs can pretty much charge what they want to in many markets. The biggest reason however is simply that there are more then enough people who can afford to pay them directly

    For nearly 95% of US docs Medicare and Medicaid paid for their training at a cost of close to 500k to 1.1 million (residency and internship salaries and payments to hospitals) so perhaps they should be required to pay back the cost plus interest (1 to 2 million). The entire residency concept was set up to train doctors to care for those on Medicare and Medicaid so they aren’t upholding their end of the agreement.

    I think however that psychiatry has some of the highest rates of non US medical school graduates (they pay for that on their own) and there are some cultural differences as a result?

    The other observation is that in psychiatry the highest paid professional – psychiatrists tend to cluster treating the healthy wealthy and we give bachelors level case managers to those with the greatest disability (schizophrenia) wheras in cardiology it is entirely likely that regardless of your income or disability people with the greatest “disease” receive the highest level of care.

    • FEDUP MD

      If doctors had to pay $1 -2 million in addition to hundreds of thousands of dollars in loans, good luck ever finding a physician. I am in a low paying pediatric subspecialty that has a lot of need but I would have to quit because at that rate I would be committed to involuntary servitude because I could never pay it all back and actually pull any salary. I am committed to my patients but my kids do have to eat, need a place to live, clothes, etc. The majority of doctors would be in the same situation, especially PCPs and nonprocedural specialists. We did not sign up to work for free and sacrifice our families on the altar of societal betterment. If you want to put your money where your mouth is, go ahead and quit your job and spend your time doing charity work instead for free.

    • azmd

      If one is going to write about what others should and shouldn’t do, it’s important to first get the facts right.

      It is unclear where you are getting the figure of 500K-1.1 million per resident. Most residents do a 3 or 4 year residency, and CMS pays the hospital around 90K per year per resident, with plans to reduce that amount in the coming year.

      The payments were, in fact, set up, NOT to “train doctors to care for those on Medicare and Medicaid” but to pay the hospital for the service that the residents are providing to Medicare patients DURING THE RESIDENCY PERIOD. There has never been an intent that the residents would use their training to provide care in perpetuity after they leave the hospital.

      It’s important to remember that in exchange for that payment, the hospital provides high-quality care to Medicare and Medicaid patients, using the resident as slave labor (the typical resident makes about half of minimum wage on an hourly basis), and, by the way, paying their teaching attendings far less than those doctors could earn in the private sector.

      Most hospitals lose money on Medicare patients, and the CMS payments for graduate medical education help to make up the shortfall, although there is still a significant gap between the cost of providing care and what the government ends up paying.

      The payments are helping to ensure that hospitals used by all of us, including you, have doctors there around the clock, available to care for people in the middle of the night. It’s a public good, and suggesting that doctors should be in servitude to the government for the rest of their working lives in exchange for participating in that public good, can only result in more of our bright college students (and their parents) deciding that it doesn’t make sense to incur the significant personal expense involved in going to medical school.

      • https://www.facebook.com/arobert6 Alice Robertson

        I live near two teaching hospitals who use Case Western, etc. and the residents are so thrilled to be working there. I just love them and get irritated at the way the specialists often boss them around (my experience two days ago with a Svengali was outrageous…no details…I need the guy for future treatment but would dump him in a second for the residents if they had finished their training). Anyhoo….one hospital near me has no residents and they are extremely profitable (proudly so).

        Now that said Cleveland Clinic has found a way to capitalize on Medicare and Medicaid patients. They made a shipload of money the last few years and claim they kept it safe for the looming Obamacare mess that awaits with bundling, etc.

        But at this point they are highly profitable. What the future holds I don’t know…the predictions are terrible unless you talk to a doctor who wants to be a bureaucrat because bureaucrats gets a nice weekly wage, with benefits and better insurance than the Average Joe. Many are on here with their sales pitches about how great single payer is. I have lived it and it is not something I want here. My daughter with cancer could die on a waiting list in many of these countries. And that’s not a myth, but in those countries like the UK physicians get private insurance so they are covered well.

    • kjindal

      that’s like saying anyone who attended a public university is indebted to serving the public for the rest of their lives.

      residency is like slavery – working 80-100 hrs/wk for like $40,000/yr. And attending physicians who run resident care teams are often voluntary. Meanwhile hospitals get gov’t subsidies to care for the uninsured & medicaid patients, where they otherwise would lose money. Of course, this goes to their bloated 7-figure administrators rather than the ones actually treating patients.

      • Dana

        “residency is like slavery”

        Except that

        (A) It’s voluntary – you made a conscious decision to do it, and you can quit anytime you like

        (B) You get paid for it

        (C) It’s a finite apprenticeship period, after which you will be in a position to make more, for the rest of your life, than 90% of your fellow citizens.

        But yeah. Other than that, it’s EXACTLY like slavery.
        ::rolls eyes::

        • Tiredoc

          Actually, you’re quite wrong in the voluntary part. The cost of medical school is so high that only the salary of an MD can pay it off. As the loans required to pay for it are immune from bankruptcy, then working as an MD isn’t voluntary. As most states require 3 years of residency to work as an independent MD, then obtaining an MD comes with a required residency. You owe your soul to the AMA company store. Since CMS only pays for one residency, you’re stuck with your choice once you go in. As a resident, you owe your body to the AMA company store. It’s called peonage, and is most certainly a form of slavery.

          • Guest

            I’m sorry, were you kidnapped and forced to go to Med School against your will?

            No. It’s nothing like slavery, and your glib privileged whining diminishes the horror of all those who HAVE been enslaved.

          • Tiredoc

            The thirteenth amendment bans all forms of slavery. The most odious form, slavery by birth, is rather easily identified and eliminated. Likewise, indentured servitude, in which salary is not paid and labor is owed contractually, is also banned and easily excised. The third form, peonage, consists of charging someone for their keep more than they make for their labor. Hence the quote, “owe my soul to the AMA company store.”. It is under the law a form of slavery. Virtually all modern prosecution for slavery is for peonage.

            I apologize for my glibness. My intent was to point out the inherent immorality of the residency system that we foist off on medical students. Personally, I am well past residency and value the training I received.

            As for the offense that you took, you by common courtesy should either have been a slave or at least known a slave. If neither is true, then you are simply engaging in personal attacks instead of discussing my actual point.

            No one is owed the labor of another without unencumbered consent and fair compensation.

          • Guest

            Well, yes. Doctors who have voluntarily entered medical school and are completing their residency as part of their known requirements for a ticket to become a millionaire, are EXACTLY like 12-year-old girls sold into sex slavery by their parents. EXACTLY.

            I’ll alert the U.N.

          • Tiredoc

            I sense a problem with the English language. I listed three forms of slavery. The kind that you cited, sale of a minor for sexual services, is certainly slavery. Again, indentured servitude, where people sign up voluntarily for uncompensated labor, is slavery too. I did not state that residency was akin to sex
            Slavery. I said that peonage was a form of slavery.

            My point is that the massive amount of money that is loaded onto medical students’ backs is a lie. It doesn’t cost that much to train doctors, and the residency system compounds the error.

            The fact is that the choices that doctors make about their careers and what patients they see are constrained by the debt they incur. If you fail to account for the immorality inherent in the current system, you cannot begin to fix it.

            As for the millionaire bit, I don’t know many pediatricians, psychiatrists, or family practitioners.

          • https://www.facebook.com/arobert6 Alice Robertson

            Last week I posted the Department of Labor statistics and doctors went wild. All anonymous mind you and one posted for Alice to “Shut up”! It was a riot! But out of the top twenty job that pay the most ….most of the jobs are doctors. I don’t know how many times I said “You are worth it” but it went on and on in the “How dare you step on our whining rights!” Ha!

            Let’s get real it’s one of the top paying jobs…sure it comes with debt…so did all my kids college degrees….huge debt that takes what feels forever to pay off (I am 12 years into my one son’s private school loan and he was working three jobs to try to pay off his debt at over 80 hours a week so he can get out of debt before grad school and after he is done what will he make teaching at a university?)

            Doctors protest too much to a society drowning in student debt themselves and some without your earning power.

            I am grateful beyond words for my daughter’s doctors and I hope they are paid a lot. They seem really happy. I just wonder if the internet doesn’t lure the more curmudgeon types of patients and doctors out? The happiest ones rarely post because they move on. Just thinking aloud really. Better shut up before Mengles blood sugar gets low and he goes on his daily witch hunt! Ha!

          • Tiredoc

            I will assume that your Department of Labor statistics are correct, that most doctors make an excellent living. I will also assume that many people in different professions leave their training with a staggering load of debt. How does someone else getting it worse mean that residents don’t have it bad?

            Aren’t you trying to make the point that you don’t like doctors saying that they have to make so much money because the school costs so much?

            I agree with your point, but instead of attacking doctors, why aren’t you going after the AMA, medical schools and residency programs that create the problem?

            Or do you actually think that, “suck it up, rich guy” is a substantive argument?

          • https://www.facebook.com/arobert6 Alice Robertson

            LOL “Suck it up rich guy”? My husband makes as much as you and we have huge amounts of student debt, six kids, and one income because I gave up a wonderful bureaucratic job years ago. It was a good decision and we are blessed (plus I have medical bills in the thousands because an ENT at Cleveland Clinic screwed up and a delay in treatment caused my daughter’s cancer to spread. And you want sympathy?)! I homeschool so at my next parent/teacher conference I guess while looking in the mirror I will have to also tell myself, “Suck it up rich guy” ….what to do with all this wisdom:)

          • https://www.facebook.com/arobert6 Alice Robertson

            This is for TiredDoc: Why don’t I go after the AMA? Are you kidding me? I go after them on these boards
            continually. They were instrumental in Obamacare being passed because
            they wanted new codes that are copyrighted and makes a segment of
            doctors ultra-rich, so instead of trying to make patients with opinions
            grovel why not just go after your greedy colleagues? Surely they have
            made your life more miserable than any patient could or will?

            Residents? They make over $40,000 a year but doctors like to say they make prisoner wages as if they are making license plates with medieval tools! Ha! Okay being dramatic, but gosh my husband suffered to get where he is and he ain’t whining like this. Admittedly it is hard work to be a resident, but so are a whole lot of other vocations. I just think you need to broaden your horizons and let’s get real the average doctor makes about five times what their average patients makes. It doesn’t mean the patient doesn’t feel your pain, but they are low on sympathy when life is pretty rough for them too.

          • Tiredoc

            I’m not a resident. I paid off my student loans 10 years ago. I haven’t made any patients with opinions grovel. I just don’t think that there is anything productive about the statement that doctors make too much money.

            Doctors make too much money because there aren’t enough doctors. Lawyers used to make as much money as doctors before they made a lot more lawyers.

            The supply of doctors is limited by state licensure and hospital priviledges. The first two years of medical school are simply a cash grab for the medical school. Hospital priviledges are enforced by state authorized cartels. Hospital bureaucracies expand with government assistance to inflate the duration and quantity of residencies at no benefit to patients.

            That doctors make money at the end does not justify the process to get the high salary. Senior GM assembly line workers made equivalent wages in the 1970s using the same process of legislated scarcity. The AMA has burrowed itself into a corrupt abcess in the meat of our culture and needs to be lanced.

            The process needs to be fixed. Residency is peonage for two reasons. First is the high cost of medical school. Second is the length of time of the residency for advanced training. Anyone should be allowed to take the part one boards and go on to the second half of medical school. Increase the number of medical school slots by 50%. This would cut the cost of medical school in half and reduce the demand for physicians in underserved areas. Drop the federal funding of residency programs. It’s a waste of money and only strengthens the AMA stranglehold on hospital priveledges.

          • https://www.facebook.com/arobert6 Alice Robertson

            TiredDoc …..sometimes doctors are scary when they don’t know slow down and actually read what a writer is saying (scary in the sense that I guess patients expect you to be a medicinal Holmes character…or at least a Watson…who can see what we don’t see. Who can diagnose and catch clues and intent because we actually believe you are trained to do just that). It’s really disappointing because you did this previously with a slavery comment too, so it’s not just my posts you have misread.

            Who said you make too much money? Who said you are a resident or inferred it? It’s fine that you want to explain yourself and that may be your strength but your lack of empathy and reading skills because you feel such a strong a need to state your agenda at strongly defending your wages is worrisome.

            Please try to slow down and think….and see that previously I said doctors are worth it. God Lord I have a child with cancer…if I thought a doctor could cure her there is no material possession I wouldn’t give up. It would be so absolutely priceless it would be worth well beyond anything I own or could afford.

            Sometimes your profession protesth far too much. I haven’t launched a diatribe about why my husband supposedly earns too much. It is what it is.

            Your strong points are not in defending your supposed sacrifice to humanity in your residency which landed a well paying job. It’s in your other aspects. What do you really want? Patients to shut up and worship you? Ha!

          • Tiredoc

            I offer my prayers to the health of you and your family. Good wishes if my prayers are unwanted.

            My impression of your points are as follows:

            1. Residency is hard, but is not comparable to forced labor.
            2. The cost of medical school is high, but isn’t that much different than the cost of training for any other profession.
            3. Residents are paid a reasonable living wage.
            4. The cost of medical school is more than made up for by the salary that an MD generates after training.

            My (limited) impression of your life:

            1. Your child has cancer.
            2. You were a successful businesswoman or university administrator.
            3. You husband is successful.
            4. You take care of your family, including their education and health care.
            5. You have insomnia.
            6. You are fiscally conservative, but not of the libertarian stripe.

            If I am incorrect, please rectify.

          • https://www.facebook.com/arobert6 Alice Robertson

            LOL I like it, really I do. Excellente! I loved the insomnia observation…it’s true….and it’s why my late night rants are on the WTH level:) But I do have libertarian leanings, but have trouble being associated with Republicans (not the moral aspect the Ayn Rand stereotype. I can’t stand that woman:), nor Libertarians (the I can anything I want because my crazy Uncle Ron Paul says so types:)

            Addendum: I need to fix those typos. How did you get through that? I was on the phone…trying to answer you… and late for a very important date…no time to say….oh gosh…too much fun says Alice!:)

          • Tiredoc

            I’m glad I got some things right. As for the typos, I have some patients who don’t seem acquainted with consonants. I’m fairly creative at filling in the missing pieces.

          • https://www.facebook.com/arobert6 Alice Robertson

            You know from a patient’s vantage point we often think your white-coat career choice is dazzlingly brilliant and that patients can’t wait to bare their souls and vivid details of lives we would rarely admit to experiencing far less fraternizing amidst. Your fill-in-the-blanks skill may very well be born of necessity (I had no idea patients lie so much until I started to read here….nor that they forget so much when they leave your office). But when I started to email my daughter’s one doctor who rocked our world with his skill levels he would laugh at my dramatics (while my daughter’s would tell him not to encourage me while rolling their eyes:). But how revealing it was when he admitted that after all that training his job is at times dull and boring. Say what? Therefore, a hurt mom entertained a doctor via a world where my created characters don’t suffer from illnesses (mental ones perhaps:), but if they did he could have cured them (or tried to:) I appreciate doctors more than my posts seem to be expressing, so forgive my niggling it’s usually good-humored and well-intentioned.

          • Tiredoc

            In my profession, I feel that someone who criticizes me is someone who cares. A patient can always find another doctor. I’m not blessed with perfection. Silence doesn’t help me at all. (Abuse, of course, can find the door with my assistance.)

            As for the bored, I don’t get that. Even if all you’re doing is try to get HgA1Cs below 7, systolic below 140, LDL below 100 and BMI below 30 the job is challenging. Stressful, yes. Bored, no.

          • https://www.facebook.com/arobert6 Alice Robertson

            Well then I just a review for a book and your post reminded me of it. It’s a new book by a literary physician (who fascinate and terrify a bit. Don’t ever read Atul Gawande before your child’s surgery..holy cow:), and since I can’t write to you privately I need to ask you publicly if you have read it or recommend it. I think he’s a PCP and I think it looks intriguing? Dr. Brendan Reilly, MD One Doctor: Close Calls, Cold Cases and the Mysteries of Medicine

          • querywoman

            Tiredoc, you are really funny. This is the Alice whom I know!

          • Cyndee Malowitz

            Not true – U.S. educated physicians are only required to complete 1 year of a residency to practice as a general practitioner. Foreign educated physicians are required to complete a 2 year residency, but that may soon change. If a certain bill passes Congress, then foreign educated physicians will not be required to complete a residency nor take any type of exam…as long as they treat medically underserved populations or work in a rural area for 3 years. After that time, they’ll receive a Visa and can live/work anywhere they want.

          • Tiredoc

            There is no such thing as a US requirement for physician licensure. All of the states set their own requirements. Some require international physicians to have the same as US graduates, some require up to 3 years. The bill that you are referring to references immigration status, not licensure. The physicians would still have to be licensed in the state they practice.

          • querywoman

            I’m not aware of any kind of license that isn’t a state thing, like a driver’s license or a beautician’s license.

          • kjindal

            every time I read a post of yours I feel dumber for it.

            When freedom of expression has morphed into the ability to misinform armies of agenda-driven, under-educated, left-leaning, MID-LEVELS, we have just gone too far. And perhaps a neutral mediator (kevin?) should step in and either verify or refute what you’re saying, since in this post you’re not positing opinion, but rather making a (wrong) statement of fact.

            To practice medicine, one must have the legal authority to do so. For that there is licensure, And as far as licensure every state is different in their requirements (as with nurses, physical therapists, etc.).

            If you are treating patients it’s scary that you feel so free to speak about things you clearly don’t know about. Do you tell your patients “no, no way is that mass on your chest xray cancer. Cancer ONLY ….”??? Again that’s what is sometimes scary about a little knowledge – unwarranted confidence, and not enough humility.

          • Guest

            that’s what is sometimes scary about a little knowledge – unwarranted confidence, and not enough humility.

            My experience with mid-levels in a nutshell. The arrogance is terrifying. If only patients knew…

          • querywoman

            Tiredoc, the entire student loan system has been compared to indentured servitude. But it really isn’t, because there are options.
            I’m speaking public loans here. Private loans are a new societal evil.
            Medical student loans should be no different than other student loans. They can be deferred, placed in forbearance, or put in an Income Based Repayment plan.
            I’m currently in an IBR for one year of grad school, and my monthly payment is zero for now.
            If a medical grad can’t get a job, or gets a low paying job, he or she could contact the student loan.
            If, after a few years, the doc decides medicine is not his or her best calling, or gets his or he license revoked, he or she should contact the student loan company to discuss loan options.
            The worst scenario is being issued an IRS tax form for loan forgiveness about 25 years after the debt was incurred.
            For a doctor, that could mean a $300,000 loan forgiveness receipt. The IRS will work out a payment plan. If you just can’t pay, and they have formulas for that, you can be put into Currently Not Collectible status.
            They usually only put nonfilers in jail (big-time ones), and also people who hid piles of money.

        • kjindal

          a- not exactly voluntary – once you get thru medical school you MUST complete a residency in order to obtain a license, sit for board certification exams, get hospital admitting privileges, participate in medicare, medicaid & private insurances, and thus get a job.

          b-you get paid BELOW minimum wage, and certainly below the value you provide to the hospital. THEY get paid fees to train residents and care for medicare & medicaid patients, then pass on a fraction of it while generating more than that in revenue from caring for patients that otherwise wouldn’t be profitable.

          c- yes we probably make more than 90% of our fellow citizens, for training longer & harder than 97% of them, and working harder than probably 95% of them.

          Not sure what you do for a living Dana, but residency (esp gen surgery) is HARD. Very few who’ve not actually experienced it can appreciate what it’s like.

          • https://www.facebook.com/arobert6 Alice Robertson

            It is quite a sacrifice, but one wonders if mandatory volunteerism in high school as a credited course would have given you a different perspective. You get paid nothing, and it’s very hard work for zero monetary compensation to people whose lives are so difficult, Ultimately you walk away feeling that you were rewarded in a way that money can’t buy. I know kids who went to New Orleans after their disaster and ripped out walls of flooded homes and had cockroaches crawling all over their bodies while working in over 100 degree temperatures. The list goes on….but I think if these types of opportunities were mandatory (as they often are in private schools) it may change your perspective about your monetary compensation and sacrifice *(on your road to one of the highest paying jobs in America according to the Dept. of Laborr) when your resume included a sacrifice to humanity on that level.

          • Michael Rack

            1. Residency is more a form of indentured servitude than slavery.
            2. Volunteerism in high school/college (which many doctors did) is a lot different from performing a large amount of volunteer work in your late 20′s when you have a large amount of debt and a family to raise.

          • https://www.facebook.com/arobert6 Alice Robertson

            You know I think most residents would agree with you (some view it as an opportunity while others view it as martyrdom:), but your number “2″ point isn’t adequate because of the way you defined it with the usage of the words “large amout” of volunteerism (small amounts work even in a large family like mine. I have six kids). I take my kids to the innercity with me for volunteerism, but I homeschooled and private schooled which means I had more control over our time and adventures. It was good diversity and empathy training:) So volunteerism comes naturally to them which was my goal. They also learned to call political candidates while teens at the think tank I volunteer at. They learned more via those calls and organization than a civics class would have taught them.

            I really have to disagree about your indentured servant analogy and residents (biblically when a prisoner served his sentence he could voluntarily proclaim to stay where he was at and proclaim his indentured servanthood by hammering a piercing through his ear into the owner’s door. Obviously there are more biblically analogies and colony experiences but residents here at the big teaching hospital start out at $40,000- $50,000 a year which is far from indentured. Maybe indentured to your career choice.. And unlike an indentured servant there is great gain at the end of your training.

            Now the current administration somehow considers non-profits of more importance than profit organizations because.they are offering a way for doctors to become debt free after ten years if they will work for a non-profit (which is a nice opportunity because non-profit employees often make good money).

            You know I only know two doctors who volunteer their time. One at the think tank I volunteer at (but he is retired) and the other one volunteers but somehow has an overlay that she makes money from peripheral jobs attached to the volunteerism. It appears to be an exceptionally small percentage of doctors volunteering which is ashame considering you have such a magnificent gift to share.

          • Michael Rack

            To Alice Roberson, thank you for your thoughtful response. I agree that indentured servitude is a flawed analogy, but it is a better analogy than slavery. I was referring to the American colonial experience rather than Biblical. In some ways residency is like American colonial indentured servitude: a resident gives up control of his life for a period of time for a desired goal (licensure, board eligibility); the American colonial indenture servant received passage to the colonies in return for his servitude. I had no problem with my salary years ago when I was a resident. “Maybe indentured to your career choice..” -exactly, it is very difficult for a resident to change positions. If he leaves a residency program he may never get another opportunity. By the way, I did a lot of 100 hr+ weeks when I was a resident. Residency was a lot harder back then.
            Regarding volunteerism, I was just trying to point out that residency cannot be done for free (sorry, I was responding to several posts and that comment was not directed at you specifically). I do know a lot of doctors who volunteer, but we could certainly do more.

          • https://www.facebook.com/arobert6 Alice Robertson

            This is what I love…when a real discussion tkaes place and refining done well via communication and not throwing up your hands and walking away. Kudos to you!

          • Tiredoc

            If it’s mandatory, it isn’t voluntary. If it isn’t voluntary, it isn’t volunteering, it’s community service. I don’t work for free. If you want me or my children to clean up cockroaches, you’re going to have to pay us.

          • https://www.facebook.com/arobert6 Alice Robertson

            LOL Maybe I didn’t explain it well:)

            You need to differentiate. The cockroach gig was voluntary (it was mostly a type of missionary thing where kids used to volunteering via school or organizations willingly went there. They took their civic duties to meaning action to help others, and it was mostly homeschoolers), but some of the better private schools and better type of charter schools are having a mandatory class of public service before you get your diploma. It’s a very good idea. It’s learning outside the box of stuffy academia’s over reliance on textbooks.

          • kjindal

            “mandatory volunteerism” is an oxymoron.

            and many (probably the vast majority) of doctors did volunteer before practicing. And when a private practice MD takes “service call” at a hospital he/she is responsible for all patients admitted to their service, whether they are paid or not. Since many folks admitted thru ERs these days are uninsured (or on medicaid), these docs ARE volunteering to care for them. The hospital receives generous subsidies for these patients, but pass none onto the private MDs, who are liable for the care of those patients medico-legally. Of course as things got worse, the hospitalist movement sprouted and burgeoned as community hospitals could find fewer and fewer suckers to voluntarily take such service call.

          • https://www.facebook.com/arobert6 Alice Robertson

            Ummm…..I don’t think so!:) You are caring for those patients because the law makes you. You can’t label that volunteerism. Although your point about the hospitals is quite good. Now if you were off the clock of your job it would be volunteerism.

            It is true mandatory volunteerism would be an oxymoron if the participant has a diploma hanging over their head, but *overall* it’s not in most cases, nor the context it’s offered in right now. But so far it’s used in private/charter schools as a type of class where the kid’s choose what organization to volunteer at. These schools have stupendous results when the bondage of the union is off the table and their grades go up via activities like their volunteerism (although at Stuyvesant [a very interesting public school of top test takers who gain entry via their SHSAT score but still had to go on a waiting list for the best classes] the famous author Gatto [Dumbing us Down] implemented this into his classroom and the waiting list only grew. It’s a 20 hour a month mandatory gig on a long list of other mandatory duties the parents signed their teen up for and he found out some interesting things about what the smartest kids in the system were capable of. Completely blows the stereotypes of top test scorers out of the water).

            The kids choose whatever organization they want to volunteer and help, so it’s not a type of bondage or slavery if the student signed up for the class and then has the liberty to choose where they will help out for 20 hours a month (and some say at the end of the year surveys the students proclaim the volunteerism as the most life changing and most wanted to do it again). You know judges are doing this with city gardens etc. and for whatever reasons the juvenile delinquents who do it have a low rate of getting in trouble again. I know I would take pulling weeds over living at a juvy detention center.

            So I think the intent of whatever mandatory volunteerism is out there is it’s a reality but maybe not in the sense you see it. It’s meant to heal not harm (like a physician) and usually there is an alternative offered to the student or criminal, but one thing is certain….it works and they choose to become better people.

          • kjindal

            for a voluntary attending MD at a hospital, there is no “job clock” as we are self-employed. The responsibility to care for those admitted patients who otherwise do not have a doctor is due to the relationship the MD has w/the hospital. Caring for the uninsured / underinsured (e.g. Medicaid) is not “because the law makes me”. I do not get arrested for not caring for such patients. The police don’t come to my office & take me away in handcuffs if I refuse to accept Medicaid, as many many doctors do.
            I personally do feel some responsibility to care for those less fortunate, and do feel I have been fortunate in my opportunities (and have leveraged them appropriately to make a relatively good living, albeit working hard for it). But when my good intentions are turned into others’ “rights” to my services I feel cheated. Remember that one party cannot claim a “right” to some service with the other partys’ right to freedom being infringed on.

          • https://www.facebook.com/arobert6 Alice Robertson

            So you can legally walk away from a patient in need? I don’t think so. Yet your point about “rights” is fair enough but it goes way beyond the analogy here. I think the second part of your post is worth dwelling on.

            Quite frankly, I don’t truly see healthcare as a human right (catastrophic care yes…and that’s where the regulation came in because your predecessor’s really left current doctors in a right mess with their neglect, greed….fraud. If a segment hadn’t been so self-serving we wouldn’t have this regulatory mess and now we have the problem with a segment of patients), but I see it as a segment of the rest is a human responsibility (but that needs refined). I see little accountability in this Age of Entitlement.

          • guest

            “Voluntary” is when you could choose not to do it, no one is asking you to do it, but you do it anyway. If there’s a quid pro quo (the hospital gives me admitting rights in exchange for my taking turns looking after others’ patients) then it’s not voluntary.

          • Mengles

            Oxymoron – seems to describe Alice and Sherry to the t.

          • https://www.facebook.com/arobert6 Alice Robertson

            Mengles do you know what an Eejet is? I would like to propose you either change your online posting name to that, or man up and do your insults under your real name. What a wimp you are!:) If you can’t debate on the facts and refuse to give your name how about you stop demeaning people all over online on a peronal level just because they had the audacity to disagree with you. You are giving your colleagues a bad name. One is inclined to suspect you have several “Guest” accounts and go around upvoting yourself:) Just sayin’! And I am sayin’ it under my real name and picture instead of a hit and run by a blooomi[ blue balking bouncing ball gravitar!

          • Cyndee Malowitz

            U.S. physicians are only required to complete a one year residency. They are absolutely not required to finish a residency nor become board certified in a specialty. There are plenty of general practitioners in my area.

            BTW – NPs aren’t paid a dime for their clinical hours. They deserve a paid residency just as much as the physicians.

          • pbat

            Neither are 3rd or 4th year med students. I’m not sure where you live, but I have met very very few physicians practicing out there with only 1 year of residency. Are you in a very rural area?

          • https://www.facebook.com/arobert6 Alice Robertson

            That’s interesting. And really interesting you got 3 Dislikes. I always scratch my head at that, I mean who the heck is so angry they would anonymously click that stupid button that shouldn’t even be here. Just defend your position under that silly blue gravitar with words….ugh….they should put the title of Eejet above that button to label the person who hits it. It’s an effort to discourage open dialogue.

            Oh yes about what you shared. My friend is an MD who isn’t board certified. If what I have read about all the “Don’t use any doctor who isn’t board certified” is true, then why do studies show there isn’t really much difference as far as treatment and it’s a type of political strong arm where doctors definitely could proclaim it’s a mandatory mess. There are good past threads on this topic.

            Cyndee….there is a hilarious thread on this site where they discussed the board certification. Doctors were sharing about colleagues taking ADHD drugs like Adderall and doctors said there should be a drug test before the test. Then the one that was really funny was the doctor who said his friend had a pair of James Bond type-like glasses that literally could take pictures of the tests. I was reading the posts on my cellphone at the Cleveland Clinic and the specialist doing a procedure on my daughter’s neck said he wanted me to read them to him (because I was laughing). So I tried to read to him in-between giggles and he got a very serious look on his face and said, “I could use a pair of those glasses.” He was dead serious, then he went on and on about those boards. Then someone posted about alphabetized names testing on the first day where those with later initials of their last name BUY the test questions off those who could get a picture or remember the harder questions (how unfair if your last name begins with A through maybe G:)

            But I am absolutely certain no doctor reading this would ever engage in such nonsense. Yes, I am quite convinced they are far too sophisticated to engage in THAT but they CAN hit the dislike button:)

          • kjindal

            you are so misinformed and ignorant on this issue that I will let it stand on its idiocy.

          • Mengles

            And trust me, she has more than enough of it to last a lifetime.

          • Mengles

            “U.S. physicians are only required to complete a one year residency. They are absolutely not required to finish a residency nor become board certified in a specialty.” —- Proof that you are just blowing smoke and know absolutely nothing about what you’re talking about.

          • Jason Simpson

            Cyndee once again showing your ignorance.

            Name one physician who has hospital privileges with only a 1 year residency.

            Name one physician who is credentialed with an insurance company who has a 1 year residency.

            Yes, you can “practice medicine” with a 1 year residency if you mean by “practicing medicine” that you are a consultant with no patients or a research scientist. Otherwise, you aint gettin anywhere close to treating patients.

            Unlike the NP cracker jack box “clinicals”, MDs have to put in real work in order to practice.

          • Tiredoc

            The third and fourth years of medical school are akin to the NP clinical hours, only longer. They are not paid, to say the least.

            There should be some mechanism within the nursing track to achieve MD equivalency and access to the MD residency programs. There should not be NP residency programs.

            If the DRn programs manage it, then taking the USMLE boards at the end would make sense.

            The problem that I have as a physician with NPs in general is the educational and cultural emphasis of protocol first. If I were to compare the prevailing attitude to specialty of medicine, NP’s act like cardiologists.

          • kjindal

            medical students PAY big bucks for the privilege of shadowing interns & residents in their 3rd year, and then assuming some independence in the 4th year. Of course, this is aside from the reality that the screening process for admission is extremely competitive to med school, whereas NP students are generally a more mixed bag.

            Then what I notice where I work, NP students are “supervised” by mediocre uncaring and lazy NPs (in this case who really probably shouldn’t be legally entitled to prescribe, for example, narcotics) who send their students to see their patients, write their meaningless and lengthy notes, then cosign their notes, all the while not even witnessing a physical examination or any other evidence of actual thought and judgment. It seems that this is the model of apprenticeship for NPs. I cannot imagine them surviving even a week as an intern at a busy NYC hospital, e.g. Bellevue, surrounded by nervous, but educated & highly intelligent, medical students, interns, residents, and attending physicians.

          • Tiredoc

            There is a wide variance in the training provided to medical students as well. The main reason that MD schools generate doctors of reasonable quality is that they are highly selective at the outset.

            The high selectivity comes at a price. There are different kinds of intelligence. The best doctors have high IQs, but also high emotional intelligence, creative intelligence and social intelligence. Entry into medical school screens for IQ only.

            It is difficult to judge the quality of a doctor. Do we judge their productivity, their accuracy, their ability to diagnose oddities, their ability to treat oddities? The science of judging doctor quality is in its infancy.

            Would you prefer a brilliant doctor who forges ahead even if they’re wrong or an ignorant doctor who has the emotional intelligence to ask for help? How about a creative doctor who never does the same thing twice, and wouldn’t be able to replicate a successful treatment? Then there’s the mature, well-balanced diagnostician who’s excellent in everything but has the personality of a circular saw and patients won’t listen.

            Don’t confuse culture with trainability. There are NPs that can perform. There are MDs that can’t. I agree that the NP culture is toxic, from the perpetual inferiority complex to the slavish devotion to paperwork.

            Osteopaths forged their place by emphasizing their unique role. As an MD who learned DO manipulation to treat my patients, I respect that role.

            For NPs to achieve parity, there needs to be something unique about the nursing pathway that both patients and fellow practitioners of a different stripe can identify. “I’m as good as” always breaks down when answered with “then why didn’t you get an MD?”

    • Tiredoc

      You are correct that hospitals that train residents receive ample remuneration from CMS that is specifically labeled as for resident training. You are incorrect is assuming that residency requires this funding for training purposes. The funding is for the hospital to be able to see uninsured patients. Like many other bizarre things about the US medical system, the name for the funding doesn’t match the purpose. Do you really think paying MDs slightly above minimum wage for doing all the work no one wants to do actually costs money? That a couple lectures a week from volunteer teachers really costs $1 million dollars?

    • Mengles

      You know absolutely NOTHING about residency and the process of training doctors. Doctors are not your indentured servants. Get a life.

    • Jason Simpson

      “docs can pretty much charge what they want to in many markets”

      LMAO what a fool! Yeah I’m sure my doc can just call up Blue Cross/Blue Shield and tell them “hey I’ve decided to increase my charge for a visit from 50 to 75! I hope you dont mind!”

      Ask Cyndee how well that is going to work out!

      LMAO

  • Guest

    “What good is Medicaid expansion if no doctor sees Medicaid patients?”

    A lot of people were actually asking this question BEFORE the Democrats passed the bill to see what was in it.

    They were decried as “racists”.

    • guest

      Each state can choose if they want federal money for medicaid. If so, they can use it to build county hospitals that would do inpatient and outpatient work with medicaid pats. the docs would be paid by the county as well through in part of the federal funds.

  • guest

    A concern i have with Obamacare is that people with marginal incomes are getting huge federal subsidies that basically pay almost in full for their care. I think people should have to pay for their insurance. The example given in the Wall Street Journal was a couple that made $24000 per year in Ohio. Not a great salary but their healthcare costs are going from $1363 per month to I believe $21. I am hoping the ACA is not going to turn into welfare. I think you get what you pay for.

    • disqus_z9d5lJX92l

      And what you don’t pay for, you often don’t value. People need to have some skin in the game.

      • guest

        yes that is a good point. there is a disincentive of making $63000 or over in Ohio under the example i read. in WSJ. At $63000 one is paying 100 percent of the cost. Does not make sense to me either.

  • Kaya5255

    Have experienced this first-hand with my Mom. Her physician of over 30 years dropped her like a hot potato when she became eligible for medicaid. It was hell trying to find a new physician who would accept medicaid. Fortunately, Mom’s in exceptional health and didn’t require any interventions. When I did finally find a physician who would accept her, I had to sign an agreement that I’d pay, if the claim was rejected.

  • Cyndee Malowitz

    I know several NPs who own practices and almost all of their patients are on Medicaid. They are reimbursed less than physicians for the same services, yet physicians won’t even accept Medicaid due to low reimbursements. See anything wrong with this picture?

    • Jason Simpson

      Why the hell would I pay the same to see a nurse when I can get a real doctor instead?

      • Guest

        I know, right? The more I look back on my experiences with NPs I cannot imagine why someone would trust one. People have no idea how totally clueless they are.

  • PLOTCH

    Notice how an artificially created entity named money is always used as
    the excuse that we as humans cannot help others because somehow we are
    slaves to the fictitious money god. It is simply an excuse for really
    saying, we have limited resources on this planet and we cannot help everyone out, too bad for you.

    The question remains then why is human life on this planet anyway? None
    of it really matters in the end as we all leave it all anyway. So why
    not make it bearable for others if this is all there is? Are we as a
    race that dumb that keeps us from asking, that just maybe we can think
    beyond money for a change and just do something good for someone else at
    my expense because it is simply right?

    Now for you money
    worshippers here is a workable plan from the New England Journal of
    Medicine that should have been implemented 20 years ago.

    Here is a small abstract of the problem from the New England Journal of Medicine.

    “Reprinted from the New England Journal of Medicine 320:102-108 (January 12), 1989.

    Abstract:

    Our health care system is failing. Tens of millions of people are
    uninsured, costs are sky-rocketing, and the bureaucracy is expanding.
    Patchwork reforms succeed only in exchanging old problems for new ones.
    It is time for basic change in American medicine. We propose a national
    health program that would (1) fully cover everyone under a single,
    comprehensive public insurance program; (2) pay hospitals and nursing
    homes a total (global) annual amount to cover all operating expenses;
    (3) fund capital costs through separate appropriations; (4) pay for
    physicians services and ambulatory services in any of three ways:
    through fee-for-service payments with a simplified fee schedule and
    mandatory acceptance of the national health program payment as the total
    payment for a service or procedure (assignment), through global budgets
    for hospitals and clinics employing salaried physicians, or on a per
    capital basis (capitation); (5) be funded, at least initially, from the
    same sources as at present, but with payments disbursed from a single
    pool; and (6) contain costs through savings on billing and bureaucracy,
    improved health planning, and the ability of the national health
    program, as the single payer for services to establish overall spending
    limits. Through this proposal, we hope to provide a pragmatic framework
    for public debate of fundamental health-policy reform. (N Engl J Med
    1989; 320: 102-8.)”.

    Notice the date was from 1989, why so long letting a problem like this fester?

    And for those negative commentators with old and tired argument, who is
    going to pay for this?, well, the abstract gives a workable solution do
    you not think?

    • Guest

      you reap what you sow in a free market economy and many people are left
      behind in this type of economic system as opposed to socialism that
      takes care of everyone.

  • PLOTCH

    Notice how an artificially created entity named money is always used as
    the excuse that we as humans cannot help others because somehow we are
    slaves to the fictitious money god. It is simply an excuse for really
    saying, we have limited resources on this planet and we cannot help everyone out, too bad for you.

    The question remains then why is human life on this planet anyway? None
    of it really matters in the end as we all leave it all anyway. So why
    not make it bearable for others if this is all there is? Are we as a
    race that dumb that keeps us from asking, that just maybe we can think
    beyond money for a change and just do something good for someone else at
    my expense because it is simply right?

    Now for you money
    worshippers here is a workable plan from the New England Journal of
    Medicine that should have been implemented 20 years ago.

    Here is a small abstract of the problem from the New England Journal of Medicine.

    “Reprinted from the New England Journal of Medicine 320:102-108 (January 12), 1989.

    Abstract:

    Our health care system is failing. Tens of millions of people are
    uninsured, costs are sky-rocketing, and the bureaucracy is expanding.
    Patchwork reforms succeed only in exchanging old problems for new ones.
    It is time for basic change in American medicine. We propose a national
    health program that would (1) fully cover everyone under a single,
    comprehensive public insurance program; (2) pay hospitals and nursing
    homes a total (global) annual amount to cover all operating expenses;
    (3) fund capital costs through separate appropriations; (4) pay for
    physicians services and ambulatory services in any of three ways:
    through fee-for-service payments with a simplified fee schedule and
    mandatory acceptance of the national health program payment as the total
    payment for a service or procedure (assignment), through global budgets
    for hospitals and clinics employing salaried physicians, or on a per
    capital basis (capitation); (5) be funded, at least initially, from the
    same sources as at present, but with payments disbursed from a single
    pool; and (6) contain costs through savings on billing and bureaucracy,
    improved health planning, and the ability of the national health
    program, as the single payer for services to establish overall spending
    limits. Through this proposal, we hope to provide a pragmatic framework
    for public debate of fundamental health-policy reform. (N Engl J Med
    1989; 320: 102-8.)”.

    Notice the date was from 1989, why so long letting a problem like this fester?

    And for those negative commentators with old and tired argument, who is
    going to pay for this?, well, the abstract gives a workable solution do
    you not think?

    • https://www.facebook.com/arobert6 Alice Robertson

      I think you can’t sum it up as easily as this. Yet you sound young and passionate? One caveat though is I am not sure if you encouraged responses (I hope you did), although I am sure you meant to challenge?

      I am no worshiper of money. I am just a mom with a child with cancer who keeps her eye on how the system is going (and having lived in the UK gave me a holy terror about single payer)

      But have you gone back even further in history and read the intent of Medicare when it started and life expectancy was about age 67… and people weighed about half of we do now… and we didn’t have rot mouth from Mountain Dew and diabetes? Omgoodness….did I just say this: Ha! Or before patients were demanding every test known to mankind whether they need it or not and whether or not it will harm them?

      But the bottomline is we can’t afford the smorgasbord as it is:)

  • http://nickysworld.wordpress.com/ Nicky

    Which is why I believe PA’s and NP’s will profit under Obamacare and they will be the ones making the most money

    • Jason Simpson

      PAs and NPs have a choice on whether or not to accept Medicaid. Tell me why they would agree to take a 50 percent paycut in order to take Medicaid?

      I’ve got news for you — PAs and NPs are just as “greedy” as the docs are and they refuse medicaid at the same rates.

      • Guest

        Seems like a lot of them do take Medicaid, possibly because the independent ones don’t have another option at this time. Paying patients and those with insurance are not going to choose a midlevel. Those without a choice may get stuck with one but I think Nicky is right in part. They will pick up all the undesirable volume and likely make good money (from volume).

        • Cyndee Malowitz

          I’m a full fledged nurse practitioner – I’m NOT a mid-level. I’m not even sure what that is.

          You are WRONG – thousands of paying and insured patients would rather see me over a physician. Every day there’s at least one patient who wants me to become their primary care provider.

          • querywoman

            What you are competent in is general practice! From years of experience! A good GP gets and keeps patients.

      • http://nickysworld.wordpress.com/ Nicky

        The way I see it, PA’s and NP’s will be the ones to profit under Obamacare. They will make the money regardless of what patients they get. Even if they get Medicaid patients, they’ll make the money because of the volume of Medicaid patients that they will get. It translates into dollars and money for them.

  • ephraim_1

    What is happening already in Brooklyn is that physicians are staffing offices and Urgent Care Centers with Physician Assistants, who see patients without the physician even being present during the entire office hours. The physician’s name of course is on the prescription pad and the physician bills the insurance company.There is a Pediatric D.O.here in Brooklyn who runs several facilities simultaneously, and what is troubling is that the advertisements for the facilities solicit adult and pediatric patients. This is pushing the clinical -commercial envelope to questionable limits. Apparently the Affordable Care Act will produce many more such clinically questionable enterprises as physicians attempt to achieve certain levels of financial viability.

    • guest

      And if the NPs and PAs get their wish that they’ve been lobbying for, to get paid the same as real doctors, then these offices and doc-in-a-boxes will start being staffed by pharmacists or nursing assistants. We’ll keep moving “FORWARD” … to the lowest common denominator.

    • Jenness

      This is happening all over. As a Physician Liaison who only coaches & consults independent solo practitioners on how they can stay in business and thrive in our current economy & healthcare changes, I’m appalled at how many physicians have asked for my help and I’ve had to turn them down because they end up revealing they spend little to no time at all in clinic and the PA & NP’s are left to do everything. I’ve never had an American educated physician do this, only foreign trained and they see nothing at all unethical in it and in several occasions have argued with me and been highly insulted when I gently had to turn down helping them. I was told once that it didn’t matter because he was only “here” (aka in the US) until he hit his endgame goal and he figured he could get enough income to retire in his country and live like a king forever. When I thought about how many clinics he had, the lack of educated staff & his income goal I realized that for him, it would only be 5 years max in practice here in the states and that isn’t enough time for Medical boards to even get him on their radar. He would be well gone, well funded, US patients used as guinea pigs so he could practice ‘real’ medicine in his own country leaving us with a legacy that I’m sure was not intended but allowed by the way our system is being setup.

      • beautyis everywhere

        That’s how all the psych snakepits (and the corresponding outpatient state “clinics”) always ran too….no doctor anywhere and when one did show up the idea was they were there for their own selfish purposes, and everything they did and said STANK of it. Scandalous history there, and the unnecessary suffering this corruption created….is unspeakable.

  • artful

    We’re about to find out!
    Will the young adults, needed to finance PPACA, spend their “excess money” if they are employed on something they almost know they won’t use, when if they do they can pay a $750 fine if they end up in an ER? They are billed more now if this happens but they don’t pay that, but they’ll do it now “to win one for the Gipper”? Since the “Gipper” promises to subsidize some of them “Later on taxes” do most even do returns.
    If they don’t where will the money come from for that has to happen even in a single pay system and we are broke because of health care now!

  • https://www.facebook.com/arobert6 Alice Robertson

    I was just reading about the Oregon study and it appears thought worthy that the very patients best get their act together because at least in Oregon the data isn’t looking good for slothful patients who overuse the system and refuse to help or deprive themselves of the good things in life.. I am putting a snippet below because it ties in with the Medicaid mess that goes far beyond doctors denying Medicaid patients. It could be that Medicaid not only has low reimbursal, but the type of people it tends to create are a right mess:): It may take a progressive type of program like Newark is using to get a middleman to help these people (in one case a person running up monstrous ER bills was found by a type of middleman intercessor to be living in a moldy apartment. Move the person out and the problem goes away. The savings are fantastic and their health improves. A win/win because the system was tweaked to over personal help, not just hit and run help.

    Snippet (the lottery winners were because far too many qualified and Oregon used a lottery system to select who entered into the program):

    The data after year one seemed promising. The lottery winners used
    more health services and got more preventive care, including cholesterol
    screenings, flu shots, and mammograms.

    But the Oregon study looked at more than just health usage after year
    two. It also examined health outcomes. The researchers measured
    enrollees’ blood pressure, cholesterol, and blood sugar levels. These
    metrics are risk factors for stroke, heart disease, and diabetes — all
    of which can be managed or prevented with early intervention.

    The results? Although Medicaid patients used 35 percent more health
    services, the coverage appeared to have no effect on blood pressure,
    high cholesterol or elevated blood sugar. In the researchers’ words,
    “Medicaid coverage generated no significant improvements in measured
    physical health outcomes in the first two years.”

    With “no significant improvements” in health outcomes, it’s hard to
    see how being on Medicaid is any better than being uninsured.

    The behavior of many Oregonians who actually qualified for Medicaid
    suggests as much. Some 40 percent of those who won the Medicaid lottery —
    and thus could have received free coverage — didn’t bother to enroll.

    Previous studies have found that Medicaid patients actually fare
    worse than those with private insurance — or even those without
    insurance.

    A 2010 study of 900,000 surgical cases, for instance, found that
    Medicaid patients had the longest hospital stays, the highest total
    hospital costs, and the highest risk of death. And according to a report
    published in the journal Cancer, Medicaid patients with the
    publication’s namesake disease are two to three times more likely to die
    than other patients.

    A 2011 study found that Medicaid patients were 8.1 percent less
    likely to be alive ten years after a lung transplant, compared to those
    with private insurance and those without insurance.

  • Jenness

    The reason our practice does not see Medicaid patients is due to the reimbursement being less than the cost of seeing the patient plain and simple. The amount of paperwork required and skill level of the employees that must track, fill out and manage the paperwork is quite high versus the small amount reimbursed even for complex E/M and procedure services. The reimbursement almost never factors in the cost of supplies from paper, tongue depressors, alcohol swabs, gel, needles, HIPAA compliant shredding and EMR costs which have all risen exponentially w/all suppliers w/zero reimbursement increase adjustment.

    We just started a requirement that has all patients sign a form that states the insurance was never meant to cover the entire cost of their healthcare but as a subsidy. This factual statement only seems to infuriate the patients that consistently want free care, demand to show late or not show to appointments with no penalty and in general are very difficult patients. It does not seem to upset the patients that have private insurance or even our private pay patients. There really is a large segment of the population that wants to be taken care of, not work, not create, not contribute and have everything handed to them for free.

    This is the root of the problem. not big bad insurers. As business owners they can only pay for what they receive back in employer and employee monthly payments. Simple math shows that if our unemployment is sky high with a large segment of the working only working PT w/no ability to pay for benefits or get benefits then companies must cut back all reimbursements to fit the income they are receiving from the shrinking workforce. More people working & a better economy solves a lot of ills – not welfare-minded programs that only seem to dilute care and quality to appeal to masses to bandaid issues, not cure them.

    • Guest

      The other problem with growing our entitlement programs is that a lot of those people take on the mindset that they’re “entitled” to have everything they want, for free. So that then it’s hard to even start moving them into the workforce, since they’ll grouse that it’s “unfaaaaair” that now that they’re earning money, they’ll actually have to start paying a bit towards their own food/housing/healthcare/obamaphones…

      • querywoman

        Well, guest, as a former welfare worker, I agree with you on that. One of the problems with the really low income or zero income types who get food stamps, housing assistance, etc., is that when they get a job, they don’t want to spend their money for necessities!
        Their food stamps are cut and their housing assistance raised!
        When I still worked and had to give an oral speech to welfare clients before they were interviewed, I started including stuff like, “if your income goes up, your food stamps will probably go down. If you spend a bunch of money to move, that’s not an acceptable deduction for food stamps.”

        Most of us who post on this blog probably aren’t really rich or poor. Most of pay our utility bills by setting aside a certain amount of money for them.

    • querywoman

      I don’t expect free care. I expect to pay a certain portion. What I don’t like is when I arrive to pay a certain amount of money for a specific illness and then barraged with upselling into costly screening procedures.
      Insurance was intended to be a supplement, yes, and spread the risk.
      Whatever fees you charge, you can charge because of the very existence of third party payers. Remember, in the good old days, doctors billed, took produce, and worked free one day per week.
      Or did they?

      • Jenness

        I think if you want someone to do that hell job for free one day a week for produce you damned sure should be willing to work for free for food one day a week yourself. If not, then you’ve got some nerve lady.

        All I do is work with Physicians and last quarter of 2012 a record number of physicians declared bankruptcy and committed suicide. Now..they kill themselves at higher rates so that isn’t really a shocker, but being bankrupt is. Plus, you have to realize that every lawsuit, and each doctor I know gets sued constantly, creates a new pain in the a** protocol that all patients have to suffer with. You don’t like a screening procedure or additional stack of papers to sign, well bet your bottom dollar one patient caused it. Your doctor doesn’t have to be guilty at all. Even if he’s completely innocent it is cheaper with some insurers to settle than the cost of court and there are many scumbag lawyers who only sue doctors and pay other doctors huge money to write negatively about patient outcomes. It will only get worse under Obamacare because they are upping reimbursements for all diagnostic procedures & tests. You are going to be tested for everything before you are ever treated to”save money” which is ridiculous as it is really a money waster. I just spoke to one doctor who had to scream at the insurance company who was saying that the patient would be required to get a lesser treatment, like aspirin, for a debilitating migraine that the doctor wanted an emergency MRI for because she feared the patient was having an aneurysm. The doctor had to spell it out and let them know that she was going to thoroughly document and advise the family that insurance would only pay or advocate a treatment that would had a large chance of killing their loved one and that in her medical opinion, not the opinion of a desk jockey who was not a medical doctor & had no medical school education, they were sending their loved one to their death.

        That is reality lady, so unless you want real care driven by physicians and medical knowledge and not money then you probably should vote against Obamacare and stick up for physicians and not demand they give you one day free a week when they are already working 7 days a week, on call and get paid less for their time than any other professional who hasn’t spent an additional 8 years of their life in school or hellish internships.

        • querywoman

          Why so volatile towards me? I didn’t make any of these policies, and I have always paid for my own medical care.
          If it’s such a “hell job,” there are still people begging to get into medical schools.
          I’ve worked uncompensated overtime on plenty of “hell jobs,” which paid less than doctors make. Yes, I know why it’s like to work free, and not have the government enforce overtime laws. When I worked for a federal agency and a state agency, I generally got paid for my work.
          You must know some really bad doctors if they are constantly getting sued! Malpractice suits are very difficult to bring.
          Medical debt could have driven me to bankruptcy, but I know that most personal bankruptcies are unnecessary, and I am mostly judgment proof.
          I spoke of what medicine may have been once, and I doubt that it is anymore. I doubt that many doctors ever worked one free day per week.
          Most medical doctors have a much higher standard of living than their predecessors, much nicer houses, etc.
          However, I don’t think what we think medical practices really existed until the 20th century. Prior to that, both doctors and hospitals were dreaded. I’ll have to research that more.
          The early 20th century brought stuff like antibiotics and insulin, which provided good relief to some old problems.
          I could list many ways doctors ripped off my private insurance companies, when I worked, and how I got sold preventive this-or-that only to still be sick with whatever my original complaints were and not have any money left for them!
          I have worked sick and go to ER’s with stuff I told private doctors about in their own offices.
          What you are are calling Obamacare, or the Affordable Care Act, is a federal statute that was never even on the ballot. Many hot issues are never on the ballot, like abortion and Daylight Savings Time. Our elected reps passed it into law.
          Health care should never have become a multi-layered payment system in this country, People started out with no insurance, then a few got it, and it was usually tied to employment, then everyone was expected to pay the higher rates that the very existence of an insurance system enabled.
          Nobody needs health insurance; most people need health care! Since I went on Medicare about ten years ago, most of my problems with getting health care disappeared. However, I am not one of those to deny other people the care I get.
          Most doctors have a much better lifestyle than their predecessors 75 years ago!

        • querywoman

          This site does not like hyperlinks, so please Google, “examiner,” and this article, “Why do physicians have the highest suicide rate in the USA ?”
          It states that, in the early 1950s, when doctors made house calls and really knew their patients, the doctor suicide rate was low.
          Few people in the 1950s had insurance that covered doctor visits. There was also much less technology.
          Would an MRI been ordered for a serious headache in the 1950s? Would the doctor have just prescribed strong narcotics?
          Along with the burgeoning insurance industry, technology has grown. To say that modern medicine has changed rapidly from its past is an understatement.
          How many people can afford all these tests in addition to the doctor’s fees? Insurance enabled all this medical technology too.
          Life expectancy is more also, but many of us just want a doctor to talk to us and evaluate our symptoms, without all the tests.
          A current US medical student graduates from a medical school loaded with all kinds of technology. When you have the technology, it’s tempting and scary not to use it. How many recent medical school grads can afford equipment?
          Insurance companies question the constant ordering of expensive tests.
          So medicine has really, really changed, with all this expensive equipment, and the coming of massive educational loans.
          We would not have all the medical technology today without insurance companies.
          I saw a TV special once on how three hospitals in one town had the same piece of costly new medical equipment. There was only a need for one hospital to have it. The business community, through private insurance, paid for the equipment.
          Prenatal screening and hospital labor, as we know the process in the United States, are also socially new.
          So, as I type this, I am musing how all this burgeoning technology, insurance, and educational school loan debt helped turned modern American medicine into a mess!

    • querywoman

      As for legalities, do you discuss how you will handle continuing care if a patient cannot keep paying? Are you familiar with the laws for medical abandonment.
      Most Medicaid patients are best served at public hospitals and clinics attached to medical schools, since the doctors get additional funding for their salaries.
      Private doctors who do take Medicaid do lose money on it. The better private doctors simply limit Medicaid to a percentage of their practices.

      • Jenness

        I suggest defunding Obamacare immediately and focus on the real problem of small businesses & jobs. There will never be 100% free healthcare for all because that is not feasible. There will be people who can’t pay who will have to travel to free clinics & government supported hospitals and they will have to endure long waits and waiting lists for procedures. That is never going to change & the ones that envision that live in a fantasy land.

        there should be ZERO free healthcare given to anyone without an ID who is not a citizen of the United States, Visa holder or green card holder. unless they are dying and their checkout should be to a holding facility to be shipped back to their country. People have misinterpreted “Give me your tired, your hungry and your poor…” and forget the “hard work for the chance of a better life” part of it. It isn’t “countries of the world send us your laziest criminals, the infirm and the insane and we’ll force a very small percentage of the population to work like donkeys so your people can do nothing all day and suck us dry and contribute nothing at all to the world.

        And your former comment about only bad doctors getting sued is a joke. Most doctors get lawsuits constantly, it costs nothing at all to find an ambulance chaser who will work for free, send you to paid off doctors, use false MRI & surgical reports to extort money from the doctor who pays out of pocket expense. They just are gambling for a settlement and after the doctor has paid his malpractice deductible, usually a fee of thousands just like you have co-insurance or auto deductible when in a wreck just for attorneys to get started, then all the ambulance chaser does is bombard with paperwork and threats hoping for the doctor to settle out of court because they know they have no case if it goes to court. It’s gambling but the only person who pays is the doctor and the insurance company.

        Why do medical students still sign up for medical school? Because no one tells them this.

        It’s also why they have the highest rate of suicide among any other profession.

        • querywoman

          I’ll research the incidence of malpractice. I doubt that it’s up that much.
          I once attended a large church with doctors, lawyers, other professionals, and the homeless, etc. Some legal support-type people with whom I had lunch once said clearly guilty malpractice is settled out of court.
          If a doctor believes he or she is truly innocent of malpractice, let ‘em go to court. I quote Lady MacBeth, “Screw your courage to the sticking point.”
          In my state, malpractice settled out of court is not reported on the state medical board’s public info section.
          I live with malpractice or under practice every day of my life, some of it from as long ago as 39 years. I never got to sue anyone. I live by courage and determination.
          Tort law, by its nature, is a barrier to malpractice. Malpractice is forever, not within a 2 year statute of limitations. I met a high-powered lawyer once socially, who told me that, “Misdiagnosis isn’t necessarily malpractice.” To be able to sue, one has to have a good grip on the problem and an alternative scenario. Very elusive in most illnesses!
          Now, you suggest defunding Obamacare. The Affordable Care Act is now a federal statute. Write your elected officials about it. Ask them why it was never on a ballot. We’ll see how it plays out, and I feel confident it will be an administrative night and day mare for many years.
          As for the undocumented aliens, I called a federal representative’s office once about some other issue. He told me that ER’s are supposed to provide care, and not ask about citizenship or money, at first.
          There are programs like Medicaid that pay for immigrant women, with or without papers to have babies. I used to enroll people for Texas Medicaid, which would pay for an undocumented alien’s hospitalization days only in labor and delivery.
          Without the Medicaid dollars, hospitals have to eat the bills out of local funds, etc. So they pressure politicians into paying for them through Medicaid.
          Immigration is a federal problem, and the state governments and the medical providers turn to the federal government to pay the bills. Without federal money, the way the current US health situation is, the aliens would still get free care at the ER’s! That would take a lot of law changes!
          My only victory against malpractice is my survival and being able to live more comfortably, though I’m suffering from long-time medical neglect at this very instant. Plus, the internet has provided me a new voice for my stories.
          As for physician suicides, I just did some research. Okay, they do have a high rate. But did they try Prozac first? They tell patients to take antidepressants for everything. It’s obvious antidepressants are not the panacea the meds crank them up to be. Are physicians even willing to humble themselves and get mental health treatment?

          Doctors aren’t the only workers who commit suicide. How about police? The military?
          I noticed a lot of medical people, including dentists and vets, have high suicide rates on one list. Do they have access to drugs and other knowledge of how to do it easily?
          I noticed on one list that urban planners have high suicide rates. I used to teach Sunday school to the children of upper middle class professionals, including doctors, lawyers, programmers, etc.
          One of my kids with the worst problems had a mom who was an urban planner. Her job was dull and boring.

          • Jenness

            You’ve made many anti-physician statements stemming from your own personal situation which I understand must be horrible for you to only have the internet as your voice as you stated.

            Your obvious hatred against physicians is misplaced. Your statement “But did they try Prozac first? They tell patients to take antidepressants for everything. It’s obvious antidepressants are not the panacea the meds crank them up to be. Are physicians even willing to humble themselves and get mental health treatment?” is rather cruel and vicious.

            Inferring that doctors are total hypocrites who only want to push drugs down patients throats and actually feel superior to everyone else is unhealthy. Also your flawed thinking that because they have access to drugs & other knowledge about fatal injury causes makes them kill themselves more – makes zero sense. It doesn’t take a mental giant to slit ones wrists or put a gun in ones mouth.

            I would step away from the keyboard and your own impotent rage against your own medical conditions and get some healing breath.

          • querywoman

            Wow! You are anti-patient!
            Hey, I am not the only one who has been ripped off and mistreated by doctors! Stories are all over this blog and elsewhere!
            It’s very frustrating not to have any viable complaint system against doctors! Malpractice suits are very difficult to bring!
            I currently have some very good doctors, who are helping me get better gradually.
            My original post here started with, “I don’t expect free care,” and you hit me with a barrage of stuff as a defense against issues I didn’t even mention.

  • booth powers

    It’s a very simple reason why doctors don’t see Medicaid patients: payment. Doctors made the very logical decision that taking Medicaid just wasn’t worth the effort. No one should be surprised by this very rational decision.

  • Annie

    Mean Ninguem. You just shot her unicorn :-(

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