As a general internist, I see some medi-cal only patients, but can't get anyone to see them for specialty care. I often have to just tell them- go down to the county hospital and try to get into the urology clinic.

Most physicians lose money on every Medicaid patient, and rely on other payers to balance this out. Increasing the proportion of medicaid patients will force more docs to drop out. Not only will there be fewer MDs to see the new recipients of taxpayer largess, but the current Medicaid patients will also have a harder time finding a physician. So I would predict that access would be more limited than it is CURRENTLY.

In addition, the whole Medicaid system is fraught with moral hazard. When there is no onus on the individual patient to engage in a healthy lifestyle, curb poor choices, show up on time for appointments (or show up at all), and stick to a prescribed treatment plan, the resultant waste of resources knows no bounds. As a physician and taxpayer, I find this to be the most frustrating aspect of Medicaid. The poor reimbursement is just icing on the cake.

Will access be curtailed? You better believe it.

Please tell everyone in congress that these doomed to fail entitlements are 60 trillion dollars in debt, and that unless they are phased out, they will destroy our country. Are we going to adhere to the Constitution and be a free country based on the free market, or are we going to be a socialist nation with a dramatically lower standard of living? Please do what you can to fight this. Your children's and their children's future is at stake.

I would be in favor, however, of an expansion of the Federal Rural Health Centers, to cover these additional patients. Patients would have means testing to develop a payment fee schedule. Those who can afford, can pay full price; those who can't would pay less. Obviously there is cost to this, but a lot less bureaucracy. The clinic cash inflow would not be tied to the physician's salaries. Physicians could be employed for a specified interval at moderate salaries (in exchange for med school loan forgiveness?). There would still be the problem of access to specialists. I personally do not have a problem with a two-tiered system - the ones getting subsidized care at the Clinics might have to wait longer to have tests or see specialists than those with private health insurance. Of course, there is still a cost to this plan, but then the subsidized helthcare patients would have access to social services at the clinic, and the clinic would be geared to help people without the wherewithal to help themselves.

The expansion of medicaid is the last thing this country needs. I currently have not seen Medicaid patients in years for numerous reasons including the ridiculously low reimbursements as well as the complete handcuffing of all clinical judgement and decision making. These programs are grossly in debt and are nothing but a drain on society and do nothing to produce positive lifestyle changes in those enrolled. Most patients were morbidly obese, drank heavily, smoked at least one pack per day, were noncompliant with recommendations and treatments, frequently no showed for appointments and were extremely demanding to my staff and myself.
There is no personal accountabilty in medicaid or any entitlement program for that matter and that is the problem. I'll continue to nott see these patients and am very close to opting out of medicare especially if there are any further cuts in reimbursements and further erosions into my decision making.

Sermo Doc 2 hit the nail on the head. What we need in this country is high deductable policies that are affordable, Hsa's that are tax deductable, and competition across state lines. Give us a tax deduction for charitable care and we will do the rest.

Thank you Senator for having the wisdom to ask us for input

Thank you, Senator Alexander for soliciting the input of the Sermo community. I would echo what was written above by basicscience and Sermo Doc 6. You continue to be a voice of reason in the Senate. There are many constructive ways forward in this health care debate. What I have witnessed from the majority party is appalling. I absolutely cannot support the expansion of Medicaid.

Send the illegal aliens back to their Countries, then let's have another look at Medicaid!

Isledoc: The illegal aliens do not qualify for medicaid, they drain the charity care resources - two very different issues.

Vermont covers a high percentage of its under 18 population with medicaid.However,they simulatanously raised PCP reimbusement to preserve access,and prevent physician offices from closing. One must be accompanied by the other.

Sermo Doc 10 ,

Why does "Vermont covers a high percentage of its under 18 population with medicaid" and not others??

How are you planning to fund the treatment of patients with schizophrenia?

Take the bureaucracy out of healthcare (both governmental and private), remove all bureaucratic obstacles for physicians to treat patients, remove the for profit insurances, give the one billion dollars (roughly?) wasted each year on administration to doctors to treat people, and you'd have plenty of money to actually treat people.

Chances you'll do this: Zero.

So how are you planning to care for patients with schizophrenia?

Vt made a decision to provide care for children,as they were cannot provide coverage for themselves.I believe coverage extends to families below 300% of federal poverty level.
I suspect ,if we could afford it we would have considered covering all citizens. A public option ,requiring income based coverage [ managed by private insurers] is offered to adults,who do not have access to other coverage.

I mean we get it, we don't need this poll, it's a rhetorical question, no doctor likes medicaid. What precisely is your alternative plan? What in your plan will help us and help patients, including those who truly can't pay, for example patients with schizophrenia? Saying 'no medicaid' is easy. Now tell us where we go from here.

Sermo Doc 11 maybe he is hear asking us for ideas to help him formulate a plan and it would be of benfit if you could add ideas to fix the things that concern you.

Second Sermo Doc 2. Expansion of a insurance scheme that doesn't even cover the cost of care won't result in improved physician acceptance.

I don't really want to overstep the boundaries of this thread. It's not like I haven't said it a million times before.

A flu test cost me approx $16 per test. Medicaid reimburses me approx $12.

Is expanding medicaid a good idea?

That is a relative question. Good compared to what?

From a physician's standpoint, Medicare and Medicare are huge headaches - more paper work, regulations, etc... All of which make it harder to take care of patients and more expensive to stay in business. The "law" says I have to purchase and print medicaid Rxs on special paper. This is just one example.

Healthcare needs to be simplified, not complicated with more government oversight and regulations.

For starters - a great move would be to scrap the CPT coding system, which is reported to be EXPANDING with CPT 10 (as opposed to the current CPT 9). The AMA does not represent physicians. They represent AMA's self interest, which include the CPT coding system. The CPT coding system is a part of the problem. Organizations like the AMA are a part of the problem

Forcing an 'insurance' plan down our throats that results in a net financial loss for the physician for every patient seen and expecting him to make it up on volume is an idea that could only come from the federal government.

Medicaid and medicare have bankrupted the country so they should be phased out. But that's not going to happen, so how to control costs and access? Higher co-pays/ deductibles for medicare. Medicaid should be synonomous with managed care.
That's my $.02 worth.

This is not an intellectually honest discussion. Who cares about Medicaid expansion when the real problem (the absence of a single payer, structured system for all Americans) is avoided. It is the elephant in the room, and is inevitable. The only question is how much pain do we want to endure before that happens?

Yes I would absolutely support expansion of medicaid as a way to get to the goal of universal coverage of our citizens - but I do not think that is the entire answer and I would even more support it as part of a reform effort. For example, I understand my fellow healer's reluctance to see patients that offer very low reimbursement rates, particularly if the reimbursement does not even cover the cost of seeing them. No one should be placed in the role of sacrificial victim, regardless of the worthiness of the cause. But why just stop at expansion. Why not link it to tort reform, such as, say, mandatory arbitration for patients seen under that program? Why not link a percentage of medicaid patients to the forgiveness of part of the student debt? Why not earmark a portion of those funds to preventative programs that may actually save money in the long run by having these patients not show up in the ED with neglected health problems that cost 500,000 to fix - and they will be fixed - rather than $500 in preventative care? Why not take the cost differential between seeing a medicaid patient and seeing an insured patient and allow physicians to take a tax credit thereon?
You all see what I mean here. These are problems with solutions, if we really have the goal of taking care of the American people, rather then doing lipservice to the idea or playing idiot-ball with dishonest political commentators.

Reimbursement rates have to rise for physicians.
Dumping more medicaid patients into the hopper without it will cause declines in care for everyone.
Many specialists already refuse medicaid. When patients get medicaid and cannot access care, they either are referred to the ED by their PCP or show up there when they are sick.
At that point they have to be treated if sick enough to require inpatient care. The on-call specialist, who may not take medicaid, has to come in to cover. Refusing to do so risks his license in most states and the threat of EMTALA fines for both facility and physician.
At some point, if able, the physicians will drop hospital coverage. Some hospitals will try to compensate by paying MDs for call, others can't afford it.
When the docs drop off call and they drop hospital privileges, no one can get care at that hospital, not just the medicaid patients.
Under the guise of improving access for all, we are on a slide towards the collapse of our system of access for many. Rural hospitals followed by smaller suburban and urban hospitals will eventually reduce care and close down due to lack of providers, as specialists join ever larger groups in large systems in urban areas to spread call burden and lower overhead to maintain income.

Just like medicare reimbursement issues, this is a double edged sword. IF we provide sufficient access and payments to keep the programs viable, the cost is going to skyrocket. If we don't provide relief for Medicare payments, primary care doctors are going to be going bankrupt if they care for medicare patients (proceudre-based specialties still seem to have aprofit margin). If we provide state insurance, it seems likely that a lot of currently-insured will simply drop their insurance and seek the "public option" -- more costs to the taxpayer.

No fault insurance, and mandatory insurance, surely heped change the picture in automobile insurance. If we can do that for liability, who not for medical care?

And when are going to get some relief on the issue of liability caps . . . I waste huge amounts of money ordering "cover your ass" tests that are simply not needed medically. When a neurosurgeon has to earn $190,000 a year just to pay his med mal insurance -- well, doesn't take a genius to figure out why neurosurgical care is so expensive. And we need rational decisionmaking protection in near-end-of-life care. I suspect we spend BILLIONS in useless care for terminally ill patients just so the family will think they've "done everything possible".

I think expanding will only work if it is "restricted" for others. I am an endocrinologist who sees lots of chronic disease. I hate generalizing, but the VAST majority (well outpacing MediCare and other insurance) of patients With MediCaid with diabetes, obesity, HTN, dyslipidemia make no apparent effort at lifestyle management and I feel that continuing to cover more and more drugs (for which I HAVE to make an appeal for) wihtout any "return from the patient- going to the gym, altering diet, etc" is essentially endorsing their lack of effort. THIS is not right. I think at the least, vaccinations and basic HTN, lipid, diabetes drugs shoulud be covered, not not "elective" drugs for erectile dysfunction, allergies, pain meds, etc. It would be one thing if it converted the patients to contributors to society, but that has not been my experience.

As the caveat to this, I DONT WANT TO BE THE WATCHDOG or making the call on if they get any of the above. If it's available to them and it is in an individual's best interest, I feel obliged to pursue it. Individual doctors should not be asked to make those decisions, it needs to be a system wide decision.


On the other hand, I see patients with true endocrine problems such as adrenal, pituitary, thyroid pathology- for these patients who have little "lifestyle control" I find it outrageous when medications are with held /denied- as an example, the locale MediCaid program just switched it's administration and a woman with history of brain tumor who is panhypopit and has diabetes insipidus with a degree of thirst mechanism disruption (a HIGH risk for getting dehydrated/hypernatremic or hyponatremic if she alters her regimen) is now told that her DDAVP is "no longer covered." I have called several times and written a letter asking how to appeal and have gotten NO response. THIS is not right.

So just "expanding MediCaid" will lkely be quite costly, mostly to endorse poor health in the majority with chronic obesity /lifestyle related disorders.

I have absolutely no desire to see a single payer Government HMO. The government's failure at primary education should be a harbinger of just how bad that will be.

We need to deregulate medicine. Patients should be able to see Nurse Practioners without physician oversight. At least 1/2 of my patients could be managed by a nurse practioneer.

And we need torte reform. None of the countries in Europe who's health care system we're trying to copy has an torte system like we do. There's a 30% savings at little cost.

Lastly, focused on medication costs as I did see some fairly recent county statistics on MediCaid (MediCal) spending. For 1 year, 11.8% of the money went to physician reimbursement- that was the statistic given. I can only assume that the remaining 88.2% when to lab testing, pharmaceuticals, ADMINISTRATION and HOSPITALIZATION. How/why should doctors be interested in the expansion of a program that screws the providers in terms of reimbursment!?

In addition for those of you who see "single payor" as the panacea that will solve my previously posted response, please tell me how "single payor" without increased physician comp solves anything?

All I can see to solve the access problem above with "single payor" without "compensation reform" is the coercive power of a central authority requiring physicians to "take all" or "take none" and go out of business.

Increasing Medicaid access is a brilliant underhanded way of doing the same thing as offering a public option AND cutting back medicare funding at the same time! Nice try.

You'd be insuring the uninsured while forcing the provider to get paid the lowest reimbursements in existence- Medicaid reimbursements.

Ask around- so far Medicaid patients could care less because they are indigent and low expectations about the care they receive- and it is the poorest quality care because only desperate physicians agree to take it. These are also the most non compliant patients and the the sickest. The middle class patient who would go after this would throw it back in the face of lawmakers once they see how horrible it is.

To propose the idea is frankly flabbergasting, but not unexpected from a bunch of lawmakers that obviously have no touch of medcial care reality and who pay God knows who to adviuse them on such policy considerations.

....now that I think about it , though, passing such a thing would make it even easier for me to start a low level concierge practice- charging the difference between Medicare reimbursements and Medicaid reimbursements to those new Medicaid patients for the provision of a poor man's concirge level of care. LOL.

If we want to focus on providing coverage to those who legitimately cannot afford to purchase coverage, and to do so without dismantling the existing insurance industry and healthcare system, expansion of Medicaid would appear to be the most logical. The unemployed and the working poor currently have no option, unless you are female and can get pregnant. Similarly, the uninsurable (prior conditions) are left without options unless they can qualify for disability. I see the Medicaid expansion as the least costly--it shouldn't cost in the $Trilllions! You can accomplish this without any of the other healthcare provisions that have been proposed.

Diatribes against illegals and against the CPT system are addressing separatable issues, and "Expansion of a insurance scheme that doesn't even cover the cost of care won't result in improved physician acceptance" fails to recognize that all proposals are very costly. But this may be the least costly.

For those who "could" afford insurance, I would support the IRS looking at a statement of insurance, and if there were none, to deduct from refund or add on to tax the proportioned "actual" cost of Medicaid, and send the taxpayer a Medicaid card.

Sermo Doc 16:

If that single payer is the US Government, look forward to making even less money with which to take care of your patients. Every system associated with healthcare that has been conjured up and run by this government has proven to be a time-wasting, money-wasting disaster. Now you want to put the entire thing in their hands?! THAT is pain.

Many probably remember not so long ago when you would go to the clinic and there was just a nurse, receptionist, and doctor. Now we have business managers, clinic managers, nursing managers, coding specialists, billing specialists, etc and the list of non-patient care employees keeps growing. Lets not even talk about the hospital. These employees have to be paid and benefited. How can the cost of health care not increase. Unfortunately we need these people because of all the red tape due to government regulations and insurance policies. Until something is done to simplify healthcare, there will be no cost savings. Expansion of medicaid will not fix the problem. It will only make it worse because now we will need more people to deal with the phone calls, bureaucratic paperwork, and entitlement that comes with the program. That doesn't even take into account that physicians are paid 10-15 cents on the dollar for services. No one will accept any more.

The way medicaid is set up, it will not work. Major changes need to be made including:
- Major tort reform to lessen litigation & malpractice insurance costs.
- Identifying conditions that the Government cannot afford to treat including conditions where expensive tx extends life only a short time.
- Making every family receiving care who are not severely mentally disabled to pay for at least a small amount of the costs, so that they are responsible.
- Make it much easier for providers to administer care - simplify the paperwork, etc.

NOOOOOOOOOOOOOOOOOOOOOOOOOOOO!!!!!!!

Illinois Medicaid pays 30% of COST of providing care. I support single payer but states will use the money for everything else then pay doctors and hospitals.

Expansion of Medicaid is simply part of the overall effort to introduce a massive new entitlement to Americans that our progeny will have to pay for.
The politicians are clever to sell this program by pandering to the basic economic philosophy of millions of Americans, i.e. "buy now and pay later" ( witness the millions of citizens with installment credit card debt). Pity our future generations who will face a huge tax to pay for prodigal Americans who live lifestyles they cannot afford.

Sermo Doc 24

"Every system associated with healthcare that has been conjured up and run by this government has proven to be.....a disaster." My Dad uses the VA system and he would politely disagree with you. So do I.

I accepted Medicaid patients for one year when I first started practicing many years ago and, for the most part, it was a disaster. The patients were sicker than non-Medicaid patients and their follow-up was poor. Many were diabetic and the only time I saw them was when a crisis developed. I was paid poorly for my services and opted out of Medicaid after one year.

the Medicaid Programs in most states i have practiced or evaluated are in Disaster. and SHOW , again , how GOvernment Medicine is a disaster..

the BEST SOLUTION , is to "GET GOVERNMENT OUT OF HEALTH CARE as Government WILL DESTROY IT" so a FP told me at one of my first meetings as med student in approx 1971... HOW did HE KNOW THIS?? easy... he had seen how Veterans Care goes from FEAST to FAMINE.

and thus this is the way of Medicare TOO.

truth is that unless you really DEAL with TORM REFORM and the REAL reasons for Escalating costs to private medicine of Government Abuse and massive rules and systems NO ONE understands anymore.... You will never solve this problem... Cost shifting from FAILED Government programs to Private Insurance is MAJOR cause of currrent disaster .. then you add the Legal Mafia ( sorry but they do NOT follow the Statutes or EVIDENCE) and really do NOT want to HELP THE TRUE and RARE (really!!) cases if malpractice .. but to take the cream out of health care into the maize of nonproductive Garbage!! /Educated Boards can help determine if any case..has credibility and not just Blocking the truth and getting "so called experts " to say,,," THEY followed the GUIDELINES and the patient DIED of Hospital Induced overdose of morphine... therefore NOTHING wrong was done! and we will never stop doing this insanity as it is the guidelines...!!!!!!!!!!!!!!!! We will and CAN cont to Kill more patients because we are sticking to strict guidelines EVEN WHEN THAT IS NOT APPROPRIATE for future patients!!" sorry but THIS IS Happening NOW!

I DO BELIEVE each community can and should expand LOCAL clinics to care for Uninsured who then are advised that some of their ASSEts CAN and will be taken from them for care.... this includes their furniture etc... too many patients can show No income and have tons of things to sell for care.. and then there are those who CAN afford and refuse to buy insurance............... these people must understand that if disaster strikes ,, they will LOSE some of their assets................. and not just take from the other workers who paid for insurance and are now paying for them... this is called being responsible.................. and yes there are those who can not be responsible... but they should NOT be in fancier individual apt than the workers who pay taxes to keep them better housed and fed than the workers... this insanity has gone on too long..

the problem with expanding Medicaid is that it is a political game... and will NOT SOLVE the health care disaster

set up free and small pay clinics that do NOT waste resources filing to garbage medicaid insurance that then does NOT pay for services.. but advise those using this or the ER that a financial counselor will be coming by if they claim they need free to assess and educate them.. and send them to night school for priorities. of keeping Insurance to maintain Assets like house car etc

In NY state.. one of the rare states to have Medicaid and School taxes directly on property owners... increasing Medicaid WILL destroy homeowners with massive tax increases as the state is incapable of EVER decreasing taxes except in a way to divert the decreases onto the PROPERTY owners..................... every crisis has seen them increase budgets and force property owners to pay more.. this is NOt sustainable...

We are on a fool's errand with the present political efforts to reform healthcare. We are ignoring the economic realities. The nation is broke, and the present solutions will do little to correct the problem of escalating cost. The politicians will be back within a year attempting to correct the patchworked mess they have created. Our expectations are too high. First we need simplicity in the system and the commitment to provide healthcare for all citizens. Every citizen will pay taxes on a progressive scale to support healthcare. Horrors! Every physician who practices in the U. S. will be paid a salary based on levels of education and years in practice starting with a base of 175 to 200 thusand dollars. I think that most of us would prefer this to the haggling over nickels and dimes that we go through now. The gov't would know what its costs would be from year to year. It would be responsible for the maintenace of the facilities that physicians would work in and they would pay for the ancillary personnel employed in the system. Finally, my point is that we must address the economic crisis of this country with common sense not some overblown idea of our self importance. I almost forgot. No malpractice lawsuits will be allowed. There are better ways to compensate people injured in the system. R.W. Cyrus, M.D.

I do not even take medicaid patients. The ppm on this patients is $10 a month of capitation. Who in their right mind can work like this. Give us Loan Forgiveness, Increase reimbursements and Tort Reform and you will see the true next level of american medical care.

Medicaid reimbursement is below the cost of providing the services. No pediatric practice in my community will accept new medicaid patients.

FURTHER, the structure of the Medicaid program promotes irresponsible use by patients. These patients over-use the ER, fail to take medications as prescribed even when they pay nothing for them, and have a very high rate of no-show on appointments. If you schedule a medicaid patient 3 times and see him once, your revenue per scheduled visit is 1/3 of whatever you get paid. This is THE primary reason why Medicaid patients are high-overhead.

Patients abuse the Medicaid system. I see parents and patients every day who sport expensive electronics, drive costly cars, and describe lengthy vacation trips. Parents complain about the cost of the $5 copay because it cuts into their Christmas budget, "you know, with all my family, I will spend over $800".

Health care reform MUST place more responsibility for financial good behavior and responsible use of resources on the patient.

Expansion of Medicaid is not the answer. Honestly, I think if we could just break the monopoly stronghold the health insurers have on the country, doctors and patients alike, and introduce competition into the marketplace, this would go a long way to fixing our problem. Buying health insurance across state lines will not do anything to foster competition because if you want to be seen "in network", depending on where you are in the country, your choices will still be limited to a few health insurers. For example if you live in Indiana and want to purchase insurance from a small company in Nevada, no doctor in your area will be "credentialed" with that small company, and you will have to pay the "out of network" rates. Please do NOT expand the Medicaid program. The "public option" is a MUCH BETTER option than expanding Medicaid.

Medicaid reimbursements are so low that it is difficult for me as a primary care internist to find specialists who will see my patients. The wait for an orthopedic visit at the University Hospital clinic is 6 months for a Medicaid patient! Expansion of Medicaid will simply perpetuate this two-tier system - with good care for the well-insured and poor care for those on Medicaid. Physicians for a National Health Program has calculated that we could save $300 billion (or more) simply by eliminating private insurance companies. This would be enough to insure everyone with a "Medicare for all" system. As a primary care doc I care deeply about those for whom I provide care, and it is painful for me to see how dismally they are treated at these "Medicaid clinics." At the same time, I stuggle to make a living with the NJ Medicaid reimbursement rate of $20 per visit (for a complex HIV patient, for example).

Please do all you can to make health insurance reform truly meaningful for ordinary folk.

Boy you sure see the split between primary care and the procedural based specialists here. In N.C. I see lots of kids with medicaid and I'm happy to do it. Very little "hassle factor" and I know what the rules are. It's true reimbursement for adults is pathetic but this whole argument is reminiscent of the AMA's vigorous stand against LBJ and Medicare in the 60's That turned out to be a HUGE windfall for doctors as all of a sudden people over 65 started going to the doctor.
Senator Kay Hagan had an idea to let people 55-64 BUY Medicare. For whatever it cost the government to provide it. Public Option? Yep, sort of. After seeing my most recent 57 yr old guy with newly diagnosed lung cancer and no insurance because his wife lost her job at BLUE CROSS, I'm for it.
All this noise about Tort reform (although I agree it should be done) is like weapons of mass distraction. The true cost of malpractice and lawsuits has been going down and has NEVER been more than 1% of health care. Those that argue that they order all those tests because they are afraid of lawsuits are often disingenuous; they are making money on the tests. A cut of the LabCorp bill, a CLIA waived flu test.... "just to be sure."
Unfortunately to be a GOOD doctor one needs to order fewer tests, fewer refferals etc.. To be a good businessman one needs to order more. Guess who wins.
I say open up Medicaid, increase the funding, have those who can pay pay premiums and finally get some :"pooled risk."

www.insurancejournal.com

I think we should all, en mass, refuse to see Medicaid and Medicare at once. This is obviously a problem that is coming to a head. NC just cut our Medicaid rates 9% out of the blue...no discussion...and now are expanding the restrictions on services, requiring more prior authorizations be obtained for services. More work for our already prior auth burdened staff, and for less money. I say to hell with the whole thing...Congress won't give a crap about our problems unless we get their attention.

If the goal of health care reform is to provide access to quality care for the uninsured, expanding Medicaid is not a viable solution. Current Medicaid patients have limited access due to poor reimbursement in the private sector and public clinics are so underfunded and overcrowded that quality suffers despite great efforts of the clinic workers. In addition, since most State governments have to balance their budgets services, membership and/or reimbursement are always slashed in response to revenue reductions. Medicaid is the most "broken" part of the health care system.

The reimbursements for orthopedics are so low that the salesman feels sorry for us. It is even harder to find another specialist for these patients. "LIfe, liberty and the pursuit of happiness" never included free healthcare. That was a political thing so people can be elected in their districts! Working retirees have to worry that their medication has a high co-pay and if you come in this country and get medicaid- everything is free! Where is the justice for the veterans, the widows, the middle Americans? Healthcare cost a lot because it is run by businessmen who look for ways to make a buck- more tests, MRI, shoes, ambulettes, access-a-ride, therapy, acupuncture, home health aides, back supports, pillows, braces, etc. Cut out the middle man and let the doctors do medicine.

ARE YOU KIDDING???????????????????

Why not just put everyone in congress on medicaid first?

In Oregon we ration (oh my God, not the R word) the benifits that medicaid patients can recieve and thereby expand the number of citizens eligible for those benifits. Why can't we do this on a national level? What we really need is insurance industry and tort reform and I don't see either political party having the backbone needed to take on the insurance lobby and trial lawyers.

Dear Senator,
There is no free lunch. Any program that promises that will accelerate decline of this great nation.
From purely personal perspective I would greatly benefit from medicaid expansion (Can you believe that!), but as a citizen, I know it will further add to our huge fiscal imprudence.

But, I bet you dont have courage to tell this unpopular truth to your vote bank.

As for the comments of Sermo Doc 36, people don't make money on all of their tests. We have in office CT, but the test we order the most in ENT to CYA is an MRI, which I do not make a dime on. Acoustic neuromas are slow growing tumors. One could argue for following an asymmetric hearing loss and only ordering the MRI if progression is seen. If we had tort reform I might be willing to do that.

As for the comment about specialists...we actually make more of our money in the office these days, not in the OR. Not sure if Sermo Doc 36 takes call, but my theory on the rise of hospitalists if that fewer PCP's take call these days because their income is not worth the lifestyle hit. So I don't agree that the PCP's are somehow better people than specialists (which is what I read between the lines with the "happy to do it" comment. I enjoy taking care of my Medicaid kids too, but I am not going to be an idiot and watch my reimbursement whittle away.

I do not support expanding Medicaid, unless the Government will be setting up Medicaid clinics to handle this population. I have a limited number of Medicaid patients. They cost me money to provide care, billing medicaid, filling out paperwork, prior authorizations, etc. I have not dropped medicaid, because these are my children, and they have no say in their insurance. I will not take any additional medicaid patients. They will have to seek care elsewhere.

Respectively, 1, 2, 3 & 4:
1. In a moment of rare disagreement with Sermo Doc 7 et al &, conversely, rare agreement with choirmd & chetmmd, I would probably support some type of expansion of Medicaid, at least as an interim solution to the health care problem.

2. Of course I agree with nicole10 et al that tort med-mal reform is absolutely necessary.

3. However, tort med-mal reform legistlation unlikely to survive the inevitable gauntlet -run of left-wing 'consumer' lobbying (e.g. trial lawyers) unless it is linked (piggybacked) to some type of expansion-of-coverage legistlation targeting lower-income people.

4. Hence, a siamese-twin style legistlation so consisting of tort med-mal & Medicaid expansion inextricably inosculated.

Medcaid does not work in California. Payment does not cover overhead.

I received excellent care as a patient and was happy as an employee of the two of the largest socialized medical systems: the British NHS and the US Army medical system. We need a single payor system. Medicaid, with rationing and copays as mentioned above, is one way to improve things. AS you see from those who disagree with me we need to ensure adequate (ie more than now) compensation for physicians.

Would expansion of the public health service corps be an option with health care reform? This would provide an opportunity for the government to pay for medical education for future and current students in medical school in exchange for payback for a length of time in at public health service corp hospitals. Have this work similar to the current Health Professions Scholarship Program that is used for students entering the military health care system. Broaden the scope of current PHSC hospitals and build PHSC hospitals which allow free care to those without insurance (like the Veterans Hospitals). Mandate that because it is a federal institution that no lawsuits can be made! Once established, these would run much like our current military hospitals which have mandatory pharmacy formularies.

Medicaid in NY is unique as it is designed to pay only hospitals (Art 28 facilities), which use the vast sums of money as a jobs program, employing huge numbers of union members who vote Democratic. Medicaid subsidizes the NYC Health & Hospitals Corp, the largest employer in NYC. Medicaid does not pay docs in private practice.

LAMAR MEDICAID PAYS 20-30% BELOW OVERHEAD. MEDICARE PAYS AT ABOUT 0-3% OVER OVERHEAD. THE ONLY WAY YOU CAN AFFORD TO LOOK AFTER THESE PATIENTS IS TO (1) COST SHIFT ON TO THE INSURANCE PATIENTS----NOT EASILY DONE SINCE THE INSURANCE REIMBURSMENT RATES ARE SET BY CONTRACT (2) LIMIT THE NUMBER OF MEDICAID OR MEDICARE PATIENTS YOU SEE. OR NOT SEE THEM AT ALL SINCE THE BEURACRATIC HASSLE IS NOT WORTH IT. DOCTORS FOR YEARS HAVE CARED FOR MEDICARE PATIENTS FEELING THERE WAS SOME RESPONSIBILITY TO DO SO BUT WITH THE BURDEN OF REGULATIONS AND THE LOWERING OF REIMBURSEMENT FROM OTHER SOURCES THE MEDICARE BURDEN AND CERTAINLY THE MEDICAID BURDEN CANNOT BE CARRIED. PERHAPS, IF INSTEAD THE GOV. WOULD GIVE A SMALL TAX CREDIT TO THE DOCTOR FOR LOOKING AFTER MEDICAID PATIENTS IN ADDITION TO THE USUAL FEE, YOU MIGHT CREATE A SCENERIO WHERE DOCTORS ARE FALLING OVER THEMSELVES TO LOOK AFTER MEDICAID PATIENTS. MEDICAL REFORM NEEDS DISCUSSION AT THE PROVIDER LEVEL AND A PROGRAM NEEDS TO BE BUILT FROM THE BOTTOM UP ,NOT FROM THE TOP DOWN AS IS BEING DONE . THANKS FOR YOUR INTEREST. VANDY '64

Most physicians I know will see Medicaid patients only at the request of another physician or as a favor to a patient. Many physicians do not submit a bill to Medicaid and it will be a rude shock to see how much uncompensated care was going on all the time.

My recommendation would be to adopt the principles of the French system in which the patient pays the doctor first and then is reimbursed by the health plan. France has a national fee schedule that is not mandatory so the doctor can charge more than the plan payment. That introduces an element of market function since patients may choose a more expensive doctor knowing they will pay the difference. The plan payment, however, allows the plan to know what its expenses will be. Obama is going the other way with an attempt at a command economy which does not work. All you get is a black market, like that operating with Canadian patients coming to the US.

We seem to be following in the path of Argentina which was once the richest nation on earth.

agree with Sermo Doc 11 and rural doc- bash the problem, avoid solutions. A nearby county has the highest repeat teen pregnancy rate in the developed world. So we blame those kids making poor choices, getting disabled etc. when access to services will help. If the docs care enough and we fund the program adequately. Hawaii has the lowest per capita Medicare spending and longest lifespan. Also 2nd lowest insurance premiums. They cover almost everyone from birth.
Take the easy route, blame the patients, but the problem remains. I will get back on Medicaid when the rates improve. So will lots of other docs. Maybe the Senate could support physician pay for a change.

"Less government and more responsibility."- Robert O. Welch
We need:
Less taxes.
Less federal government altogether.
Less NAFTA.
Phasing out of government entitlement programs.
This will bring the JOBS that are needed so that people may become self-sufficient and CHOOSE for themselves what kind of health care plan they want to BUY for themselves and their families.
People on Medicaid are generally the most noncompliant and least thankful for their care. They EXPECT it. And this is what the gov't has wanted all along. Another dependent class to keep voting the tyrants back in office.

What this country wants and needs is quality affordable healthcare. the quality is there; you get what you pay for; The only way our country can afford healthcare is to completely enslave the doctors (we are only partially enslaved now)!

Senator,

I will not see Medicaid patients even if reimbursement is improved to the point of being competitive with private insurance. The bottom line is that most patients who are on Medicaid are not poor - they simply do not value their health care and prioritize spending on unneeded products instead. It's not enough for me to be paid for the work I do. My patients need to value the care they are receiving. At a time when most doctors are finding the burdens of private insurance to be not worth the reimbursement, why would I or any other doctor want to add to our long list of ungrateful patients? We all know that if you improve Medicaid reimbursement now, over a matter of time it will eventually decrease. What is the benefit to me? Will having a census full of Medicaid patients mean less administrative burden? Less hassle getting paid? More satisfaction that my skills are valued? No, No, and NO.

WHY HEALTHCARE COSTS SO MUCH::

Dr. Ewie Reinhardt, the prominent health economist at Duke University recently said in an interview that he doubted they have a nurse for every bed in their hospital, but they do have an insurance clerk for every bed. Administrative excess, inconsistencies, and manual rather than electronic processing adds hugely to the costs of healthcare in the U.S.

Big Pharma still does business in Canada, where pharmaceutical prices are 30% to 50% less in the U.S. They would not be in business there to lose money. Abusive pricing for medications and hardware consume massive amounts of our healthcare dollars.

Doctors too can be avaricious. Medical fees have been reined in and moderately well controlled with the Relative Value system originally developed in California and still basically in use throughout our healthcare system. Appropriate monitoring is necessary here as in every other healthcare area, but this can and should be routine, transparent and digitally automated. It should not be left in the hands of insurance clerks. Peer review committees of organized medicine are the appropriate review body. Not the for-profit insurance industry.

Advertising is another abused and tremendously expensive drain on our health economy. It should be given the insurance company designation: NCC (non-covered care). And taken away from pricing for drugs, insurance and medical services. Doctors need training on appropriate treatment and services, but this should not be applied to advertising to the public, at least not at the expense of better healthcare coverage and cost containment.

Hospital charges exemplified by the $5.00 aspirin pill are another component of cost structure. Advertising by hospitals, clinics, doctors, insurance and especially big Pharma add huge expenses that offer nothing to help patients.

A standardized reasonable non-litigated compensation for most medical injuries was suggested by Speaker Newt Gingrich in his book "Saving Lives and Saving Money." This too would significantly download the cost of care.

To maintain cost control, the sanctions should be automatic, universal and transparent. The cost control tool should be an overall budget for healthcare, digitally monitored with adjustment of payment rate by actuarially designed criteria so that if costs project to overrun the budget, pay rates are automatically decreased to all participants across the board. That includes big Pharma and the insurance industry. Everyone will object to abuses by anyone else and this will be powerful. Committees of representatives from all involved groups should be organized regionally and supported by government (meeting space and costs, not compensation for participation). Quarterly or semiannual State-wide Healthcare committee meetings should be held at or near the State Capital with open invitations to Government representatives to attend.

California can lead the Nation in implementing these cost saving measures. The savings would more than cover the cost of Universal Healthcare Insurance. More details are reviewed on the web www.GoodMedicineAmerica.com and in the book "American Medicine MisManaged Care."

Respectfully,

Carte V. Multz, MD, FACP
1835 Park Avenue
San Jose, CA 95126-1650
doc@GoodMedicineAmerica.com
DrMultz@ArthritisCareCenterInc.com
408-279-3330 (office)
800-800-9111 (home)            link:    www.GoodMedicineAmerica.com

Senator,
I am an ER doc in Florida. I see many uninsured and illegal aliens. I am also a conservative and typically vote Republican. I do favor expansion of Medicaid, but in a much different way. What upsets me about the current system is that if a person makes just one penny above the eligibility limit, they are cut off 100%. That is wrong. What I would support is allowing persons who are not 100% eligible to medicaid, but unable to afford private insurance on their own, pay premiums into Medicaid. For instance, if a person is 10% over the eligibility income limit, then they should be charged 10% of the premium cost into Medicaid. This would also solve the pre-existing medical condition issue. If a person cannot have access to healhcare due to pre-existing condition, allow them to buy into medicaid by paying 100% of the premium cost.
I agree with you about rationing healhcare issue. My arguement is that Medicaid will be the only system that is rationed. We will not be rationing Medicare or private insurance. The reason why I say this is because Medicaid should be regarded as healthcare coverage as a last resort. This will make persons very hesitant to switch over to Medicaid unless they absolutely have to.
I do understand about the re-imbursement issue. Here is a solutiuon to this problem.
Physicians such as myself should be allowed to volunteer their services to a Medicaid Clinic, and allow us to write off our usual reimbursement charges against our income tax. The arguement against this solution, is the precedence issue...if doctors can write off their volunteer services, then every other occupation should be allowed to. This is a valid point. But I would also argue that if physicians work for free, and write off their services to taxes, the tax payers who are subsidizing the Medicaide system are getting their best bang for the buck.
I see many illegal aliens in the ER. I can give many examples of the abuses that foreigners commit to our system. My favorite example is when a family member in the US flew in her mother from the country of India to Fort Lauderdale. She immediately got off the plane, went directly to the ER, was vomiting bright red blood. Was hospitalized for 4 months, over half that time in the ICU, was diagnosed with end-stage liver cirrhosis, had schlerotherapy for esophageal varices, splenectemy, and TIPS procedure. After the millions of dollars that she incurred, she was discharged from the hospital, and pt flew back to India. Bottom line, this is a HUGE hidden tax on our healthcare bill. Everybody pays for this. Here is the solution to this problem.
There should be comprehensive illegal immigration reform. However, the government should go after the employers who bring these illegal immigrants into the US and profit from their cheap labor. The laws should demand anyone who pays an illegal immigrant for cheap labor should be responsible for their healthcare. Either buy them insurance, or be responsible for their healthcare cost.
Here is the solution to the tort problem. Give medical insurance beneficiaries a choice. They can pay cheaper premiums by allowing the to waive their right to sue, and instead, go to an independent health care court or arbitror where only knowledgeable medical professionals judge their case on the merits, no trial lawyer, no expert witnesses, and there should be a limit to punitive damages. IF the medical insurance beneficiaries will not agree to that, then they can pay the higher premiums, and allow them to use the conventional court system, and hire trial lawyers.
Further, beneficiaries of the Medicaid system will have not choice.... they will have to accept independent arbitration or healthcare courts, and limits to punitive damages.
Thanks for requesting my input of Sermo.
Darren
Palm Beach County, Florida

As an Emergency Physician, my answer to question number 3 is "very likely". However, that is only because Emergency Physicians, by law, take all comers, and, if Medicaid is expanded, I will take more Medicaid patients.

The problem with medicaid is that is run by the states and there is a large disparity of coverages and eligibilities. Reimbursement for Medicaid used to be dismal in my state and they finally increased to be a little more than medicare. That is obviously not the case in other states. It is also more paperwork intensive in some ways. I am a Republican but I think we need to KEEP IT SIMPLE. Currently there are so many plans that change with the wind we cannot keep up with it. If we expanded Medicare to younger people who are healthier that would help keep medicare in the black because the population over 65 are sick and use a lot of resources as a necessity and having healthier patients paying in would reduce the strain appreciably. The insurance companies can compete with medicare products (primary and secondary) to give them business and choices for the consumer but the basics would be medicare based. How would medicare handle all of this? Just like they do now, expand using insurance companies as contract agents. At least the rules would be consistent. I had a dear friend who was 60 with medicaid who with advanced cancer who could not move to another state to be with his family in his final days because he was not eligible for medicaid in that state. As a physician and a patient I am not pro insurance company. I own my practice and I personally pay 1800 a month for me and my husband with a 3000 dollar deductible because my practice is a small business and we have only 16 employees. If I became disabled, I cannot even Cobra that insurance because our business is too small. There needs to be overall reform not just more complex choices. Thank you for listening.

Senator Alexander - Thank you for asking for our input. I do see Medicaid patients, although I have also worked in a practice where we did not see them. My feeling is that most doctors want to help as many patients as thye can, but most of us also cannot afford to work for significantly less than what Medicare pays, which I personally consider to be a minimum standard. The fact is that when we see a patient whose insurance pays so little as to barely cover our overhead costs, we are in effect working for free. How many other professionals do that, and how often? Most doctors are not independently wealthy. We have offices to run, staff to pay, and families to support, not to mention medical school debt topay down. Please do not think for one moment that expanding the size of this country's Medicaid population is any way an acceptable solution to the problem of covering the uninsured. It will not lead to increased access to care - quite the contrary, if we all go out of business!

Mike Ford, MD

My first patient this AM was a Medicaid patient. I don't take Medicaid, but he was my patient when he had insurance so I saw him for free. Treated his DM, Hyperchol, CAD, etc... He had labs, takes 6 or 7 meds. The lab gets paid, Pfizer and Merck get paid, the hospital gets paid, doc doesn't get paid. I don't try to submit a bill to Medicaid because it's always the same - no check ever came to any doctor I know in this area who treated a Medicaid patient. No specialist here takes Medicaid so if I have someone with an acute illness I am screwed when trying to get a consult. Expansion of Medicaid will only cause a large number of patients with coverage but no access.

You guys and gals (congress) are floundering around back there. You should start over with the principal of cost control rather than expansion of coverage first. Once you wrestle out the presumed 30% overtreatment (excessive scanning, 80 year olds with pancreatic cancer getting $150,000 chemotherapy that may improve their survival by 4 months, etc...) there will be enough money to cover everyone - including the illegals.

Medicaid is not the answer. As a practicing Tennessee physician, I have seen how TennCare has morphed into Amerigroup and Americhoice, which are no better when it comes to access, for primary or specialty care. You still cannot see an orthopedist, dermatologist, most urologists, most surgeons, any plastic surgeon, most vascular surgeons in Middle Tennessee if you have Medicaid. The hassles associated with the program make it frustrating at best to deal with, and most specialists do not take it because of that, coupled with low reimbursements.

I continue to be confused as to why this needs to be done in an omnibus fashion. If everyone agrees with 80% of it (or so the news report) why not take those things that you agree on, and make a bill out of it. Then that would leave you with the remaining 20% to debate. As it should be. The only reason, valid or not, that you would have to do it all at once would be because the 20% is barely palatable for most of our representatives. Thus, if they are going to vote for it, they want cover by reminding everyone how "they did the bad so they could get the good".

I will be closely following what happens with malpractice reform, if it could possibly be in the bill. It certainly needs to. That of all things, I would think, would help to lower costs.

Isn't that what this is supposed to be all about?

The question isn't whether access to Medicaid should be expanded. The question is how to intelligently do this This can be done by funding best practices research, decreasing bureaucracy, increasing reimbursement rates to keep up with inflation and negotiating better pharmacy benefits.

What is it about 47 million people uninsured that doesn't bother you enough to take action Sen Alexander? Or should they wait while you and your fellow republicans suggest that we keep stalling on this issue by throwing out more questions in a friendly forum to try to prove your point.

didn't read any of the above except lead-in, too busy in ER

Let's see - add in more Medicaid, more of the least compliant, most demanding, most litigious, and worst paying patients we see . . .

WHAT A GREAT IDEA!!! ARE YOU F'ing Kidding me??????????????????

For any of your politician friends who think this is a good idea, they can kiss my ass. Another unfunded mandate will result in a pool of patients with "no benefit." We'll quit seeing them.

gotta go, ER calls . . .

WHY ON EARTH would you give more people an insurance that no self-respecting physician would ever accept on a regular basis?????? It is like giving people monopoly money to buy food at the supermarket!

Oh, if you want to force the hospitals to suck up the expense, perhaps, but then you will put more hospitals out of business - which may very well be your goal...

Thank you Senator Alexander for taking the time to ask us what we think.

Medicaid is a charity program which the Feds supply only 1/3 of the cost of the care. The state provides 1/3 the cost, and the provider "donates" 1/3 in reduced reimbusement. It is cheaper to the provider to give someone $40 and ask them to go away (seriously).

In Tennessee, the state mandates payment of Part B medication (in office medication) at 80% of the sales price, which means no one can afford to treat medicaid patients with cancer, MS, RA, etc.

Only DSH (disproportionate share) hospitals make out well. THe government mandates they can purchase medication at 1/2 price and reimburses them for actual expenses.

Taking on a patient on medicaid with a chronic disease means we are continuously "losing money" in the truest since of the word. Furthermore, converting uninsured patients to Medicaid patients usually means we can do less for them and they go from a profit to loss in a business since.

Sermo Doc 62, suggesting decreased bureaucracy, negotiation of pharmacy benefits, best practices research and more...I'm very proud of you!

47 million people having trouble getting health care should bother all of us. How to get them needed care is the real issue. There are ways to do this that the democrats aren't talking about.

I no longer practice because of illness. When I entered practice in 1980 I felt, as I still do, that taking care of anyone with illness was my mandate.

In PA (where I practiced for 28 years) Medicaid was managed by the Department of Public Assistance. For years and years I saw all comers and usually never bothered to submit claims because DPA often threw them out or requested more information, etc before ever allowing their meager payments.

In the 1990s state law moved the management of medicaid to several HMOs. Our office found them to be so difficult to deal with and so abusive that we discontinued our participation as soon as we could (ie, at the end of our first year).

Because they were HMOs requiring "precertification" I could no longer see participating patients in my office. We were always permitted to see patients in the hospital or Emergency Room (though others...chiefly physicians in training had to be the doctors of record). To accommodate outpatients I had to donate my time to a clinic. To accomplish this my time was limited to 4 hours per month. medicaid in pennsylvania was a disaster for specialists and for the patients requiring their care, at least as outpatients

Reimbursement rates for Medicaid, and Medicare, too, for that matter, are below overhead expenses. I always give Medicaid and Medicare the same level of services that are given to private patients, and so far I have not had to restrict the number of these patients I see. Reimbursement for Medicaid in our area is about 36% of usual and customary, and Medicare is about 32%. Overhead for my small multispecialty clinic is between 55% and 60% The only ways one can survive financially are: 1) Cost shift to private patients, which is what I do. 2) Decrease level of services (i.e, run an "assembly line," which I have never done). But, if the number of Medicaid/Medicare patients were to get too large, the clinic would go bankrupt and close. In all the discussions at the legislative level, as least as far as they make it into the news media, there never seems to be anyone addressing this simple fact of economics. If a doctor is not reimbursed adequately, he/she will no longer be able to practice and will not be there.

One of the biggest problems of State run Medicaid programs are the high administrative costs and lack of continuity care for patients because of those administrative rules. People are tossed off the roles and then allowed back on - see the classic case of the young woman diagnosed with SLE in college and then when her employer was unable to provide health insurance she was unable to get insurance on her own or be covered by her parents' plan. She was on Medicaid (this was Tenn or Ky) and then developed a complication that coincided with being tossed off Medicaid. By the time administrators (read 3rd grade level clerks) decided that she was indeed eligible - retroactively, she was dead.

If there were not so much monthly checking and double checking for income eligibility, Medicaid might actually be able to reimburse at the level of Medicare and then the patients might actually be able to find doctors who will help them. We decry the administrative waste of the commercial insurers, but that is but a fraction of the administrative waste of Medicaid. (Likely equivalent savings - consider usually quoted 20-40% administrative costs for commercial insurers compared to 3% for Medicare.)

The keys to the VA and Kaiser is the continuity issue. This is one way the keep overhead low.

As much as I hate the VA, it is effective - in part because of the strict guidelines, clearly spelled out. I've always suggested that something like the VA would do well as "the public option." The VA insists on a yearly visit for each veteran - as that overall gestalt and expectation of risk assessment and recommendations for the year (e.g. cholesterol, colonscopy, immunizations.) It's the closest model to a "medical home" short of Kaiser (but that's a different universe.) Then, the commercial insurers can always tout availability or the like, but the cost is indeed $. But you have the back-up. The back-up provides ONLY Evidence Based Medicine (even if it means that some "standard of care" might not be adhered to, but that "standard of care" has yet to be proven) unless you become involved in a research clinical protocol/trial.

Medicaid is almost "half dead", how can you expand this in this situation. It needs resuscitation as far as I am concerned. We need a different idea or ideas. Congress does not have the brain to do it.

Lamar, I sent you a "private" e-mail via your website, with a link to my national healthcare proposal, posted on my FaceBook page (notes). In summary: government's role should be limited to helping provide catastropic coverage for everyone, with HSAs used to pay for all routine and ongoing medical care. "Health insurance" that pays for office visits and routine tests should be outlawed at the national level, in the same bill that establishes univeral HSAs and tax exemptions for contributions thereto. Put self-interest back into the equation in place of "entitlements" and you have some hope of reducing costs. Get the government and the insurance industry out of the physician's office and you will increase efficiency and allow enhanced care. Best wishes, and thanks for your interest. Your old friend, Larry (VU '60, '68, '70).

Sermo Doc 70, you are absolutely correct!

Thank you so much for asking for input from practicing physicians. The AMA definitely does NOT represent the views of most practicing physicians. Most of what I was going to say has already been said above. Tort reform, graded eligibility for Medicaid rather than an all or nothing cut off, immigration reform to lessen the burden on providers so more money is left to care for Medicaid patients, tax credits for charity care, decreasing the regulatory paperwork imposed by the government, that takes time and costs money, but does nothing to improve patient care, increase competition by loosening the restrictions on who can provide insurance and where and what they are required to provide (like car insurance is.) PLEASE take the examples provided of how to actually reform and improve the system, rather than worsen or destroy the system, back to Congress.

I will not repeat the many great ideas proposed here, but I will include my 2 cents about Medicaid (or 0.4 cents at Medicaid rates.) As a neurosurgeon, I see Medicaid patients with brain tumors and infections and traumatic injuries. It doesn't pay much, but it is more than I would get if they had no insurance at all, and most patients' poor lifestyle choices did not cause their own brain tumor (smokers excepted). Despite the low reimbursement, those patients do not require many resources from my office staff or from me, and their treatment course is relatively straightforward, so there is not much government hassle involved. I lump it is with the charity work we all do as doctors (my tax money is used to pay me for taking care of someone who pays no taxes and pays nothing for the care I provide!)

See next comment for continuation (went over 5000 characters)

Continued from previous comment.

Back pain and neck pain patients are a completely different story. Except in rare circumstances, I do not see Medicaid patients with back pain and neck pain, even though operating on those patients would pay me a lot more money than taking out a brain tumor. Why? Because there is no point. Those patients do not get better no matter how many surgeries I do on them. Medicaid has crazy rules that impede my ability to take care of them, like not paying for physical therapy after back surgery, so the surgery is usually useless. Also, as has been said by so many above, there is no personal accountability for Medicaid patients. They have no incentive to get better. A normal post-op visit is 10 minutes to check the wound and x-rays and address any questions a patient may have about how much exercise they can do or if they have any more limitations at work. A Medicaid post-op is 45 minutes of addressing every excuse they can come up with about why they still can't work, even though their back is fixed. They have no incentive to get better. They do not need to get back to work so they can buy food and make the house payment, because the government pays for all of that for them. In fact, the government rewards them for not getting better. Many Medicaid patients I operated on early in my career just wanted me to fill out their disability paperwork so they could continue to get a check. When I told them their back was stable, and there was no medical reason they could not work, they would report me and file complaints about me. Seeing Medicaid patients for back pain and neck pain is actually a good source of income for a neurosurgeon, but the drain on my office staff, the time it took away from my other patients who are actually paying for the service they receive, and the incredibly high personal liability made it not worth the money. Until the permanent entitlement programs in this country are reformed to give people an incentive to work and provide for themselves and contribute to society, and we as physicians get some legal protection from patients who are receiving free medical care, I will not take Medicaid patients with back pain or neck pain. As we have seen for the last 150 years all over the world, when people have no incentive to provide for themselves, they won't.

Finally, as may have said before, expanding the Medicaid program will do nothing but increase healthcare expenditures far out of proportion to the increase in covered people. The lack of accountability and personal financial stake causes massive overuse. They call my office twice a week to complain, and they want an office visit for every little ache and pain that may come or go, whether it has anything to do with why I am seeing them or not. When my nurse asks me about them and tells them what I said, they insist on an office visit to hear it from me in person. If I don't see them, I get accused of "abandonment." Of course, I get paid by Medicaid for every one of those unnecessary visits. The private insurance patients with a co-pay do everything they can to NOT come in. They e-mail me directly with short questions, or they call my nurse and they accept what she tells them I said about them. They get better care at a fraction of the price. Giving more patients medical care without requiring anything from them in return is going to skyrocket the cost of healthcare even more than Medicare and Medicaid already have.

I say damn the torpedos. Strike a no dr work day during week.they can flood ers. no refills etc.Pick a week day. jf

Any system where the patient and payor are totally separated, like medicaid, where the patient has no say in reimbursement and has little if any discretion, leads to overall poor quality. Expansion of medicaid will predictably result in poorer quality and poorer satisfaction.

A provider or doctor facing medicaid will maximize his payment from the payor and meet the payor's requests so that payment will follow. How happy or pleased the pt is is immaterial to the contract between the provider and the government. Such distortions, in my opinion, explain why we have the problems we have today.

Private pay patients look at their bills, challenge charges, and we doctors must earn every penny from them. Private pay patients are more careful about imaging and consultation and they respect and appreciate their doctor's efforts in their behalf. Private pay patients are grateful that they have a doctor.

Expanding medicaid will further corrupt the system. Rent seeking, fraud, poor quality, medicaid mills, abuse, and poor care will follow. Recent studies, I believe, show no difference in survival between cancer pts with no insurance v medicaid (correct me if I am wrong). Expanding medicaid serves no one except the tender conscience of government employees and politicians.

Dear Senator Alexander,
I don't believe the USA has the physician resources to handle 14 million new insured patients if they had the best paying insurance possible. The notion then of adding 14 million patients at the bottom of the reimbursment pool will only serve to drive physicians away from this tidal wave of people who we mostly lose money treating.
You would increase animosity between people, politicians and physicians alike. The Sermo community has offered numerous proposals to facilitate effective health care reform we need and can all live with. I salute you for your interest and diligence, and strongly suggest you do everything possible to slow this Sermo Doc 64 of frivilous reform into a real truly bipartisan dialogue and then come up with policy recommendations. Look how long it took the 911 commission to publish its findings. I can only suggest
that you and your colleagues ponder the Delaware river on frigid night, and put
yourself in George's place---what would Washington do? Washington D.C. must
start behaving like Washington, or surely we as a nation stand no chance of
continued greatness. America, the land of entitlement, the home of mediocrity.

HIgh deductible policies with pre-tax health spending accounts is the answer. Even medicaid patients should have to pay something, so should illegals, even in a medical emergency. the patients should pay for their health care so that way they have to be responsible for themselves. I just saw a medicare patient today who did not know what kind of operations surgeons had done on her, she did not go back to her last surgeon for a post-op check to make sure everything was healing properly. she just kept doctor shopping until she found me, and I am sure she will leave my practice soon because I told her I am not responsible for her health, she is. This society kills me, yes we should help those who need it but there should always be a limit.

Sen. Alexander, you are from Tennessee. Dont you remember that Tennessee expanded medicaid with a public option. It was called Tenncare and forced the state into Bakruptcy.

I agree with much of the above, except the need to expand a broken ridiculous program such as Medicaid and the contention that any Government-Run Single-Payer Health System is good and efficient. Give me a break. I've worked in the military and with the VA and love the people, but they are very inefficient compared to a private system where there is accountability. On the patient and administrative side Medicaid and even Medicare are the definition of entitlement without personal responsibility. This is a disease itself which can sometimes infect any patient taking those benefits. If you want a free and prosperous country, then you can not have Medicare and Medicaid patients threatening me to order any and every test on them for no reason and demanding incredibly expensive procedures and ambulance rides, etc. without any thought about cost and without any cost to the patient. Any government entitlement taken from hard working citizens needs to have rationing, requirements for tests ordered, and requirements of the patients. This is not the job of the doctors to enforce. Why would anyone in their right mind want to expand the most expensive insurance plans of all (i.e. the Gov't plans run by money stolen from us, money that is handed out without accountability, plans with the highest administrative costs even without making a profit, plans which further increase our national debt and associated interest payments, and plans which foster bad behaviors without any personal accountability).
On the other hand, people who choose to afford insurance can then participate in a system which is superior to the entitlement plan, and people will then strive to get off of the entitlement plan. Insurance should be like car insurance with limits, good behavior discounts, lower premiums for higher deductibles, etc. These insured patients perform self rationing because they will not want to pay a deductible for unnecessary procedures, etc.
A single payer government system is slavery for patients and doctors regardless of any initial intentions. I want to take care of poor patients for free when I choose to do so, not when the government tells me I have to or I will lose hospital privileges. I choose freedom and responsibility for myself and I hope there are enough real Americans left who feel the same way. Every pretax dollar that I earn from my labor that I can keep to spend on health care for my family will go further and for better care, than $2 that I would have had to send to the government for them to care for me.

I would be in favor of expanding the FQHC model with some sort of "catastrauphic" coverage for patients who are seen by a FQHC to allow them to obtain speciality consults and expensive tests i.e. MRI

Last week I was in washington DC for the AAP conf. 2000 pediatricians were in town. All in one place at the DC convention center. I noted that the Republican nor the Democrats sent anybody to come have a session to hear our thougths. - - If they really cared about our opinion there would have been a "town hall" for pediatricians - - the truth is that none of the attorneys in Congress care about physicians.

Patients and doctors both deserve a better system than Medicaid..

Medicaid varies from state to state. At best it is a humiliating coverage for those below the poverty guideline, which in itself is a farce. Tenncare? What ever happened to that.?? Straighten out the insurance companies, form a large American pool, make it socially unacceptble for young people not to have health insurance...make everyone a ccountable for their care. (Ie, send them a statment whether they pay for it or someone else pays for it.
Eliminate medicare and medicaid fraud by requiring the patient to certify that he (she) received the treatment which is being billed (on the billing statment with a unique secure password or PIN number....Expand Medicare??? Expand Medicaid? Why? Just because the administration is already set up? It is already contracted out to a number of private contractors.....Medicare is a sham. The butterfly effect will undo anything the government tries to do with rewards and punishments

I still have 7% of my practice as Public Aid but lose my shirt to see them. I see them because I am an old doctor who sees it as my duty. I can tell you my young partner wants nothing to do with them. She was mad as hell she called into the ER to see an urticarial patient who couldnt get into see anyone. If tort reform doesnt come I am out in 8 yrs who is going to see Public Aid then?

Poor solution for reasons stated above.

I quit taking Medicaid patients ten years ago.

I agree with Sermo Doc 2 (above). The problem with the Medicaid system is that things that do not come with any cost have no value to the recipient. In India, everyone pays one dollar to receive health care!. (I would agree that everyone is "entitled" (oh, how I hate that word!) to one checkup each year, in their birthday month, with any necessary preventive studies done at that time), but co-pays for all other things. Then, the medicaid folks would not present in the ED or offices, demanding prescriptions ("free") for over the counter items, etc.
The Durable Medical Equipment (DMEs) are another source of medicaid corruption. Equipment rentals are irrational, on items that should cost under $100.00 "Free " motorized wheelchairs are immorally marked up.

If (and we should!) have universal health care, this should put an end to social security disability payments for kids with "asthma," (get your mom to quit smokin,") and adhd - they will get all the care that is really necessary.

If we have a universal health care plan, this would seem to me the precise time to achieve tort reform - if there is universal healthcare, all of one's complaints would be assumed by the healthcare system, not the lawyers.

why are senators acting concerned about our reimbursement when they just approved the paycut for us for january? they talk like they want higher reimbursement but then vote against it.

Medicaid pays lower than Medicare for the same procedures and visits. The Medicare and Medicaid systems are broken and we are considering dropping out. We lose money on every single CMS patient we see. Having more patients on Medicaid would be worse, because the reimbursement does not cover our business expenses, assumed liabilities, and overhead. Until the government fixes the broken pay scale for physician services, CMS patients will have less and less access to healthcare.

Medicaid was so overwhelmingly unworkable for my 30 doctor group that we stopped participation long ago. The hassle factor is too great and reimbursements so close to nonexistent that we decided it was not worth it. We see some Medicaid patients, but they are considered "charity work." We do not bill for those services.

Senator,

To understand what may happen to mediCARE, you need only look at the state of mediCAID in my community. It is difficult for me to find a specialist who accepts medicare patients. I am one of the ever-dwindling specialists who does. If medicare cuts go through, the first thing I will do is stop seeing medicaid patients, because I will need to plug a monetary gap somewhere and it's not coming from malpractice reform or other sources of overhead, because I already run a pretty tight ship.

So if you expand medicaid in my community, you will merely add to the rolls of people who can''t easily find a doctor to treat them. There will likely come a time in the future when I no longer accept assignment from medicare as well (I'll opt out or go non-par). The financial, administrative and regulatory pressure are just simply starting to overwhelm me; and then medicare providers will also start to wane.

Others of your colleagues have asked for our opinion in this forum. However, I still don't accept that you collectively as a group really care about us. We are a precious national resource and your are squandering us.

Regretfully,
JRL

I am a board certified emergency physician with 30 years of experience and have seen "America's Emergency Safety Net" gradually erode. I have personally suffered episodic ill health due to work stress and am forced at the age of 56 to consider retiring from my specialty. Many of my colleagues are burned out and want to leave the specialty of Emergency Medicine. Government has mandated we see all comers but is reducing our compensation disproportionately.
Please help improve access to "real" emergency care and not increasingly overwhelm us more by your bureaucratic mismanagement.
While an Emergency Medicine Resident at Harbor-UCLA in Los Angeles County in 1982 I treated an overdose patient that was inappropriately transferred from a neighboring hospital. This case became one of the sentinel cases in California that resulted in anti-dumping statutes that later led to passage of Federal EMTALA in 1986. I worked on a California/American College of Emergency Medicine Committee with Michael Jay Bresler, MD, FACEP, who is given credit for establishing several legislative amendments during his tenure on the Cal/ACEP Board.
I therefore speak with some experience in helping to draft legislation to improve patient care outcomes when suffering emergencies.
Lets for a moment agree to disagree...
Having worked in an Urban ER for 7 years that serves primarily the indigent, I have seen that providing Managed-MediCal in no way guarantees access to care. Instead, it puts up more HMO barriers, and many frustrated patients have no alternative but to seek non-emergent and non-urgent advice at an Emergency Department.
I am afraid that the currently proposed AAHCA of 2009 ("America's Affordable Health Choices Act of 2009") will guarantee coverage but does not guarantee timely access to care. Enrollees will be forced to stand in line at increasingly overcrowded ER's.
My plan would be to provide vouchers for the patients declared "stable" by triage standard and who could be safely directed to affiliate-licensed Urgent Care Clinics for timely rapid evaluation and care.
The problem is, at present, this type of referral would violate EMTALA, and ER's & Hospitals prefer the "bread and butter cases" waiting (for as long as takes) to fill in their "down-time".
According to HealthDay News, patients on Medicaid already have difficulty accessing health-care providers, according to a recent national online consumer survey by PricewaterhouseCoopers (PWC) Health Research Institute. Nearly a third of Medicaid patients reported waiting 30 days or more or an appointment with a doctor. What's
more, many Americans still use the emergency room inappropriately. According to PWC's consumer survey, more than half of those who went to the emergency room in the last year did so for non-emergency reasons. news.yahoo.com
Ten years ago and again last year, Harbor-UCLA ER (where I did my internship and residency) performed a study that showed that 10% of the LWBS (left without being seen) patients had significant morbidity and mortality within 24-72 hours of their initial attempted visit.
My plan would be to have these potential LWBS patients directed to the clinics for a timely evaluation.
The Canadian Plan is indeed an excellent plan for most patients. Problem is, doctors were guaranteed a significant salary increase by the government and they did indeed get it according to several Canadian friends I have spoken with.
No such plan seems to be feasible in the United States where there are no longer available financial resources short of increasing taxation. Instead, the present plan seems to further guarantee reduced reimbursement to US physicians.
This will not engender acceptance and may jeopardize real health care reform in the Unites States.
I DO believe there should be a National Health Care Plan.
I just do not agree that the present plan, as written, guarantees access to timely care... it is just false hope...
Respectfully submitted,
Mark S. Wagner, MD, FACEP
PO Box 338
Dana Point, CA 92629-0338
Phone: 310-218-3892
Fax: 424-203-3065
Email: Sermo Doc 88md@cox.net
Website: sites.google.com
Facebook: www.facebook.com

Once upon a time, I looked at Medicaid patients on the airline model: they would rather fly a passenger buying a deeply discounted ticket than fly an empty seat, But as I became busier and busier, I made the decision "no more Medicaid patients" - I did not fire the ones I was already seeing, but I just made it plain that I would not take new ones. This had the strange result that patients I was seeing at the Free Clinic, when they FINALLY got Disability to agree that they really could not work, could not come to see me in the office because what Disability got them is Medicaid!

Medicaid payments to physicians caring for adults have NOT kept pace with inflation. My phone bill goes up, staff salaries go up, postage goes up, rent goes up - and Medicaid payments don't. Remind me - WHY do I want to see patients where I do not make the cost of seeing them? And why ever would I want more?

Please see my recent post/survey on Medicaid to Sermo physicians. That should easily answer your question.

BUREACRACY and ENTITLEMENT as many of us agreed... with all of the TIME, TALENYT, TREASURE and CARE given to these group of patients since FDR... that I believed we FOSTER their DEPENDENCY and ENTITLEMENT .... because

we have been generous and sincerest in the exercise of our calling,, and had been willing SLAVES and SERVANTS for years...!

NO.... I agree with my colleagues that MEDICAID should ONLY be for CATASTROPHIC and EMERGENCY cares only!

SEN ALEXANDER , the best you can do is to pass a bill intended to EDUCATE "Medicaid RECIPIENTS" of their DUE responsibilities to PAYBACK society especially the medical profession!

Great and often poignant comments.

The best solution, and one I heartily agree with, is to put all the Federal employees, retirees, congressmen/woman and their dependents on Medicaid.. then see how the program will morph into something palatable for all!

Medicaid in its present form doesn't work, as evidenced by the many comments above. I cannot afford to treat patients under that program, and have never participated. Better to provide free care to those existing patients who fall on hard times and avoid the frustration of dealing with an inadequately funded bureaucracy.

If a reform effort is to be successful, it must incorporate financial involvement of patients so that they are motivated to get care which is economical and to modify their behavior so as to avoid the need for care made necessary only by poor personal health habits. Period.

Senator, you need to see this as any other business.
First, let's calculate how much each doctor needs to get for an office visit to cover all the expenses and be profitable.
So if you need to pay a doctor let's say $50-75 for a consult and Medicaid is paying $15, then stop right there. You either fix the problem or kill the program. But don't make medicaid bigger so it can bankrupt us all.
The same calculation goes for labs, x-rays, hospitals, surgeries, procedures, etc...
Simple accounting 1.0.1.
And make sure you include the skyrocketing malpractice insurance cost into the calculations.

Senator Alexander, start with legal reform. President Obama, tepidly, called for experiments in the states. Here's one: form the National Physician Health Corps; invite any Physician to join, and he /she will be given immunity from all but gross negligence. In return he agrees to see 10-15% of his patient contacts, Medicaid, or unfunded. Solves the access problem-Docs will stand outside their offices, inviting patients in, in order to make their quotas. And I, as an ER Doc, will not order a $175 chest x-ray on every cough, or an $1,800 CT scan on every headache, just to cover my own ass. When I instruct a patient to return in one week to check on his cough, and he doesn't, bingo; no negligence, no lawsuit, when that's the cough due to cancer. Patient's got to do his part. At the end of 5 years compare this system with the one we have, for quality; I'll wager there won't be much difference.
I can practice very good quality, cost effective clinical medicine, just the way my colleagues did 50 years ago, if I don't have to worry about lawyers feeding on my carcass. I practice Medicine conscientiously because I took an oath, not because lawyers make me. Get them the hell out of Medicine-their motives are base.

Senator, I appreciate your inquest to the sermo community, I hope you or one of your asssitants reads these threads. This is truly nuts and bolts of what happens in the trenches.

Do not read your congressional/senate reports... they are not accurate. Listen to us, you may be very surprised...or not.

I love what I do, as a surgeon I like to believe that I do make a difference, and I absolutely put patients first, with no regard to pay. That being said......I have bills, school loans, need food, and have a family to care for. Therefore, with all humility, and truth....If medicaid is expanded I will not only opt out of that, but will likely opt out of medicare. My first and only goal is for my patient, with no regard to abiltiy to pay or not. There is no difference for a sick pt. However, ALL patients [myself included] must take responsbility for their care, health, and progress. That INCLUDES PAYING THEIR BILL. Similarly, that includes valuing them [by medicaid] at the same level as anyone else. Why is there a different fee schedule for medicaid? Is diabetes or cancer or astham less virulent or easier to treat? Is there some magic forumula that reduces resources for them that is not present for medicare or BCBS? I don't recall EVER hearing that everyone has a God given right to a home, food, clothing. Why is healthcare/doctors different, and how so? Interesting that most pt's have a cell phone, HDTV, restaurant access, a car...etc.

As a parallel, for those peoplel that use food stamps, to assist them, the food stamp is valued at the same rate the paper dollar is, not 60 cents on the dollar. Similarly, grocers don't have to discount their products based on who is buying it. The price is the price. If you don't have 2.99 for bread, you don't go home with bread. Why are my services, care, training, expertise different?

Expansion of this system/philosophy is disasterous. If there is a plan to trap docs to seeing all patients on gov't terms/fees schedules, what Obama et al don't realize is that you can only kid a dog in a corner so long before it returns serve. YOU WILL LOSE THE MAJORITY OF DOCTORS, AS THEY WILL RETIRE OR CHANGE CAREERS. Everybody is replaceable, but not at one time!

How can anyone possibly expect a business to cater to a client but be paid 60-70% of the cost, then once the product/service is renderd [if payment is given at all], the doctors are fully liable and can be sued for 500,000 x the amount paid for the service to begin with. Really, does this question even need to be asked.

How about a tax credit for schools loans, or seeing medicare/medicaid patients. Expansion would be an option provided the fees provided some chance at parity, and was actually paid. The only proposals thus far have centered on increasing a sector that strains all those involved to begin with, but also offers REDUCED reimbursement on top of it.

Not only do we need medicare/medicaid fee increases, there MUST be tort reform, and regulation of the malpractice providers. There should also be sanctions and penalties placed on lawyers that submit baseless suits or dropped suits.

Every thing that we do is taxed or there is a fee. Everything that we do is mandated by some board/body and is mandatory. It costs alot, and there is no regulation on that either. Add to that the amount of overall regulation placed upon us, and you have a situation that is oppressive.

I am exhausted. I wish politicians left us alone and went away.with their lobbyists .somewhere... far, far away, where they cannot hurt humans anymore.

I know a colleague of mine and I answered this, but now I can't find it. We accidentally hit "send" and weren't done. At any rate, Center for Medicare/Medicaid services is a JOKE and this whole things is a FARCE. See above comments. As an anesthesiologist, I can't afford to accept Medcaid patients, but am doing so because our hospital requires it. I am considering how NOT to do it in future. By the way, get the Pay Czar to limit the pay of sports figures, actors, singers, lawyers, and politicians (lucrative speaking engagements, etc) and then talk about limiting medical costs and paying doctors only about 60% of actual costs! I'm sure the lawyers lose money on every client they see, right?

In my state, many Medicaid patients are enrolled in (mis)managed care programs which improve the reimbursement above the absolutely ludicrous Medicaid level, but which still means that I am carrying society's burden upon my shoulders, and my work, time, sweat, and expertise is compensated at a level well below the commercial rates. Why not allow physicians a tax credit for the difference between average commercial reimbursements (already discounted sharply) and the MC reimbursement? At least I could use the credits to lower my tax bill. This would resolve access problems as well. It might diminish the tax revenues derived from physicians, but it is clearly an excellent solution to access for Medicaid patients and their increasing numbers in these trouble economic times. Since the bill are originally submitted to manage care companies like Blue Cross and United, fraud would be difficult on the part of physicians. The determination of the tax credit would be relatively straightforward based on the differential between the commercial and MC medicaid rates. Primary care physicians whose practices are foundering on the low reimbursements from commercial and government insurance programs would be enabled financially to provide access and quality care without risking bankruptcy.

One of the distressing aspects of this "reform" of healthcare is the sense that the insurance industry is writing the legislation. When will Congress begin to represent the people rather than corporate special interests bearing campaign contributions for legislators? Frankly I despair of anything rational and helpful coming out of Congress as it is configured today. What is needed, Senator, is term limits on legislators (sorry), with publically financed campaigns within reasonable limits. I realize that this reform would impinge upon issues of 'free speech' under the Constitution. Yet it is clear that under this umbrella and subterfuge of Constitutionality, the government is now 'bought and paid for' by contributors. I believe that is related to fascism....

Medicare, Medicaid represent the worst in paradigms of government mismanagement and inefficiency. Individual patient empowerment is the key to reform, not at the organizational level (employer, "insurance" companies, government).

To Sermo Doc 9 from way-up-there, illegals are not qualified for Medicaid but their babies (born in US as soon as they cross border) and baby's babies are. So, send them back!

In the current scheme of things, expanding Medicaid will be a disaster. As noted by so many of my colleagues, less physicians are interested in handling patients with Medicare. This will only further overcrowd ERs and increase morbidity and mortality for them AND the hard working citizens whose tax will have to pay for this.
Let us look at some places where there is obvious wastage. What is the amount spent in the last month of life?? I have seen so many patients on vents when they are 90 with a terminal cancer. I believe in patient choice, but the problem is, there is no incentive to have a family meeting to discuss what the goals of care should be. Coordinating the time of multiple specialists- which the family wants- for free is impossible. Now, this was called "death squads" and "killing grandma" and killed. Patients continue suffering. So when I hear the need of cost saving, this is obviously just political posturing. How about having all patients sign a advance directive to be eligible for Medicare? They could be changed any time, but let everyone be allowed to express what they want. After all, we want to honor their choice right? If I know in advance that my patient never wanted aggressive measures, I can make the right decision for him.
Next up, what percent of the medical expense is administrative? How can we cut down on this? Tort reform to protect doctors and decrease defensive medicine. CT scan for all headaches?? CT abdomen for all tummy pains?? Yeah, if we dont do it, it will come back to bite us in the backside. Further, the coding system and the paperwork for reimbursement. No physician ever has found out how much patient care pays. The system is too complex, and the only folks who make money are the insurance companies and the AMA. Why do the insurance companies enjoy anti trust exemption?? Cut their profit margin to buffer physician payments, and allow this to be negotiated- at this point, we can do nothing by law.
I still believe that everyone should have access to health care. I also feel strongly that one should take responsibility for their health. If I do not pay my tax or my utilities, I do not have a social worker help me fill up forms to receive aid. There is almost no reward for living healthy. Being morbidly obese gives you the advantage of getting medicare without having to work for it.
The problem is, the vested interests (lawyers and insurance companies) are deeply entrenched and care only about their bottom lines. Unless we do something to completely overhaul the situation, we are going to be in mess that is worse than today. It is tragic that those on capital hill ask for our opinions only to see if it fits with their policy, but not whether it is for the greater good. You could make an exception by responding to the comments in this thread, and prove that this is not so.

eleven dollars in NY for an office visit.
This is a joke and insult to my intelligence.

I agree with tax breaks for seeing Medicaid patients and mandatory arbitration if they decide to sue. Or, payoff of student loans based on how many Medicaid patients one sees, plus the mandatory arbitration.
Kaiser has (had?) a mandatory arbitration.
We need incentives, because we have to make a living.

North Carolina just decreased Medicaid reimbursement by 8.9% on all but a few e&m codes such as routine visits. The rational was a budget shortage for the state. The global fee for obstetrical deliveries and antepartum/postpartum care were not spared. Medicaid is already our lowest reimbursement and now we will get even less. At some point, the time we spend is worth more that the compensation we get and it's not worth accepting Medicaid. I just wondered if the state cut the amount it pays BCBS of NC to administer the state health plan?

All great answers above. Alas Senator Alexander is playing with you. He is from Tennessee and knows full well about TENNCARE. I seriously doubt any of the above comments will even be read much less considered. Its all politics

Sermo Doc 106, agree 100 %.
We spend hours giving advice and suggestions to Sen. Alexander and Coburn but they are only interested in those proposals that fit their own Policy and help improve their own situation in the Senate, esp. with lobbyists from Pharma, Insurance, and Trial Lawyers.
Vote them out in 2010.

Medicaid and Medicare are entitlements, not suggestions. therefore, the federal courts will make the government increase rates so that there is access to care. Nancy Reagan was right...JUST SAY NO! IF your state decreases Medicaid, drop out and have your medical society help the patients file suit in federal court. this happened in Arkansas when then Governor Clinton decreased Medicaid reimbursement. the Fed Court made him rescind the cuts because of lack of access to care.

The only downside to this, what the gov. is planning anyway, is nationalizing us like air traffic controllers. Highly unlikely in the short term...people know their docs, not their air traffic controllers.

Agree with most of the above posts. No use expanding a broken program that re-imburses less than the actual cost of care and is ran poorly. This will only flood the ER with non-emergent cases at best and preventable critical illness at worst. Fix Medicaid first, then talk to us about any expansion.

Medicaid in our area is better than nothing, but not a lot better. Access is still very limited as most docs are not accepting new Medicaid patients, so they get their care out of ERs at very high public expense. Most of Medicaid is handled by Medicaid PPOs which have extremely limited formularies, so the patients often can't get the drugs they need. It would be a lot better if real insurance was provided for the uninsured.

Psst, psst. So many voices and not a sound heard.

Let me echo the comments made by other physicians. Here in Washington state, medical coupons (our Medicaid) pays 100% for pregnancy, pays break even for kids, and loses money on every adult seen. Some practices here in rural Eastern Washington are allowed a special designation which allows them to doublebill medical coupons and receive nearly 100% reimbursement. Many practices in this area limit the amount of medical coupons they take, if they take them at all, because of poor reimbursement. Extending Medicaid as a public option would not increase accessibility, unless the reimbursement issues were dealt with.

Republicans, do not have clean hands on this issue. They had 8 years under Bush to increase reimbursements and did not do so. They also had eight years under Bush to do something about tort reform and did not do so. Now, they want to use physicians as a club to beat up Obama.As soon as Obama receives his beat down, physicians will be yesterday's news.

Politicians, regardless of party, do not seem to understand that when the government pays poorly for medical care, third-party payers soon follow suit. If the government says women over 50 only need mammograms every two years, then third-party payers decided they will only pay for mammograms every two years. That's just one example of how the government sets a standard that injures patients.

So to answer the question at hand, increasing Medicaid coverage will not really solve the problem unless the government is willing to pay fair market rates for services rendered. At this point, I see lots of proposals for taking money away from Medicare, which also doesn't pay market rates, in order to pay for all of this extra care. Just robbing Peter to pay Paul.

I will echo comments made repeatedly on these issues. You cannot take a serious look at reimbursements, or costs, without dealing with tort reform. Even that will not solve the problem for this reason. Ordering unnecessary tests began as a way to protect physicians from unscrupulous lawyers. When reimbursement drops occurred, it was only a small step from ordering unnecessary testing for defensive medicine to ordering unnecessary testing to increase production and increase revenue, which is called "churning". Every "integrated healthcare system" churns patients to squeeze out every possible dollar. It is due to the slippery slope that started with defensive medicine. Only by reforming the tort system, protecting physicians, and lowering the cost of defensive medicine will you see any cost-benefit. It may be too late for significant change to occur, because churning has become so much a part of the culture of medicine.

How the patient who can afford private insurance arranges to pay for his care is between him, his insurer, and their god. With public funding it affects us all.
Two arrangements could change everything. One is the elimination of the liability threat. The other, which would in part achieve the first, is a financial stake on the part of the consumer of health care in the utilization of healthcare services. This is not achieved by a simple co-pay with a ceiling. It would be achieved by payment for every service, as in days of yore, except with the percentage of the fee set by a patient's income, the remainder funded by Medicare, Medicaid, or whatever government scheme that is or would otherwise be paying an insulating amount of the tab. A bureaucratic nightmare? Actually, a walk in the park compared to government rationing. ED users who must be seen regardless? It comes out of the welfare/SS check.
This puts the decision making/rationing in the hands of the patient, brings prices down as patients select the cheapest alternatives, and brings costs down as they chose to do less rather than more - dramatically less. Supply and demand rules. Common sense is again seen in the land. It's hard to imagine that such a form of empowerment wouldn't save us all from insolvency.
If this were to be implemented, perhaps Medicaid could afford to pay and expansion be a reasonable course of action. Otherwise, I concur with the sentiments of basicscience , Sermo Doc 3 and others.

This discussion reminds me of an editorial I wrote a couple of months back. Here are some exerpts:
"I decided to embark on an experiment. If WE were congress....how would WE fix
the problem? Many of you have opted out of health insurance. Many of you are
thinking of going Fee for Service because you can no longer afford to remain
hamsters on a wheel. All of us have ethics. We feel for those who cannot afford
health care but know that we too need to be able to make our mortgages.

So then, if we were to create an IDEAL system, what would it be?

Some of my thoughts are:

1) CHOICE: The patients, not bureaucrats, should be the ones to decide who is
the best for them. Whether this is a physician who spends an hour every time
going over all aspects of their life and medical options or a physician you
offers internet access and on-line visits, this is a decision that should be
left to the consumer.

2) TRANSPARENCY: As a physician, I am willing to post my fees. If I am willing
to do so, the insurance companies should do so as well. They should not be
allowed to pay Physician A $70 for a 99213 but Physician B who is right down the
street gets $55. Many patients do not see the true cost of health care. They
have their physicians file their claims for them and forget about it. People
will only realize the TRUE cost when they have a vested interest in the cost. If
an insurance company, hospital or physician does not meet their needs, they can
take their dollars elsewhere. Perhaps instead of the usual medicare tax, we
should have a "health savings account" tax. The patients can tap into that fund
as needed, and then have the ability to purchase or "elect" a catastrophic plan.
Everyone should have this choice, the poor, the elderly, the middle class. The
difference is that the money directly goes to a patients HSA-not to a
bureaucrat. The patient decides how to spend it.What do you think? Any other
ideas?

3) COMPETITION: There is a need for health insurance. However, more competition
, and I mean REAL competition, is needed. A person should be able to take their
insurance with them when they leave a job or transport it across state lines.
Employers who wish to provide this as a benefit should be able to have real
choices. Insurance companies that cut bureaucracy and provide good customer
service should be viable and allowed to survive. Those that are inefficient and
have poor service should be allowed to go bankrupt. The power needs to shift
from the insurance conglomerates and the rules/regulations back to the patients
and physicians. Should small business who provide this benefit be allowed a tax
break instead of actually being taxed? Think about it yourself-we are all SMALL
BUSINESS OWNERS..any other ideas? Should insurance companies be forced to take
on "pre-existing conditions" or should they get a "tax incentive" to do so?(not
government $-don't need another Fanny/Freddie Mac)

4) TORT REFORM: Enough is enough. We as physicians are willing to be
accountable, but we can no longer be paralyzed by fear. Should we be able to
deduct malpractice insurance premiums? Force caps onto torts? What about the
physician registry? If the registry has the number of law suits files against
us, why not a registry of the patients that have filed?

5) PREVENTION AND OUTCOMES: We all agree that we not only need to treat disease
but actively prevent disease. I must admit, I have a fundamental opposition to
Pay for Performance. I feel that the current system is another bean counting
program that creates more of an administrative burden for the physician, all in
the spirit of attempting to get paid. The other issue that irritates me about
P4P is the possibility of cherry picking your patients to bolster your numbers
so that the physician can get paid. Patients that have an opposing view or who
are non compliant will be dropped from practices. Perhaps we should have the
consumers decide. They should be the ones that choose how well we perform.
Hospitals already have performance measures, however it is more difficult for
the individual physician. Any REAL solutions to this? The P4P concept seems
flawed.Remember, some patients do not take well to aggressive treatment. They
may not want to take another medication for their diabetes. Isn't that their
right? Should the physician be penalized for doing the right thing?

6)ACCESS and PHYSICIAN RECRUITMENT: We do not want to repeat the catastrophe in
Massachusetts, universal health care-no physicians. We need to recruit the best
and the brightest. The issue of course is the lack of monetary incentive and
crushing debt. We do not have enough primary care physicians, the back bone of
the health care system. We also do not want to irritate or sacrifice the
salaries of specialists. They spend more time in training and should be allowed
to charge more. They should be allowed to focus on their specialty instead of
primary care. Outcomes are better with primary care access. We can agree that
many of us did not go into medicine for the money, but we did not anticipate
barely making the mortgage. We should be allowed to make a decent living based
on our years of study and training. If we change the system to a consumer based
system, this could help. Should we change our fees to a "time based" system?
Charge an hourly rate? Tax deductions for student loans? What are your thoughts?


We CAN change the system for the better. The real solutions are not being
discussed. Let's put our heads together...what are your thoughts? More
important-what are your solutions!"

I believe that those that have paid into a Medicare system should have their $ given BACK to THEM in the form of an HSA. Let the individual decide how to spent their dollars...across the board.

Some of the ideas circulating here are good ones: increase FQHCs, tax credits to specialists and primaries for "charity work", etc. I am sure we can come up with more creative solutions that include high quality care, efficiency and freedom for all. Unfortunately, we were not privy to the discussion.

One of the major problems with Medicaid that I see as an Emergency Physician is the lack of consequence for irresponsible (convenience) use of the ER for minor (or even non-existent) medical problems. A common problem is the mom who presents with her 3 or 4 kids with simple, unambiguous COLDS.

It takes a lot of time, undisciplined kids running around while you're ttrying to examine the others, etc. Most of the time, they haven't even attempted to call their PCP for an appointment because all they have to do is walk in - see a doctor - no muss, no fuss.

There needs to be some ground rules and EMTALA needs to be modified so that we can say "NO" to the irresponsible utilization of the ER.

"There needs to be some ground rules and EMTALA needs to be modified so that we can say "NO" to the irresponsible utilization of the ER.

Amen to that, Sermo Doc 113! We need to put intelligent mechanism's in place to allow for appropriate triage...if it belongs in the PCPs office, then send them there, and to discourage this kind of tremendously wasteful utilization of very high cost care.

At our hospital, last week, a mom checked into the ER at 10pm because she had run out of Tylenol. She was covered by Medicaid, she was evaluated and finally told them that she just wanted free Tylenol. There were plenty of places open in town to just buy it, but she wanted Medicaid to cover it...unreal!

Amen, OklaERdoc and Sermo Doc 7! Preach it brothers (err, or sisters)! I refuse to write scripts for OTC meds for medicaid patients any more. I just tell them, "the dollar store is down the street".

You know, it is really quite simple. In a small private practice, you can not see too many patients at a loss...that is, PAY to see these patients. Medicaid is a big money loser for EVERY patient seen. That is why, for survival, I stopped seeing Medicaid and several of the 'bottom feeder' insurance plans that pay below cost. Increasing this population of patients won't affect my practice--I still can not see them. However, allow Medicare to lower payments by 21% in January....I will have to stop seeing them as well!! To do otherwise would be the demise of my practice. Virtually every colleague that I have discussed this with has said the same thing! And to those poor seniors who can not afford to pay out of pocket---good luck finding a Doctor who will accept your medicare card!! Add 50 million more americans (senior citizens) on to the 'no health coverage' list!!

I have to agree with many of my colleagues here. Senators wanting to use us a tool in their political games have no place in a scientific forum. Let us stop wasting time on this.

1

My office called the POLICE the other day for a MEDICAID patients (threatening other patients, shouting at the office staff) to get her meds because she missed her
1. appointments
2. refused UDS
3. Made excuses like being refused at the local ER

SENATOR Alexander, Im furnishing her your office number as an EXPANSION of MEDICAID plans in CONGRESS!

Should people from Haiti be showing up at my clinic with medicaid insurance paying so they can ask me to write letters to their consulate to get them a longer visa because they need medical care here (at the taxpayer's expense)??

This has happened.

I thought not...

We no longer accept Medicaid at our office. Every time I see a Medicaid patient I lose $23, or said another way, everytime I see a Medicaid patient I give the government $23. In our community no one accepts Medicaid, they are all sent to the local university. Expanding medicaid would make access worse not better and would only encourage the few MDs that still accept Medicaid to join the rest of us and stop accepting Medicaid.

No one is talking about true reform. What makes more sense is to allow young healthy people to 'buy into' medicare and get coverage. This could be a simple 'public option' that could actually help finance and keep medicare afloat. It makes sense for younger healthy people to help offset the expense of older sicker patients. As it is the health insurance companies get the <65 year old polution, make their money, and send the >65 year olds to the U.S. Government.

NO, NO, NO!

It's a system that works poorly already - why expand it????? All of the above negative comments are correct. The Medicaid patients are the least motivated to heal themselves, the most needy (and expensive), the most entitled and the ones who contribute the least to our productivity. As I told Senator Colburn, you can have it good, fast or free - pick 2.

Link payment rates to tort reform (no pay, no judicial play allowed), demand a co-pay, require a depo/leupron shot to EVERY SINGLE RECIPIENT of state funds between the ages of 9 and 55 when they pick up a welfare check every month, require some copays so they don't waste our time with missed appointments, and take some of the stifling paperwork off our heads. That would save money.

The way things are going now, by the time I retire the country will be wallowing in it's own entitled, obese, smoke-ridden grotto of uninspired, uneducated medicaid recipients surrounded by their innumerable, miserable offspring.

BOTTOM LINE. Our primary care practice is in the red- barely staying afloat. WHY? because of our high Medicaid population. If it was expanded? We would fail. How does that help anyone?

I had a thirty percent no show rate this morning- and how many of them were medicaid? 100%. If they had to pay just 5 dollars- they would have been here. And maybe there are transportation issues?? We are a small town- most patients WALK to clinic.

Mr. Alexander,
No insult intended sir, but I do not belive that you are sincere in your efforts to incorporate our ideas. I do not know how you voted on HR 3200 or HR 3400, the bill to include congressional members on any public option, illegal immigration reform, cap and trade or any number of issues that are tearing this country down and apart, but asking us questions on this forum, without responding to our comments is disingenous at best.
Do you want our ideas on what will work? I promise you that if you invite some of us to DC to discuss REAL ideas and draft proposals, we would be there in a heartbeat. That we have gone in Sept and Oct under the banner of various groups underscores our committment to *positive* change, but I feel like it's all lip service on the part of congressional members.
NO- expanding medicaid will NOT work. There are plenty of ideas already stated that will work, and serve to decrease costs, improve access, efficiency, outcomes and satisfaction. Tort reform and integrating personal responsibility in the healthcare equation are my hot buttons.
I hope you are sincere, and do listen to our voices and take this info to all your colleagues in the beltway.
Yvette R.R. Burdick, MD

Dr. Burdick, you are so right!
If he does not know that Medicaid is a failed system (he was a governor!)
then they should not be where they are. They have the answers (we have given them to all the politicians) they just do not fit their interests. All they care is votes!

Dear Mr Alexander,
I am concerned that expanding medicaid would be a grave mistake for two reasons:

1) Medicaid has the lowest re-imbursement with the highest amount of administrative overhead ( processing pre-authorizations, denials) and therefore loses money for many physicians.
2) My State is already having difficulty funding its Medicaid liablities. Our un-insured rate is roughly 21%. There is no plan in place to adequately fund the proposed expansion of services.

If I can be of any further assistance you may contact me at idahomountains@aol.com
or (208) 955-7246

James Morland,MD.

I was a Republican, about three years ago, but the Republicans have been total failures in harnessing the deficit. In addition, they sent troops to Iraq for unclear reasons. I am not a Liberal since I was in my late twenties, when I entered the "real world". I believe our current entitlement programs *harm* rather than hurt people, because it gives them no incentive to strive for success.

Medicaid is an entitlement program that only a fraction of the people who receive it really need. The patients pay nothing for their care and maybe a dollar for their medication. It is a useless program because few doctors will see these patients. The only plus side is that the politicians can pat each other on the back and say that they are maintaining a program that gives poor people "insurance". Politicians can also get pay offs from Medicaid "managed care" companies for the money they take out of Medicaid.
Give me a break.

Senator, I answered your survey, and my sentiments are already expressed in multiple posts above.

But I do want to thank you for taking the time and expressing the interest to hear from the 'docs in the trenches'. I we work together, we COULD improve the American health care system. It remains to be seen if the current disastrous special-interest giveaway will destroy any chance at real reform. If it fails, please keep in touch here - I believe many in this community truly do want to see things improve.

To understand the farce unreasonable reality of this idea, consider the following: Maybe we should eliminate Medicare and the VA. Then we can put all the elderly, the disabled, veterans and the poor on Medicaid? Enough said. I rest my case.

Senator,

I would LOVE to go to Washington to discuss with the public policy "experts" how medicine runs in the real world. When I finished residency, I accepted Medicaid patients as part of my obligation to care for people who had less financial resources than I have. Now, 15 years later, I only take Medicaid patients because I am required to take hospital ER call and admit adult and pediatric patients without a physician. These patients scare me, and I feel I am playing Russian Roulette with them...just waiting for the time when the highly litigious Medicaid patient finds an attorney willing to blame me for their own unwillingness to take care of themselves (Example Long ICU stays for alcoholics with cirrhosis and GI bleeds. Good forbid that the paitient did not get scoped for the hundreth time or recieved that sixth unit of blood because of my incompetence!).

I agree with tax credits to doctors who are willing to see Medicaid or uninsured patients. I volunteer at an indigent ("good samaritan) clinic, and see a large number of illegal aliens. They still end up getting care, whether the American people want them to or not.

I don't buy the theory of the policy experts who claim that expansion of healthcare can be paid for by elimination of fraud and abuse. It is NOT fraudulent for a doctor or hospital to charge for a patient who developed a UTI from a Foley catheter that had to be kept in (or any other infectious, wound infection, bleeding complication as a result of a procedure. Medical care is COMPLEX. Removing the Foley catheter in a ventilated patient is not an option. Refusing to pay the hospital or doctor for care as a result of a complication does not eliminate fraud and abuse. It simply means those costs for that patient have to be passed on to other patients.

Healthcare reform in whatever form--public or private option--would be paid for in it's entirety (and I will argue till the end of time with the policy experts) by eliminating overtesting/defensive medicine to cover yourself (huge, huge huge part of the healthcare costs, not the 1% of healthcare costs that policy gurus claim).

Trust me, I live in the real world. Every patient of mine who falls and hits any part of his body gets a stat head CT. My own internist orders a transvaginal ultrasound so that she does not miss any ovarian cancers on EVERY PATIENT she does a PAP on. One patient that you miss who has a cerebral bleed, brain tumor, ovarian cancer or breast cancer will ruin your life's work as a physician. Every patient with a headache gets a head CT. Every patient with unexplained abd pain gets stat head CT, except for United Healthcare and BCBS patients, who require pre-authorization. Those patients get a referral to the neurologist, gastroenterologist or other specialist who then gets the preauthorization and does the test anyway, becasue they don't want to be sued. That way, the insurance company has now paid for a CT and an additional consult--money that would be saved if I were not a single Mom and worried about losing my practice and livlihood to an unplanned adverse event (not my error) in a patient. Oh, and did I mention that every patient with a twisted ankle gets an X ray and a orthopedic referral? And another X-ray if they are not better in 72 hrs. And EVERY DOCTOR in my community practices this way. They are who I learned this fear of litigation from.

Tort reform/universal sovereign immunity (which I have at the indigent cinic where I hardly ever order tests other than a glucose, creatinine and HgbA1C, mammogram and PSAs) is essential to rein in healthcare costs. But the attorneys in Congress are not listening. Come to the indigent clinic where I volunteer my time and see how much money we save (and do so without the help of highly compensated specialists who won't do charity work).
Profit motivated private payors have no place in the healthcare field. Private insurance CEOs who make $20 million dollar salaries have no right to tell me that I have to do an "override" to prove my patient needs the medication I prescribed. They pay for wellbutrin for depression but not for smoking cessation. This makes sense only to a profit motivated person--insurance companies and insurance agents who make enormous profits selling insurance

The problem with expanding Medicaid, Medicare or any public government health program is the unending bureaucracy. How many Medicaid clerks does it take to change a light bulb, I mean deny my claim? I don't even file with Medicaid anymore--it costs me more in paper and staff salaries to bill Medicaid than write it off.

SInce Congress has the best health insurance benefits (I take care of some members), they would never consider using Medicaid for their own needs. As a solo practitioner, I have an HSA with a $2900 deductible, just for me. I pay $300/month for insurance (I am completely healthy) and $250 contribution. Why does a Senator get better health insurance benefits than me?

In my state, women automatically get Medicaid when they are pregnant. Yes this helps them get prenatal care, but promotes them to have more children (who never asked to be brought into the world to allow their parents more money from the government). And since few doctors accept Medicaid patients, they all go to the ER (by ambulance by the way for "Severe sore throat" translation they ran out of Motrin). While in the ER waiting room, they talk on their cellphones and eat out of vending machines (great nutritional teaching for their children!!). Why do Medicaid patients always have better cellphone and cable TV plans and television sets than I do? Even requiring a $2 copayment would make Medicaid patients more accountable for their medical conditions and care.

So when healthcare reform comes, and my fees are decreased even further (how is that even possible?), I don't know what I can do. I am too in debt to retire (and love my patients and profession). Do a Urology or Radiation Oncology fellowship? Have no idea.

So in summary: No to expansion of Medicaid, yes to increased physician reimbursements, Yes to tort reform. End of millions of unnecessary tests. Oh, and don't even get me started on patients who come in asking for "total body scans" and all blood tests to rule out cancer....

Organized health insurance is part of the problem, not the solution. We need to just use insurance for catastrophic illness and not everyday office visits. Physicians need to be transparent in their office fees up front, so that patients know in advance of their appointment what their appointment will cost.

The problem with the current health care reform mentality is "medicine" is seen as a one-size-fits-all profession. They are trying to apply across the board principles to all medical specialties and it will never work.

Outpatient primary care, outpatient mental health, surgery, outpatient surgical sub-specialties, internal medicine procedure based specialties, diagnostic specialties (radiology, pathology, lab) are all tremendously different and require different approaches to reform.

Lots of things need to change in our healthcare system. Expanding the currently existing inefficient and dysfunctional programs like Medicaid and Medicare is not the answer.

If it doesn't work, why expand it? Medicaid doesn't work... it doesn't pay the overhead. No point of seeing medicaid patients.

How do you make it better? Make it work.. cut off what it covers that is not essential and recognize that those people will not get the best quality of health. You are going to have to ration medicaid more to make it work as medical coverage. Either cut down the number of people covered or cut down the things covered and increase reimburisement.

You also may want to reduce the paperwork involved termendously... there is nothing stronger at making a physician stop seeing medicaid patient than having to file forms and make phone calls. We got enough things to do as it is and dont need the extra run around. Cut the hassle please.

PS: Tort reform is the ONLY solution that will save US medicine. Today a physician ordered a head CT scan for a patient that fell that CLEARLY was not needed but was done to cover himself... that needs to stop but that will never happen without tort reform.

I agree with Sermo Doc 84...it is ironic that we are discussing this in the midst of recent passed legislation that promotes the flawed payment systems.

Medicaid is a disaster. The majority of my practice is Medicare, which as we all know has a poor payment percentage. Medicaid is of course worse and thus I cannot afford to take this. This is a shame because, as a dermatologist, there is certainly a need. Patients in need are seen regardless; however, it costs my office more to pursue the ridiculously low reimbursement and is often better spent not pursing this at all.

There must be some incentive for physicians to participate. Government cannot simply say this is how it is...they forget that physicians are necessary components to this puzzle. I am young and cannot retire now, like many of my colleagues who say they will if the public option passes. I also do not want to do this - I went to med school, worked my you know what off, did a derm residency and a Mohs fellowship, and love what I do. It is a shame that we are subjected to the policies of those who understand medicine the least.

Someone else mentionted this also...how about patient responsibility!

Let's add up the Feds unfunded mandates:
1. Conversion to 5010 electronic transactions: cost unknown
2. EMR mandate average cost over 5 years 220,000 less 54,000 stimulus: $175000
3. ICD 10 mantaed by 2013: $80,000/ physician
4. $45 BILLION saving in tort reform not worth pursuing!
5. SGR medicare pay fix not done
6. Expand Medicaid with reimbursements less than over head to pay for the above

PRICELESS!!!!!!

IT IS QUIT CLEAR WHY THE CONGRESS HAS A 18% APPROVAL RATING
The out come of this bill is the expansion of cash only outpatient primary care and severe access shortage but at least everybody will have insurance.

There needs to be incentives built into the system for patients (perhaps HSA type of financial empowerment) and physicians to deliver care in the most cost effective manner, including reducing ED visits, easier preauthorizations. The patients need empowerment, better education for preventitive care, and they need to contribute meaningful time (ie volunteer work) back into the system. Getting "something for nothing" does not foster responsibility and is a poor role model for their dependents. Throwing money at the problem without implementing meaningful changes to avoid waste is just as dangerous.

Fox News - "The health care overhaul bill produced by House Democrats would impose an array of new taxes, fees and government mandates on major players in the health industry, including insurers, doctors and drugs and medical devices makers."

Why is this process not more transparent? I am tired of the deception and lies. Why do they think they can tell the public whatever they think the public wants to hear, and hide what they know the public will not tolerate?

WHAT WE SEE IS EVERY CONCERNING. WHAT IS MOST CONCERNING IS WHAT THEY ARE TRYING TO CONCEAL. Y0U CAN BET WHAT WE DON'T KNOW WILL BE A LOT WORSE THAN WHAT WE THINK WE KNOW.

The current system of medicaid has merits. It aggregates those least likely to followup, follow recommendations, and most likely to sue. It provides the additional benefits of reimbursement BELOW overhead, so that one need not feel any guilt refusing to see this cohort of individuals.

I do however have a special subset of medicaid patients who by the process of natural selection VALUE my services enough to pay a 20$ no show charge - which they will inevitably incur. I enjoy my time with these patients, and am happy that my clinic somehow makes ends meet. NO I am not "making out like bandits" as the esteemed govenor in my state has suggested of physicians.

I will however continue to refuse to accept new medicaid patients, and the rationale should be obvious. Our patient performance statistics will be publically reported shortly. The other Endos in town refuse medicaid.

Expand medicaid all you like.

I do not take Medicaid because it pays so little. I would go broke seeing Medicaid patients. I have a hard enough time covering my overhead as it is!

I agree with those who note the problem of for-profit insurance companies - interesting that we are the only industrialized democracy in the world where these exist (plenty of other countries have private insurance, but they're all non-profit). Clearly for-profit insurance companies have an unreconcilable conflict of interest. They usually put their fiduciary responsibility to their stockholders above the interest of the patients. Eliminating exclusions for pre-existing conditions, and requiring everyone to have insurance, would be a good start.

Senator: the facts are clear. If we could take all of the money paid annually to Managed Care we have enough to have a first class health care system for All Americans. I hope you receive no money from Managed Care companies. 30% of dollars given to Managed Care go to Executive compensation and is lost to actual care. 6% of Medicare Dollars is lost to actual care. The answer is not expanding Medicaid but correcting the faulty reimbursement structure of Medicare and expanding Medicare. Medicare is very efficient but pays 4 to 5 times the actual cost of expendable and durable medical equipement and it incentivizes procedures over preventative care. But Medicare has some dedutibles and some copays. Medicaid patients have a huge no show rate and with Managed Medicaid the Physician is hit twice by increased bureaucracy and 30 % denial on top of the high no show rate. Managed Medicaid provides no added value and is 17% less effcient than straight Medicaid. I would be happy to shift the $11,000.00 "tax" I pay for my awful Managed Care plan (not including copays) to a new repaired Medicare system. I am tired of watching Managed Care executives suck the health care system of financial resources. In addition to addressing the corrupt ethics of Managed Care companies we need to address the corrupt attitude of Americans who take no responsibility for lifestyle choices. The Safeway Corporation has an excellent lesson for us by providing incentives for employees who reduce their health care risk by implementing a healthy lifestyle. Our health care plan needs to provide incentives for not smoking and leading a healthier lifestyle. There are solutions here: Americans must be told they have a personal reponsibility for their health; Americans must be told that they cannot get something for nothing; the dollars Americans pay to Managed Care must be transferred to a direct payment system with no middleman and Managed Care Executives told they will no longer get something for nothing. Senator Alexander you can be a "profile in courage" or be forgotten like a long list of Senators who have gone before you.

Expanding Medicare downward to age 55 makes more sense and would be better for everyone concerned if the SGR is fixed!

I am voter #875. I agree with the vast majority of my colleagues.

I am a physician. I am also a husband and father of three children, one of whom is autistic.

As a result I have many obligations. I have a duty to my patients to provide the best reasonable care at an affordable price. I also have a duty to my family to feed, clothe and raise them. I have a mortgage to pay (actually two!) and have no intention of joining the ranks of the foreclosed.

When the time comes that I no longer am able to adequately (not opulently or extravagantly) provide the basic needs of my family, then the time for hope and change is at hand. I will not cling to a false hope in persisting working as a physician. I will change to something, anything else that will put the bread on the table, gas in the tank and clothes on their backs.

I will not work for free, for that is what Medicaid is. By the time you pay overhead expenses, there is nothing left to take home.

You can quote me on it.

I invite you to email me and I will happily discuss the drastic state of medicine as it is for this doctor. I feel as if I have been blowing against the wind. I am spent and ready to leave.

I don't need much encouragement in this direction.

PS

In my humble opinion, managed care is nothing more than a "front" for organized crime. It is sure run that way!

I would like to see Government programs designed to get people out of Medicaid...............

Medicaid in California (Medi-Cal) covers poor people so-so for primary care (often administered by "mid-levels"), but I've seen patients nearly die because specialists won't accept Medi-Cal. I can't blame them too much, since it often doesn't cover costs!
We need a "single payer" type Canadian system that controls all costs, especially drug prices. People live longer in Canada and do better on EVERY objective scale. But when it comes to health care, pharma and the insurance industry essentially run congress and hence the country! Most civilized countries consider accepting $$$ from the lobbyists, like you do, unethical and often illegal!

Thank you Senator ,for asking our opinions. I noticed if the patients paid for service, they get well faster,the ones who don't pay , comes back for multiple follow ups, because it is free. Also medications are so expensive as compared to other countries. If we can cap the malpractice insurance , cap the reward payments to lawyers, cap the CEO salary for insurance companies, it may help...

To put it simply, as it currently stands, I would find it difficult to locate any physician that does NOT lose money on seeing Medicaid patients; that does not even account for the extra time that my staff has to spend trying to get tests and medications approved. If I did not feel the need to serve the community, I would not take any Medicaid.

Expansion of Medicaid and other proposals from the group of 545 in Washington are nothing more than an assault on the autonomy of physicians and a further erosion of personal liberties of Americans.
Furthermore, the fiscal projections for ObamaCare are laughable. Physician reimbursements having been decreasing, in real terms, for many years and health costs continue to rise. Imposing reimbursement cuts on doctors has led always and everywhere to an increase in volume of health care services producing higher costs. Currently, Medicare pays $.94 for every dollar of beneficiary care, while Medicaid pays only $. 86 for each dollar of care received. Touting costs reduction while expanding current entitlements and introducing more government funded care is ludicrous.
Read Tony Blair's lips: " We so don't have the answer to health-care. What we have is slightly better than nothing at an enormous unaffordable expense which won't last forever."
Amen.

NY state will destroy HOMEOWNERS as it usually does whenever Medicaid is too much for their offtrack budgets,, they DECREASE payments to the DOCS.. THEN THEY ALSO force the cost onto PROPERTY OWNERS.....every crisis , the state has no money for medicaid and schools but they force costly laws which force the COUNTIES to get the money from property owners.

this has been going on for decades .. both fake repubs and dems .In addition the DEMS flood us with ILLEGALS and islanders who have assests back home but are put on medicaid ,, further HURTING THE AMERICAN citizens..

No, NO , NO , NO, NO. Medicaid is a disaster - care is "free" so patients are totally uninvested in it - ER visits at midnight for sore throats, "Urgent" appointments for coughs and colds, requests for narcotics and physical therapy for every ache and pain - and it's all covered!!! My Medicaid OB patients come in twice as often for visits ( backache, I don't feel good) as my privately insured. They're not paying so why not? Medicaid patients want a prescription for Terazol for their yeast infections so it will be "covered" when over the counter Monistat will work equally well( they would have to pay out of pocket) They get mad if I refuse. Expanding this madness will break the bank. Here's what needs to happen:

1. Legally Require all citizens to carry health insurance.

2. Require private health insurers to offer STANDARDIZED plans - ie Plan A is the "basic plan" and has a deductible of X, Plan B is the "upgrade plan" etc.. so people can compare plans and prices

3. Let insurers offer plans nationally - eliminate state lines

4. Get rid of pre-existing conditions.

5. Offer a preventive health benefit - a set amount per year would be a good idea. Patients can spend this on those things most applicable to them- this year I'll get a colonoscopy and next year I'll get a bone density scan.

6. Cover things that save money - PT, nutritional counseling, birth control, generic medications, vaccinations, primary care visits.. Make pricey things a little more difficult to access - not imp[ssible - but just enough that people won't demand prescriptions for yeast infections, go to the ER for a sore throat, want joint replacement at the drop of a hat or demand an MRI for every headache. Make visits to specialists a little more pricey - this way everyone with a bellyache will not be tempted to demand a gi consult. Make "doctor shopping" expensive so patients will self regulate their consumption of care. Place mental health care on the same footing as everything else.

7.Subsidize premiums for the cheapest basic plan for those individuals who are deemed too poor to purchase their own insurance. Structure this so that families who aren't destitute can get partial subsidization - not the "all or nothing" Medicaid eligibility there is now.

8. Allow he who purchases the plan to take the tax deduction. If it's your employer they get to take it. You can refuse your employers insurance if you like and choose a different plan and take the deduction yourself. Limit the deduction to the price of the basic plan.

9. Make decuctibles reasonable. Someone working at Wal Mart isn't helped when they have a plan with a 2000$ deductible, or a 5000$ deductible for maternity care.

10. Take med mal out of the civil litigation arena and start health courts with panels of knowledgable people to decide . Structured settlements only. Limits on "pain and suffering". Caps on what lawyers can charge - or go to a "maloccurence insurance" system. If you have a complication then your maloccurence insurance kicks in to cover your out of pocket expenses so you don't have to sue. Reserve true malpractice suits for the most egregious cases. Could be "pay at the pump"-every visit/procedure has a small amount of extra fee tacked on that goes to the 'maloccurrence insurance" fund.

11. Prohibit DTC advertising for drugs.

I cannot afford to accept Medicaid b/c of the very low reimbursements. If I accepted Medicaid in my office, I would be bankrupt in a matter of months. The key to my financial survival is keeping my overhead percentage low, since I cannot really increase my volume & continue to provide quality care. Expanding Medicaid would simply put more pressure on an already overwhelmed & underfunded public sector-i.e.- mental health centers, health depts, & ERs, etc... I am currently a 'Participating' Medicare provider, but in 2010 I am going to become 'Non-Participating' & I expect in 2011 I will drop out completely due to poor reimbursement. I may also be forced to drop out of Tri-care for the same reason... Adding more patients to either system w/out improving reimbursements (esp. for non-procedural codes) will simply result in less access to care for everyone in that sysyem... Thank you very much for having the insight to ask for our opinion(s).............

Sen. Alexander:

You and your Colleagues broke CA and now you're breaking NY!! Which State is next on your Medicaid expansion list?

Scrap it and start over for God's sake if not ours!

The major problem with Medicaid has always been its poor reimbursement; from what I can tell, this varies from state to state.

A large number of Medicaid pts are seen in clinics which can provide efficiency, but rarely provide continuity of care---a necessary ingredient in developing trust. If we want patients to change their self-destructive behaviors (smoking, drinking, drugs, comfort eating), then we need, as a society, to provide them with a well-qualified, caring primary care physician who is easy to access. So, expanding Medicaid, without addressing these issues, is insufficient and doomed to fail before it leaves the gate, if you are truly interested in controlling long-term health costs.

If you care to email me, I can tell you what would work: pcobb21@columbus.rr.com

Sermo Doc 144 is an intelligent, caring person, so I suggest you email her.

Unfortunately New Jersey Medicaid reimburses only approx. 30% of Medicare (the lowest in the country), so most physicians don't see new Medicaid patients even if they are listed as participating in the program. Unless the Federal Government sets minimum reimbursement standards for Medicaid, increasing the number of people with Medicaid will not increase their access to healthcare.

The Medicaid system as a model for administering healthcare is actually a good system in our state. We can check on the internet and see if a patient is covered and the checks arrive usually within 2 wks. of posting which is also done electronically.

Patients though will need to have a co-pay or some sort of deductible in order to make them somewhat responsible for utilization of the program. An improvement in the reimbursement will be nice but not a possibility in the near future.

Dramatic expansion without some sort of personal responsibility to the patient will be a failure as overutilization will result. In order to absorb the cost lost to these patients we will have to limit the number of visits. Another form of overutization control.

Good luck to you and us. May the wisdom of Solomon be with you.

Low reimbursement rates and government bureaucratic hassle means most physicians will not see Medicaid patients. Here in CA reimbursement rates are so low that no private primary care docs in my town take Medicaid and the patient ends up in the ER dumping the low reimbursement on the hopsitals. Unless Medicaid pays at least Medicare rates these patients will be disadvantaged when seeking access to increasingly scare physicians. There is also a bias against Medicaid patients - they are seen as having less invested in their own healthcare, fail to attend for appointments and are more littigious.

I know of other type of LEGALLY ILLEGAL IMIGRANTS. You can see them in large cities. They come here 2- 3 times per year to see us. "get 6 months prescription coverage or 3 months supply of meds - take them back to where they come from (i am not trying to be discriminative, but I see a lot of them in Pakistani, indian, bangladeshi, south americans and puerto ricans communities) They all have medicaid and medicaid hmo coverage. I do not know how they get it, but apparently they do. Hundreds and thousands of taxi and limo drivers, cash business owners, construction cash workers, landscaping business, grocery store owners, fast food and gas stations - THEY ALL HAVE MEDICAID!!!!!!! Their wifes - "housewifes" - everyone is overweight, with metabolic syndrome, come to see us every day. These people drain the resourses, they come here to work - sent money out to their respective countries, pay O in taxes and complain when their brand name medication is not covered. I call them LEGALLY ILLIGAL imigrants...........

Thank you for asking my opinion. Our practice reluctantly sees Medicaid patients. They are treated just as well as any other patient. Fortunately, so far, non-Medicaid patients subsidize them. Overall, we are undervalued and under-compensated for our work. I feel that I am being taken advantage of and I resent it more and more. Expanding Medicaid and/or any other government program that will demand more of us for less will be unacceptable to most physicians. I will then opt-out or retire earlier.

agree with Sermo Doc 148: The Medicaid system is frequently abused by immigrants. At least a third of the people on Medicaid are those with means, who have no reason to be on it . The problem actually lies with the US immigration system that allows naturalization of extended family. We even go out to other countries and gather people who claim some form of torture/discrimination, a historic link to one of the "holy US partners" and we award them citizenship. The US taxpayer is the most exploited animal on the planet.

This point bothers me the most. Our president states that no illegals will be included in the plans. That sound great, but what he is not now saying, nor will he admit to later, is that the only way that can happen is to naturalize them, therefore they are now non-tax paying US citizens. Yeah!!!

The end result, we pay even more for the expanded approach.

If you don't pay taxes and live here, you do NOT deserve the amenties, and I should not have to provide that at the cost of my own family. That is what happens now, and what will increase with this legislation. I don't care if it is not politically correct, it is the truth. We need to get our head out from down below, quit mincing words, and do what needs to be done. If we do not, all will be lost, if it is not already.

Remember this country was built and thrived on immigrants....LEGAL immigrants. Illegal immigrants contribute only to those businesses that exploit their work, and use the sweatshop mentality. That doesn' contribute to teh GNP or DNP. It only drains the resources. Those resources should not be recouped from those of us that pay into to now.

My practice currently limits MCD. We had far to large a problem getting paid and when we did the accounting was a nightmare because MCD would pay a lump some without allocating the payments to the idividual statements. Even if the paperwork was easy the payments are terrible. I do not feel adding patients to MCD will help. If the state wants to help these patients then pay physicians better and PAY THE BILL ON TIME. Otherwise let the churches and charities provide the assistance-they seem to be doing a better job than the state or federal government/

the SETUP of Medicaid is part of the problem. The ONLY patients I ever hear say "Oh, it doesn't matter I don't have to pay for it myself" are Medicaid. There HAS to be a GENUINE copay (truly collectible) for both clinic visits and a LARGER one for ER visits to help them decide that getting care appropriately is important. For people with GENUINE illness that require frequent ER visits (like brittle diabetics) there could be some bonus visit funding decided on by the physician in charge, possibly reviewed by a board. Possibly no copay for genuine wellness visits/routine chronic disease management visits, with a copay charged if during those visits they come up with an "oh by the way" illness complaint, to prevent abuse. And there would have to be at least cost based reimbursement for the doctors doing this.

"indigent quality healthcare for all" should be the honest rallying cry of socialist plan proponents. Where in the media coverage comparing the US to fully socialized models is the 15,000 people who died in France during a heatwave in 2003 because the socialists didnt aircondition the hospitals?
en.wikipedia.org
Granted, we have A.C., but what future capital expenses will be overlooked due to the apathy of ambitionless healthfare?

Sick people are poor. The chronically ill often are unable to work, and cannot get work-based insurance. Many conditions are chronic, and would be described as pre-existing, and would cause exorbitant costs for individual purchasers, if they could afford them. This is especially true for conditions like schizophrenia, and genetic susceptibility problems like juvenile arthritis, or early-onset diabetes. Many parents have been bankrupted trying to get their children adequate health care for life-threatening and serious illnesses, and also, in such famiiies, the mothers or fathers have to stay home to care for the sick child or spouse, or elderly relative. There is no "give" for such able-bodied workers to be able to meet the familiial needs of a sick relative. If they stay home, they lose their own access to insurance. It is even harder when the medications are so expensive, and the patient needs other non-covered supportive services. These patients are the kind of patients who get dumped into Medicaid as soon as the insurance company can find a ruse to do so. Adolescents with mental instability or mood disorders are another high-risk and very difficult to treat problem. The insurers never want to pay for psychiatric services, especially when hospitalization may be needed. The toughest patients with the most difficult diseases always get dumped into Medicaid.
Physicians need to be paid, and we would like to not be bankrupted by charity care. In getting some payment, even if marginal, it helps keep us afloat. Many of us are struggling to keep providing care to a wide variety of patients, not just the affluent ones. If you really were willing to cover the poor, you would force the insurers to provide more services to the wealthy, to justify the cost of the policies. By having bigger risk pools, you encourage the costs to be more competitive. Without covering the poor, the cost-shifting and inadequate care for an ever-expanding layer of mothers and children and poor people continues, the ERs are more strained, and the physicians who feel morally obliged to care for the sickest patients to be at the edge of financial ruin, if not over the edge.

We don't need the 2,000 pages of crap that Congress is creating which will only add to the Trillions of dollars already poured down the drain of waste!

We need fixes to Medicare, Medicaid, Big Insurance, Physician Reimbursement, and Tort Reform. This can be done without bankrupting the Country.

The problem is how do we get the message to Congress????

OH, PLEASE! Have you ever heard of Tenncare and what a success it is???

Thank you for voting against recinding the scheduled 20% medicare cut!

I agree with Sermo Doc 2: more HSAs and insurancce shopping across state lines

Medicaid doesn't work, as it is depends on the charity of us docs!! BUT,
Expanding Medicare at a fair cost makes sense.
If younger, healthier citizens(i.e. those who are now being cherry picked by Private Insurers) bought into medicare,
It would: Spread the risk pool; Easily beat the for profit insurance pirates in terms of cost to purchasers;
Increase income to Medicare and increase the "float" which if invested properly would make money.
Medicare could easily become self funding if you idiot congressmen didn't take bribes from private insurance companies and steal tax payer money from Medicare!!

Dear Sermo Doc 40 Surgery,
You get my vote for the most intelligent, honest comment in this whole discussion!! (Certainly the hypocrite,
Senator Lamar Alexander is neither, intelligent nor honest.)

"ARE YOU KIDDING? Why not just put everyone in congress on medicaid first?"
I would only add, that congress should get paid as much as a doc who takes medicade patients, (after my rent, and staff costs, I lose about $15 per hour) so as I figure it, congress should be paying about $30,000 per year to keep their job.

Just feel that I must say, with all due respect, that it is a question like this from a politician running our nation that strikes the living fear into me.

It represents a complete lack of understanding of the reality of modern medical business practices and how very little a goverment "insurance" pays us.

Like the mythical $30,000 amputation payment that Obama made up in his ignorant mind, these politicians think that doctors are all just millionaires playing golf all day.
Wake up! Most of us are faced with abuse after abuse from medicare and other insurances and many are on the brink of closing shop because we cannot afford to keep the doors open because of pitifully low reimbursement combined with high overhead.

I am totally depressed by reading (most of) the posts above. And I agree. Medicaid MUST NOT be expanded. It is horribly underfunded, entitlement system that is in a shambles. It also gravely underpays for anesthesia services. If I had the choice I would not accept Medicaid patients.
Better solutions, many listed above:
TORT REFORM is a must to eliminate the expensive defensive medicine component. Enact alternative patient compensation for adverse outcomes; no fault, expert panels in lieu of juries are a good start.
Somehow develop some patient responsibility and accountability so that patients will have to 'perform' to receive care.
Tax credit and loan forgiveness for charity care.
Scrap Medicare and Medicaid and start fresh if you must have a government insurance entity (as much as I am in pain saying this). But they are both bankrupt and poorly run.
Do not rob Peter to pay Paul. Pay physicians fairly or you risk adding millions to the insurance roles and having no one to care for them.
Thanks for your interest.
Please help!

Sermo Doc 157, agree with you and am also depressed, esp. now that the House Bill passed by 5 votes.
Now, the ball is in the Senate and I'm not very hopeful.