You are right! It is just hard to take a stand but when a stand needs to be taken it is never easy like in 1776,the marches with Martin Luther King,The Vietnam war protests,or any other major event. Even so we need to find a way to achieve our goal.
The game is not over. They way Washington works is that the Pols keep the door open for future negotiations. They want to pass a hea;th care bill. They cna't do that effectively without us. This means that we continue to lobby, make deals and move forward. Let us not give up. We provide value that Washington needs. Let us not forget this. don't get mad, get even as politicians do.
Medicine, despite being a "calling" or a "profession", is also a business. The government cannot be allowed to legislate that we take on unprofitable endevors. It is time for all physicians to take a stand for a fare wage for a days(and often a nights too) wage. Let's forgo Medicare. See how long it takes an irate electorate to get the legislature to come around ..
I hope people saw Chuckie boys comments on the healthcare forum the other day.
He was focused on those doctors who pause at the door to say hello to their patients.
Its guys like him who have got to go.
There will be a sign posted at my door on Monday.
to defend the ama, this (sgr reform) has been their primary focus for 6 months. the government has failed us again, their promises mean nothing. i believe there is no going back to cash for most of us. we need to magnify our power(good time for a work stoppage?
I've had it with these morons! We seem to go through this ritualistic, semianual or annual dance to "please call our congressperson to beg them to preserve the pay schedule without the odious SGR", and it never happens. The pay cut gets put off at literally the eleventh hour, but nothing substanitive is ever done about this patently flawed formula. Nothing gets done until the dance starts all over again, the next time. How can we fall for this time and time again, year after year? The Medicare payment schedule is an insult as it is-it devalues our services to our patients, reimbursing a pittance, and it hasn't materially changed in ten years!! And yet the threatened cut gets bigger each year, reflecting the accumulated fee cuts and adding just a little more, to boot. So let the cut go through, and, sadly, our elderly patients will have to bear the consequences, whatever they may be. Maybe then, the real villians, our elected officials, will be seen for who they are, and we can remove the rascals from office. Unfortunately, they will still have their gold-plated medical plan for the rest of their lives-they should be required to get their feet dirty and come to earth with the rest of us. Just my $.02.
Every physician should post a sign Monday informing Medicare patients that in 30 days they will no longer accept Medicare, along with the phone numbers of their congress people.
Sadly, Medicare makes up about 50% of my practice. I cannot afford to stop seeing them all together right now. Either way I will have to significantly change my practice to reduce overhead to survive the cut. Looks like I may have to start practicing out of my garage!
I'm sure they will do a quick delaying bill like they always have, but it would be nice to have the payment formulas fixed once and for all.
Yes, do not give up yet, but if this goes through I will not take a pay cut of this or even 10% since my practice is 80% medicare. I may just go to the dark side and open a cash only methadone clinic, a diet clinic or maybe sell herbs, vitimins or some other such nonsense. In truth I would have to find a way to take no new medicare, weed out another 50% and do what ever it takes to survive. This will push the ethics and morals of some of us. Either we don't see them or they get what they pay for. A routine check up for my car by a highschool drop-out cost over $300.00 Of course that service is much more valuable than the one we provide.
The annual SGR fix enalves physicians. It never shoud have been tolerated by the community. Our lack of political savey has lead us to this. The SGR needs to be eliminated but we cannot support the current healthcare bill simply to get back the 21% for then we will be even more enslaved. Let it happen, then see what happens.
Clearly a 21% Medicare cut is a travesty that would decimate Medicare, and clearly the SGR is a broken system that must be permanently repealed, but you really should be more honest in your posting, Dr. Palestrant. Yes, Congress has clearly failed Medicare patients this week. However, you failed to mention that both the House and Senate were all set to avoid the 21% cut last night (albeit with a temporary patch yet again), but the attempt to do so was blocked by a single Senator who objected to allowing the Senate to do so by consent. That was Senator Jim Bunning (R-KY), who singlehandedly blocked Congressional action to avoid having the Medicare cut go into effect. Why not direct some of your frustration at him? Your accusation about this cut having to do with the AMA "selling its endorsement" is unfair and factually inaccurate. Fixing the flawed SGR is clearly a top priority of the AMA as well as almost every other state and specialty society in the country. Hopefully, Congress will get its act together and pass a retroactive patch next week, and hopefully, they will eventually get rid of the SGR altogether. Physicians need to work together to make that happen -- and Dr. Palestrant's continuing diatribe against organized medicine isn't going to help.
There is a way to respond - but it will hurt all of us for a bit - and this is called a Strike - and it needs to be done universally - and this means all doctors IN EVERY Specialty including Emergency, Obstetrics, Cardiac, etc - then this will catch the attention of our politicians. We do NOT fall under the umbrella of the police or the military - so there is no law that prohibits us from not working - plus, this will get all the Tort lawyers in a tizzy and perhaps there needs to be a law that puts every lawyer behind bars just because they are thiefs!
I say that if the US Congress wants to attempt to get our fiscal house in order, it needs to mandate a 21% cut for all wages for all US workers in every industry. Housing prices are overpriced, stock prices are overpriced, deficits rule the day and therefore doctor's wages must certainly be "overpriced." I'd gladly take my lumps, if the entire country made the same financial sacrifices for the good of our society as a whole. Otherwise, cuts to those who have worked so hard to care for the sick sounds like an arbitrary and self destructive place to start our "age of fiscal responsibility." God bless America!
Excellent point Sermo Doc 13. It's sad that things have come to this. What about the $200,000 in educational debt most of us incur (not to mention giving up the best years of our lives behind a book). The guy who fixes my a/c gets paid more per hour than I do -- and with 1/2 the paperwork. Ultimately, its the patients who will suffer... after we go broke.
Agree with Sermo Doc 14. We need to write our representatives to have them block the cut just to maintain the status quo OF CONTINUING TO BE UNDERPAID?
I am grateful that I am no longer practicing medicine and surgery. I am concerned about the quality and competency of my colleagues in the current environment. Quality medical care is not available to the citizen of Canada and the subject of the UK. As I age my need for health care will grow. Who will provide it? Certainly not the AMA or congress or Obama or Pelosi or Reid
As was said by many in the armed services, "Bend over and kiss yourself goodby."
How about we agree for to this medicare reimbusement if congress will pay for our medical malpractice insurance, or perhaps, tell lawyers how much they can charge their clients and cap on payouts for medical lawsuits? A little reciprocity?
The commoditization of American Medicine continues - and will continue - as long as physician livelihoods continue to depend on payors who dictate price stuctures essentially by fiat. The Medicare system is only the most prominent among these. Sweden & Great Britain modified their single payor systems to allow private clinics [with privately issued insurance programs] but not without years of the sort of turmoil now in progress in the United States. Nonetheless, all of the concern expressed regularly here in Sermo will come to naught unless this concern congeals into a single force for action.
Canada, Sweden, US trained MD
I really hope the 21% cut passes. Then the country may realize that government cares nothing for the people, and neither does the AMA. In Ontario long ago when faced with the same attitude in government, docs signed and submitted postdated letters of intent to resign from the government health care plan en masse. Suddenly tnat year fee negotiations with government improved. We may need to do something similar in this country soon.
My practice (at an academic medical center) is 41% Medicare. I won't stop seeing Medicare patients but this cut in payment will make life significantly harder when it comes to practicing high-quality tertiary care. That cut in payment will have to be made up with cuts somewhere else on the cost side of life.
78% of my practice is Medicare - I can't continue without seeing that population and I can't stay afloat with the new reimbursements......woe is me :-( ........however, I would stand with ALL physicians if we decided to do a work slowdown - leave one partner on-call for emergencies (alternate as necessary) and announce a one week work stoppage.....cancel all appointments, elective procedures and the like, give the office a one week furlough (unless there are enough non Medicare patients to stay open) and see what happens - unfortunately, some people may be harmed but the rationale will resonate with our politicians who dropped 2 atomic bombs killing thousands realizing the saving of many more lives in the long run......however, we physicians are such pansies - that will never happen.....too bad
No one has ever imagined to put a cap on the reimbursment of trial lawyers. It is a very sad news for all of the medicare recipients. Although a significant number of PCPs work for the hospitals (and have no say in the hospital practice matters and shall perhaps continue to accept new Medicare patients), still there are many independednt physicians like me, who will no longer take new Medicare clients. If I knew any other skills, will switch to that business.
What do you expect?!! Costs are rising because if increased utilization driven by physicians. We order unnecessry tests, uneeded surgeries, (it is well documented ghat 40% of US healthcare is waste).
Medicare is responding as we should expect - balance the medical cost trend with a reduction in unit pricing. We should expect this until we get our act together and actually manage the care of the public appropriately based on evidence AND effectiveness.
If only the 21% cut would make the country realize the government doesn't care. In fact, people will blame us. "Those doctors are only in it for the money! They're already rich, what are they complaining about! Why can't they work hard, like the rest of us?"
Sermo Doc 15, yes but WHY did Sen Bunning (and others) vote against it? Because it was included in a bill with a bunch of other crap. It should be addressed separately (but other Senators would not let that happen)
I can't opt out, due to my employment contract. However, I now know that I will be inundated with new Medicare patients. As far as I am concerned, except for emergencies, they can wait in line......even us hospital employed docs need to help send the message.
Sermo Doc 15,
Senator Bunning blocked unanimous consent because he authored legislation in September that repealed the SGR and funded a permanent solution. It never made it to the floor. He, like us, is tired of kicking the can down the road and is forcing a solution, not a patch.
This involves more than Medicare when commercial insurers base their reimbursements on a multiple of Medicare. What will it take before every PRACTICING Physician in the US opens the window and shouts "I am mad as hell and I won't take it anymore?"
As a radiologist working at a small community hospital, how can I NOT accept medicare patients? And is it fair to punish the elderly for this government fiasco?
My senators have both ignored my letters. I guess I have to go door to door in the fall election to get them thrown out but I think they are already headed for disaster (and they know it). Health care "reform" is like some altruistic "quest" for them.
Ah, Sermo Doc 27, just about ALL the things we do in medicine (and the "unnecessary tests") you speak of are driven by liability concerns. Especially in the ER. Its CYA.
And you know it. Send ONE patient home with mittleshmertz pains in the ER and they wind up at another facility with appendicitis- you're screwed. Just about every "cost" in our hospital has some form of liability built into it- THATS what's driving up the costs in healthcare.
After 2 years of subsidizing the costs of practice, I reluctantly decided to retire form practice as continuing it would keep depleting my retirement funding. Glad to not be faced with the current problems of lack of keeping up with the increasing costs of practice. The idiots do not realize that research yields results which add to the cost of medical care. The Genie was let out of the bottle some 40 years ago when too many of us joined with Medicare. Initially, we were given many bones such as getting some fees for what was often free care for the poor. The same is no longer happening. Cost cutting now is happening by giving practice licenses to under trained individuals and calling them by various titles other than MD or DO. I look at my younger pracititioners strruggling with bills for family and practice. JCE
I already quit seeing Medicare patients. Anyone who continues to see them, while naively pretending to be altruistic, is actually hurting themselves, their colleagues, their families and ultimately their patients. Wake up people!
what a joke... the only thing that happens when one group decides to stop seeing a particular class of patient is that the other (more desperate) group starts seeing them instead. and then the first group is sitting there with nothing to do. think hotels give out rooms on hotwire because they want to? They do it because otherwise they would be losing money. Face it. some money is better than no money...and the market will dictate prices, and there are just too many desperate doctors with too much to lose for any sort of strike or slow down or whatever you call it to seriously work. the solution is to hire a bunch of MA's, a bunch of NP and increase your patient load to 500% over capacity. Just sign off an their work, hope nothing bad happens and get a canadian work visa just in case something bad happens....
I wasn't planning to retire in my early 70's, but I am rethinking! No other profession is treated this poorly in the US! Regrettably, innocent people will eventually pay for these misguided policies.
it is a mess. no way out. i thought that doctors had been trying to band together since all this hoop lah of health care reform. once again it falls on deaf ears. just look at the democrates. even after the summit meeting they are forging onward with their wharped plans. they are not listening to anyone, not the voters, not other fellow legislators and sure not the other party. since some type of 'come together' plan didn't work then madame pelousi will just do it herself with a few others. sad time when less than 100 individuals has the power to change it all for the entire population of the U.S. the power they have is just mind boggling.
too bad for the doctors. medicare reimbursement stunk anyway and now is has just gotten worse. looks like doctors are expected to work free. good point hkmp5a3 made to Sermo Doc 27. it is just not that simple which is why the government sure does't need to get in on it.
since the government runs medicare and the fees will be $3 less than the 1991 rate wonder what commerical insurance fee for service will look like when they get through with it?
Maybe it is time to go cash only. I took my dog to the vet the other day and the exam, an X-Ray and labs came to $450! And the place was mobbed. A dentist friend is cash only and he's busier than he wants to be. He gives his patients an itemized receipt with all the necessary codes and tells them to send it in to their dental insurance. Whatever they get from their insurance is between them and the insurance company and he has nothing to do with it. Why is it that people seem to think that medical care should be free and yet they happily (or unhappily) seem willing to pay the market price for veterinary or dental services? Would we be less busy if we were all cash only? I don't think so.
I truly hope that every physician who can does leave Medicare. I truly hope that there will be an organization to represent us. The AMA sold out its soul and sold us down the drain. Their great mantra was, "We support HR 3220. The government will get rid of SGR because of that." How stupid and prostitutional they are.
I am a hospital-based pathologist. I would like nothing more than to no longer participate in Medicare but I don't see how I can do that. Does anyone have ideas on how to accomplish that as a hospital-based physician?
A 21% cut means less than $20 per patient per visit. Most people don't understand that $20 is what will close the doors and put docs out of business. They think it is an enormous amount of money. Why not allow patients to pay the extra $20. An easy fix, with little cost to the government. This 21% cut allows a true crisis to occur, exactly the position which aids the current administration to get what they want, universal healthcare. We are pawns.
My guess is that the 21% cut will not stand. We will have the usual brinksmanship as we have every year. Congress will, in all their wisdom, declare that they will rescind the cut and give no raise or a smaall increase or decrease. Everyone will declare victory (Congress, the AMA etc) and the docs will again have an effective loss for any cost of doing business.
As an Infectious Disease Physiican, doing 100% consultative work, I've already been cut about 25% with the loss of consultation codes this year. Another 21% would be ludicrus. It's certainly unreasonable of me to expect that I be additionally remunerated for an extra 3 years of training when any primary care doc can handle what I do.
For those of you that are suggesting a work slow down or strike, it will never happen. Physicians have never been able to join together in significant numbers, for any goal and their organizations are totally impotent.
The bottom line is that medical care is too expensive and the gov't isn't wiling to pay the bill. I suspect in the not too distant future hospitals will be given a DRG sum for each patient admitted and they will determine what the doctors get paid. That should be another bloodbath. Unfortunately the only viable system for the government will be a single payor one where docs are salaried or receive payments determined by the government. If you are nearing Medicare age yourself, you should hope malpractice litigation is still strong so that you have some threat for your caregivers to provide quality care. Notice I didn't say physicians. Our profession sowed the seeds of its own destruction when they hired nurse practioners and physicians assistants and convinced their patients that these caregivers were just as good as the physician.
The insurance industry as a whole made billions in profits last year. Easiest business strategy in tough times: cut out the middle man.. Some of those billions can be spread around to patients and doctors. Cut out the middle man by opting out of insurance and Medicare. Back to fee for service.
the big temporary 'winners' among us physicians are the employed by govt. or by private hospitals, academic centers, and the losers (without " ..") are we - self employed doctors, -either in a group of self employed or solo -
But the employed ones do not have anything to smile about, because they will be hit by the cut in their salaries; only the best arse-lickers (who go to bed with administrators) will see their income stay the same or drop less....
Finally the 'socialized' medicine arrives in the capitalist US of A --- without the introduction of the new healthcare, DO REALIZE that Obama cannot take blame for that state of affairs - it was coming for several years.
I did not vote in the poll because I opted out of Medicare several years ago, as did many of my colleagues. We could earn more per hour seeing patients for what they could afford to pay, and skipping the paperwork. I appreciate, though, that not everone is in this position, and I support organization.
When I decided earlier this year to stop taking new Medicare patients, first my billing company CEO and then a well-respected health care law attorney warned that such a move can be construed as a violation of my Medicare participation agreement, with all the firestorm that such a move might entail.
Does anyone have any hard facts about this matter?
Sgalia - you cant make an omelet without pissing off a few, very important voters. I'd check again - if you really want to be snitty, schedule the desired targets on a single day, then reschedule because you are sick. Wash, rinse, and repeat until n=0.
Enjoy your Fridays.
I may further my time in purgatory, but remember in war, there is damage.
I will stop taking new Medicare. I will cut my hours until I am busy again. I will priority schedule non-Medicare, and see Medicare patients only briefly and for only one problem. I will hand Medicare patients an explanation as to why only one problem can be afforded and tell them to call their congressman to complain. I will send my excess daily Medicare to ED, and I will fire any Medicare patient who insists on taking more time than their "reduced" payment is worth.
I do feel sorry for my patients. However, unless they feel my pain they will not get involved in healthcare reform.
The government has forced me to choose between my patients and my family. When I do my "free" paper work at night, my family pays for it. What does the rest of the world say? Oh I know, "its business, not personal."
As an Anesthesiologist with a hospital contract we cannot opt out. I wish I could, I want to. My partners (28) would never support such a move and doing so would violate our contract.
I am hopeful however, that once these cuts are effected Surgeons will do it for us. If you see some way to coordinate without collusion please let us know. This will end up being legally sketchy, and the Feds will use their power to come down on those they see as leaders of rebellion. That said, it was only the STRIKE of the 1970's that gave us MICRA here in CA. Personally that is the course I favor, and to be honest, even if only some of our partners cooperate it will bring the OR to standstill. It takes the full compliment of people to run things.
So Daniel, I suggest that you use some of the money this site generates and hire some really good lawyers. Find out what we can and cannot do and let the membership know what you find. I agree, it is time to take back the field of medicine from the AMA, the insurers and the Feds!
I hope the Medicare cuts actually take place. Then maybe the docs affected will stop seeing Medicare patients and then those patients will take the cause to congress, who might listen to older voters, but not to us. Americans and politicians are crisis driven these days, so let's given them one.
Also, American docs need to take a lesson from the docs in Australia.
I have a good friend who is an anesthesiologist in New Zealand. He makes much more per hour in the private sector there than private anesthesiologists do in the US. Also, medical malpractice litigation has been outlawed there. Meanwhile, the peer review system takes up the slack by being very strong.
The docs do even better in Australia. In fact many NZ docs have already left for Australia and the trend continues. The government and private insurers actually appreciate the knowledge and skills of physicians and reward them accordingly. BTW, any board certified US doctor can easily work in NZ or Australia.
I've even heard stories of recent U.S. residency grads taking jobs in Canada for more money, better hours and a nicer malpractice climate.
Remember that the 13th Amendment to the U.S. Constitution prohibits slavery and involuntary servitude.
You can't work hard enough to make up for the barrage of cuts in fees. If it's not 22 percent Monday, it's a 35 percent cut in Ambulatory Endoscopy Center fees over the last decade, while hospitals reimbursements have increased, etc.
I suspect primary care private practice doctors will lead the way in closing practices to new patients, if not all Medicare patients. If that happens, specialists will see less Medicare referrals, etc.
Until Seniors beat down legislators' doors when they can't find a doctor, we will get non-negotiable cuts.
I agree with "Sermo Doc 54". I did opt out 11 years ago and have never looked back. I would rather treat a Medicare patient for reduced fee or no fee than to be under the thumb of regulators.
You said, "If you see some way to coordinate without collusion please let us know. This will end up being legally sketchy, and the Feds will use their power to come down on those they see as leaders of rebellion"
I had this very discussion with a hedge fund manager from the UK, Michael Hintze, a few years back while heli skiing with him in Las Lenas, Argentina.
He said that the way to get around the collusion or antitrust was to do it all in the open at an academic meeting. Simply have an open forum on the economics and finances of running a medical practice, talk about historic rates and reimbursements in medicine and other fields and show what levels of reimbursements it would take to keep up with the increases seen in dentistry, law, architecture, corporate CEO's etc.
A work stoppage is the only way they are going to get the message. A doctor's office with a sign on the door "Out of business" with some elderly folks standing there on MSNBC (where the White House watches) should just about do it. Overflowing emergency rooms full of folks needing refills or blood pressure checks or INR levels will be a sight indeed. You can forget the letters and the calls, they are a waste of time. If you work on salary or for some university, expect a pay cut very soon. You are not immune.
Even without the cuts, fixed costs are rising at a faster rate than reimbursements. For an individual in practice, this is unsustainable.
I would think that not all physicians would have to stop seeing Medicare, but if a significant minority were to do so, it would likely cause a gridlock.
Either now or in a fewwyears with Obamacare, the private practice MD of any kind will dissappear. We have gone from 40% salaried employee doctors to 60% in the last 10 years. This cut, or Obamacare, will make it impossible to keep the doors open, except for those who will find a cash-niche.
And you know what this does? It RAISES the cost of healthcare for everyone, even for Medicare and the Gov't. Hospitals will have all the docs and they charge more as they get better rates from the Gov't. Great job Congress. Way to make health care costs go up.
I beleive it is all part of the Sermo Doc 44 plan to socialze medicine.
I voted "stop seeing Medicare patients." Actually I will continue to see them, but after dis-enrolling from Medicare. I will see them privately and let them file Form CMS-1490S for reimbursement. Should have done this years ago, but didn't know about this option.
Sermo Doc 27, respectfully, you forget that healthcare is still a market, distorted as it is. It is not our job to ration, unless we don't believe that the patient is also our customer. When there are legitimate choices, such as in Dermatology, to watch an indeterminate skin lesion or biopsy it today, my patients who are self-pay choose to watch it (I might insist on a scheduled follow-up if I'm concerned), and my patients with no out-of-pocket choose the biopsy today, pretty consistently. When it is clear-cut that it does need a biopsy or does not need a biopsy, then they tend to do what I advise. If the patient is not also the customer, then we are being paternalistic, or working for "the greater good", or taking some such morally questionable stance. Whatever happened to the Hippocratic Oath, and fiduciary responsibility?
Well, I intend to quit Medicare. I do feel for my patients, and I want them to become mobilized and go to their Senators and Representatives. Medicare needs to get out of the price-fixing business.
Sermo Doc 50 said "We have until March 17, 2010 to opt out of Medicare enmasse." We don't want to "opt-out." We want to dis-enroll. Then we are not subject to CMS regulations any longer.
The truth is the Medicare fee schedule was pathetic prior to a the 21% cut. I punted Medicare 9 years ago and have never looked back. I value my service and myself far too much to whore myself out for the government. The sooner the rest of us actually wake up and value ourselves, the more will tell them to stuff it. When they have no labor force, that is when things will change.
I thought that 10 years into my career, my life would be financially stable. I am tired of worrying about the threat of constant fee cuts. The reimbursements are a travesty already and now we get more fee cuts. Healthcare in the USA is going down the tubes. Maybe if doctors weren't practicing defensive medicine, there wouldn't be as many unnecessary tests, procedures, etc. And hold the health insurance companies out to dry like the crooks they are. Why are they allowed to make billions in profit, but doctors are supposed to keep taking fee cuts? There needs to be major reform in this country or there will be no doctors left...The government doesn't realize that doctors are some of the brightest people in this country, and we can easily quit medicine and change professions.
I finally got fed up enough to write to the white house. I borrowed words from some of your previous entries on Sermo. Here is a small excerpt:
Dear President Obama;
I am pleading with you for the sake of my patients, my profession, my employees, and my own family to please help the physicians in this country to continue to do what they do best; care for patients.
I am writing to you because recently The Whitehouse and Congress have embarked on a journey that may mean a certain end to my career and that of many young physicians in this country.
Today, most physicians came to understand that our worst fears will be realized on Monday February 29, 2010, when Medicare reimbursement to doctors will be cut by 21% due to Congressional inaction.
I am a solo primary care physician practicing in a largely rural area with a sizable Medicare population. Most physician practices in my area are comprised of 80-90% of Medicare patients. Commercial health insurers in my area tie what they pay physicians directly to Medicare rates for even the healthiest, youngest non-Medicare patients. As you can see, a 21%decrease in Medicare rates ultimately means a more exaggerated assault to a medical practice's bottom line, along the order of 30-40% reduction in gross revenue.
I often hear people say "oh, doctors make too much money anyway", a statement that reflects the gross misunderstanding of the sacrifice doctors make and how much it costs to maintain a practice and deliver care. For doctors, the biggest expenses of practice, the overhead, are not negotiable. Doctors have no leverage in getting more from insurance companies or cutting our rent, unreasonably high malpractice premiums, cost of complying with unfunded federal and regional mandates, or cutting already meager staff salaries. The ONLY recourse I have is to see more and more patients. I am one person and there is a finite number of patients I can see each day and still do a good service for my patients.
With previous average reimbursement from Medicare and commercial insurers of $75 per office visit, and a monthly overhead (excluding physician salary) of $20,000 in my case, it does not take a lot of effort to see how hard a doctor has to work just to keep the doors open. A 40% reduction in pay will certainly cause many physicians to ponder severe cutbacks or bankruptcy. This may also mean turning away Medicare recipients. In my case, it will likely mean moving out of the area, adding further to the local physician shortage.
If the government is genuine about reforming the physician payment system, it must implement policies that reimburse according to quality, not volume. It must also act to address the primary sources of high healthcare and practice costs---insurance reform and malpractice tort reform. Insurance companies should not be afforded a veil of secrecy and Antitrust protection.
I am not alone in my concerns. Many doctors have chosen early retirement while young students opt out of medical school altogether. Those who choose medicine as a career, more often than not, choose anything other than primary care.
Mr. President, I encourage you to please consider all of the players in the healthcare struggle. There are hundreds of thousands of practicing physicians in the US and only a very small number of them belong to the American Medical Association. If you want to know where doctors stand on the issue of health care reform, ask us, the ones who are there at the frontlines every day, not one who claims to speak for us. Please give us all a voice. You may find greater support if doctors think they are being heard.
Hyperbole only takes away from some of the points you make. While there is undoubtedly waste in the healthcare system (as there is in every other system), it is nowhere near 40%. I would like you to give us the link with this supposed evidence. While it may be an individual's interpretation, there is no evidence to support that high a number.
I cannot speak for all physicians, but I know for a fact that the "unneeded" services I provide are nowhere near 40%. Certainly I have had patients spend a day too long in the hospital or had some tests that others could deem unnecessary, but I have never operated on a patient when it was not absolutely medically indicated.
I do not perform any diagnostic tests in my office, so unlike some practices, I have no incentive to perform unneeded labs, x-rays, EKG's, etc to buff up the bill. While some of this may occur (do you do it in your practice??), I think most physicians do this as a service and convenience for their patients (usually at a discount to hospital or outpatient labs). Maybe you could poll Sermo members to see how many do this strictly for profit.
The "studies" that indicate this level of waste do so by saying there is no randomized evidence that something is helpful and cost effective, therefore it is unnecessary and thus = waste.
Newsflash, most of what we do today is not based in Level I evidence (multiple randomized, controlled studies). To randomize some things would be malpractice and unethical.
We have never randomized:
1. a trial of ruptured appendicitis to see if appendectomy is better than just Tylenol and IV fluids
2. a trial of patients with DKA to see if giving them insulin is better than Snicker bars
3. a trial of gunshot wounds to the abdomen to see if repair of injured bowel is better than prayer and cookies
4. a trial of patients with acute respiratory failure comparing mechanical ventilation to intubation and spontaneous breathing
Although we do not have "PROOF" these treatments are better than some alternatives, I would argue that is not the same as waste. We may ultimately learn that what we assume to be best treatment for a given problem is incorrect, and we should modify our treatment based on that evidence when it becomes available.
There is certainly some need to clean up our act and to do what we can to help control costs, but the fact remains that some of the growth in health care expenditure is due to :
1. More patients living to be older and sicker (patients thoughtful enough to die young are cheap)
2. New technology and drugs that are more expensive
3. Patients and family demanding that everything possible be done regardless of reality of futility
4. More spending at the extremes of life that do not satisfy the criteria of "cost effectiveness"
5. More physicians being graduated from medical schools in the 80's and 90's in an attempt to cure the maldistribution problem
6. New entitlement programs that do not encourage patients to seek care effectively - using the ED instead of a PCP office or clinic.
7. Patients not taking responsibility for their own health as evidenced by our epidemic of obesity, continued high rates of tobacco and ethanol abuse, teenaged pregnancy rates, rates of use of motorcycle helmets and auto seatbelts, etc.
To think that a 21% cut in physician reimbursement will correct these problems is foolish. What is next when this doesn't work, another 50% cut? Common sense measures need to be taken, but this will only impair access for many vulnerable elderly patients and do nothing to lead us to affordable healthcare.
The question is poorly put. How about the other two Medicare options? I would go to the third option, called private contracting. We should demand that citizens who have paid their Medicare taxes be reimbursed the Medicare allowable when they see a private contracting doctor, that is , one who has opted out of the Medicare payment system.
I, too, have never operated on a patient unnecessarily. I, like most of my colleagues, don't derive any financial benefit from ordering labs (since I send out for them, too). I order a test for only two reasons: 1) because the result will determine which course of action I pursue, or 2) because it will prove to future plaintiff's attorney's that I did check that.
NEWSFLASH TO MY COLLEAGUES: There's no need to terminate your contract with Medicare. Simply don't accept new Medicare patients until this is resolved. That's what we are doing starting Monday. Let *them* call their representative. My contract only requires that I accept their *payment* when I see a Medicare patient. No contract requires that I *treat* them...(well, minus EMTALA).
Our gov't won't listen to a few thousand "rich"doctors. They *may* listen to a few *million* average Joe Medicare patients who can't find a doc to see them.
The main reasons for increased medical costs:
1) lifestyle of patients. 2) lifestyle of patients. 3) lifestyle of patients. 4) defensive medicine. 5) increased ability to treat disease(s). <-- engineers call this "a failure of success."
The only thing government responds to is loss of service.In GB & Canada the physicians folded,worse in GB.Being retired working part-time IHS is a good place to be.Though IHS is paid by Medicare they will also get screwed I am not sure how that will affect the service.Contracts in place will have to be honored,the Native American people value honor does DC?
Dr. Palestrant,
Turn Sermo Doc 66's letter to the president into a petition that Sermo members can sign. Present 900,000 signatures to Congress. That would be the best show of strength that a profession which isn't allowed to unionize or fee bargain could demonstrate to the powers that be. Conceptually, work slowdowns, refusal to take new MC patients, and the like, all look good on paper, but most of us seem too ethically bound or financially pressed to refuse care, and others are too oportunistic--there will always be someone around to pick up the slack--which would minimize the desired effect.
What a bunch of whiners.
Let's see what you will really do.
You don't need to strike.
md.sermo.com Opt-out if you have the testicles
AMA has been kind enough to provide a form
At minimum don't see Medicare unless life and death in March.
You won't get paid for 2 weeks anyway.
You know they are going to do a temporary fix.
Now is the time to start leaning your practice to only a minimal number of medicare even after they come up with a temporary fix.
Most of you are NOT GOING TO DO ANYTHING ANYHOW.
Whiners and losers.
Sorry, but that's what most docs are.
I am all for mass strike. If we don't see patients for 1 week, we will not starve(that will happen anyway if the cuts go through). American public is helpless, but that is because of screwed up system and insurance atrocities. It is a shame to see so many professional at the end of their ropes and with wasted lives.
Well, I can't go non-par, I'm an ED doc and the hospital requires us (in our contract with the hospital) to be par with CMS. So, now I'm a totally unsupported and unpaid federal worker. The Federal Government requires me to see patients and now they pay me even less to see the patients they insure.
Where's my KY jelly, then at least it won't be so painful to get screwed. Thank You to all the politicians.
Hey--my life is not wasted. I changed careers once in my life. If I have to do it again, I will. Even at my age.
Don't know about the rest of you, but I am not a loser. I might whine a little until I get things figured out--because venting helps--but if that's all you do? Looooooserrrrrr.
I do feel for those who are stuck in contracts and/or specialties that do not permit immediate change but, you know what? You do not have to remain in those positions or specialties until the day that you die. Pursue any other goals or interests that you have.
The government wants you to stop seeing Medicare patients.
This is so they can verticalize medical care. They want to ship all the medicare patients to future government overseen facilities to control what care they get.
This is the first step in the government controlling what healthcare you (& everyone eventually) get.
The government won't ever tackle trial lawyers (because they are trial lawyers, most of them). So this is their way around it. It doesn't matter if you practice evidence based medicine, or give the best care.
It doesn't matter anymore that medicine was once an art (= dealing with people & their psycho-social problems) & a science (= evidence based medicine).
Its government takeover to force you out of private practice, so they can control people & money.
I would like to think this doesn't affect me because I practice in the military, but it will affect me because all of my civilian colleagues who have continued to see Tricare patients will have another reason to not see them. Perhaps if our military patients start raising hell when they see how difficult it can be for them to get care downtown and how all the docs on base are deployed and appointments are scarce there, someone in Congress will listen.
But, I think Sermo Doc 77 is right. The present administration wants us all to work for the Feds. The Medicare population is where they are starting. TriCare may be the next population to target.
However, I fail to see where they think they are getting the money to do all this...
The "ordering of unnecessary tests" canard is mostly BS that is reflexively uttered by laymen and physicians alike only because it is endlessly repeated by the pro-"health care reform" crowd. How many of YOU order unnecessary tests or, God forbid, surgeries? And, if you think you may have at one time, HOW OFTEN? Can any of you, as individual doctors, say: "Oh, yes, I order unnecessary tests, studies, etc everyday--- I couldn't do my practice without them"? Again, BS!
Shame on any and all of you who contribute to the assimilation and bowlderization of our profession by our overweening, socialistic federal government--- contribute to it by your tacit acceptance of their terms and tactics.
Federally configured or sponsored "health care reform" is a big lie, and the tactics being used to force it into existence were well delineated by George Orwell in his prophetic novel, "1984".
I, for one, refuse to play by their rules. Those of you who do, will be swallowed by the Leviathan.
I think we should call our Senators that it is outrageous that Wellpoint made $2.5 billion in profits and our doctors who take Medicare are being cut 21.2%. The obvious source of excess wasted money is the private insurance industry. The sooner we get single payer, national health insurance, the sooner we can pay our doctors who are the ones who should be paid, not fat cat insurance executives.
Dr. Pelistrant, please see hpymd's post. This should be sent to the press TODAY, with the trailer of who Sermo is. Physicians are going to go apeSH#%% when this registers and are going to be looking for somewhere to go.
A side note. Our 23 member group resigned en mass from the AMA yesterday and will be limiting our Medicare practice beginning next week.
You can't make it up in volume.
Academic and "Organized" Medicine has let down those of us that care for 80% of the patients. While they have snuggled close to the Administration to "have a voice" we in the trenches look up with hope only to find they have cut there own deals and now have their financial throats cut. In MA where BCBS premiums are the highest but reimburements to providers are among the lowest, we have seen the government mandates erode our income to barely covering expenses. We have the near 100% coverage of our citizens,even illegals,and the no pre existing in place and the insurance companies are doing OK. Medicare and Medicaid however are not doing well to say the least and make up 50-80% of our practices. The Medicare cuts are not survivalble at this level of payer penetration.( No Pun intended)Medicaid patients already cost the provider to provide care so I just see them gratis and sleep better at night. I am doing everthing our president wants me to do. Good efficient care, outpatient surgery center, good wages and healthcare for my employees, even a matched 401k all in a ,respectable, diverse working environment. Problem is, I don't think I can survive financially much longer. We must be paid for what we do like any other business. The answer from MA. doctors position is obviously not more government intervention. Take note from our disaster America.
God bless us all
I have not had time this morning to read all of the above postings, but, thank you Dan for putting this up! The time to act is now! Docs4PatientCare is going back to DC on March 24th and 25th. Hal Scherz will post the invitation to ALL of you to join us on Sermo today.
This is very real, and it is time for all physicians to join together in unity to stand up strong for our profession.
As with Sermo Doc 84, I am a Massachusetts physician, full-time hospital employee in Emergency Medicine. I have little voice in the decisions made by my medical center to "treat all comers" - even if, like the used car salesman, we lose $100 on every patient, but make it up in volume! The cost for state-supported medical insurance for those on Medicaid, and those with low-paying jobs, has quadrupled since its inception, and falls, once again, on the back of the taxpayers. We truly deserve the nickname "Taxachusetts" - but have little clout and few options, as noted above, whether full-time employees of a hospital, in large or small groups, or solo practice (dying a slow death). I appreciate Sermo's efforts, and think we should all support them. By the way, did the Mayo Clinic (AZ) fold and reverse its decision NOT to see Medicare patients? If we ALL did this, the patients, not the docs, would scream to the politicians, who would then pont the finger at us as the root cause of unrest. We started over 200 years ago by dumping tea into the harbor in protest - and now the "Tea Party" movement rides again!
I hope that this represents a true wake up call to physicians. I also hope that you realize that the government and the AMA are not the solution to this mess...they are the problem!
Nothing that has been discussed in the health care reform debate, including the "summit" on Thursday has addressed the root causes of our trouble.
The SGR could be "fixed" for physicians tomorrow by one simple action of Congress and the President. Admit to the American people that the government cannot afford to pay for all of health care and that the demand is bankrupting the country. This is a fact that everyone should know. There is nothing wrong with honesty!
Then, ALLOW balance billing for all medicare services across the board and let the market work it out. Patients and physicians need desperately to be reconnected to the costs of care. The government can't control this. The smart move is to put the control back where it needs to be...with the doctor and the patient!
The president and democrats in Congress feel compelled to pass some sort of health care bill, regardless of its merits. The governments solution to any problem is to throw money at it regardless of whether it works or is sustainable and regardless of the consequences. I would agree with the poster above, that this is an overall attempt to "verticalize" medicine. The days of private practice are numbered.
Medicare is fundamentally unsustainable. We, as a country, and as taxpayers, cannot afford this entity long term. The same is true of Medicaid and Social Security. The 21% drop in physician payments is simply a symptom of an underlying disease, which is the financial insolvency of our entitlement programs.
I have not decided what my response will be in reaction to these planned cuts in the short term. In the long term, however, it is clear to me that we are on an unstable path that will lead to dissolution of most of our social "safety net", and a vast reworking of the business of healthcare. Healthcare reform is coming, but it likely will not come about by legislation, but by gradual destruction of the fundamental flaws that underlie our current system.
Sermo Doc 87, I agree with you. What is necessary for our country is an honest assessment of the problem and a return to market based solutions. We must start immediately and it may still be too late. The 21% cut in our re-imbursement is a drop in the bucket compared to the over-all problem with run away spending on the federal and state level.
The citizens of this country must step up and take back the nation. That will require work and sacrifice from all of us. Allowing balance billing in medicare is a quick simple step to begin.
We all know that after some juggling, cuts will be taken back. Even if they are not, I can manage by making changes in the way I work. At the end of the day, life is about being able to live happily and be a productive member of the society. Money is a tool, not the end of it. A career of helping others relieve their pain can be one of the most rewarding way of living. We all know that. This is *the reason* that attracted us to this profession and kept us in it despite all the sacrifices we were asked to make.
Now the realities of life is that we all have real bills and real payrolls that we are responsible for. We cannot continue to fulfill the duties given to us by God if we cannot sustain basic requirements of performing a service.
What is more disgusting (at least to me) is that healthcare of 200 million Americans and almost all the US doctors is being used as a mere pawn in the political game! They are using us for their political leverage!
If I do an analysis of medical profession as a business, it is clear that the fact that our business dynamic can be changed by a stroke of a pen is a bigger negative of this business than poor pay. Walmart works at far far lower profit margin than we do but it has pricing power in its own hands.
I am disgusted at the non-medicine aspects of medical profession. Most of these aspects (CPT, billing etc) serve only one purpose - what is the minimum amount of money that 3rd parties need to pay in order to get us to work. I do not think I came to this profession to do that.
Even automaker unions get a say into what changes go on at their workplaces. But not physicians. We just sit back and watch lawyers (i.e. Congress) dictate our future. Despicable.
When a society demonizes its most committed and productive members, it is headed for a tragic downfall. We have been insulted and dismissed from day 1 of the "Health Access Reform" debate...by a disingenuous AMA and an amoral Congressional leadership.
How do we gain a seat at the table?...obviously not through the AMA (they have the highchair in the next room). Unless legislators hear an outcry from their consituents with regard to access despite insurance, they will continue with their plans. Most of us don't have the economic depth to stop seeing new/old patients, so we roll over. I am guilty of this as are my colleagues...I have gotten used to eating on a regular basis and am reluctant to jeopardize that.
We are in an illogical business from the investment that went into becoming a physician, the costs of running a practice, the hours put in weekly, the responsibility assumed, and accepting a fixed income for the last 9 years with Monday's decrease, however transient, looming.
We need a Knight in Shining Armor and the gonads to follow that person's leadership.
.
You blame the AMA? What about the moron teaparty republicans? How many of you called your senators this week? If we got somewhere these last few months on healthcare we wouldn't be in this predicament. I voted republican since I could vote, until 2008. And the message the party got from the election is Sarah Palin and fundamental Christianism? Stopping seeing Medicare patients will send a message alright. But who's going to interpret it?
I urge you all to lock yourself alone in a quiet room for a few hours today, free of any other obligation and ponder on this issue. It is *the* time that you need to take a deep breath and decide what you need to do to bring back happiness to your life.
Why did you come to medicine? What makes you happy? Why are you not able to get it? What can you do to bring back happiness in your life?
Now, think over this trade-off: Would you take all the hassles and distractions that you see today and make 170K? or You would rather get rid of all the shackles of 3rd parties and take patient as your only Sermo Doc 44 and make 110K?
Look guys - you are not going to live in a mansion working as a doctor anyway, so why not to live the way that makes you happy? Life is too short to waste on checking bullets, moving papers around, being on hold on phone or writing nonsense notes just to satisfy idiot CPT coding. No gravestone will ever say I wish I had more of pre-authorization faxes!
Make a mental image of yourself popping your head out of a 3rd floor window in Bronx and shout "It is my profession and I need it now" or "I am mad as hell and I'm not gonna take it anymore"
Just remember, IT WAS A REPUBLICAN Senator, Sen. Jim Bunning (R-Ky.) who single handedly blocked the bill! The Republican Party and the idiots in Congress are our biggest enemies. Glenn Beck, Bill O'Reily, Rush Limbaugh these are the jerks and morons that these brainless Republicans listen to; not the AMA not SERMO, not physicians. We are all going to rue the day that we got into bed with people whose IQ is less than their shoe size.
Now the question is how do we take back our profession in our hands so that we do what is right for the patient and not waste our time and energy on dealing with administrative nonsense?
Final answer is going to be unique to every individual and will require great deal of thinking it through and planning.
Change that will help us most is change from a paradigm of coding-billing-collecting-chasing-accounting-writing off to one of collecting-accounting paradigm
Most of our hassles come from 3rd party requirements, insurance contract being the most common one. Finding a way to function without insurance companies is what will help us most. Not everyone can do it, but I dont think continuing to drink free liquor will make us happy in the long run.
There are several models of cash only or cash plus la marquis insurance only models that have been discussed on sermo. If I get time, later today, I will start a thread to discuss all of them at one location. Now, I must get ready - I have a cricket match to play while you suckers try to find who moved your cheese.
Have you seen the movie "V for Vendetta"?. There is a scene where the detective working with actor Stephen Rea asks "Do you know what will happen?". He replies, "No, but its what usually happens when people with guns meet up with unarmed people (paraphrased)."
Similarly,I have been asked by my lay friends repeatedly, "Do you know what will happen when the Medicare cuts will go into effect?" "Will doctors go on strike?" I tell them (recently turning 50 and after 20 plus years of private gi practice earning me an unofficial degree in perspective) the following:
I reply, "No, but I'm pretty sure". My primary care peers who still see medicare patients will decrease or stop seeing them. An increase in consultation requests to all specialists will increase to "turf these patients". The consultations will be accompanied by little or no records, or better yet, the pseudodocumentation of today's EMR templates which to me are often worse than no records. Direct procedure referrals for EGDs and Colonoscopies will increase again to get these patients out of their offices (if they indeed still see them). Trogolodyte primary care physicians and specialists (me included) who actually still empirically treat patients for their conditions and not order testing will be placed on the endangered species list. The "safety valve" of the ER will be overrun by Medicare patients (already is). Hospitalists/APNS/PAs will admit a greater percentage of these patients because of the path of least resistance. ER docs will find a hard time setting up follow ups with the non-existent PCPs and/or specialists who don't see Medicare or who create barriers to their care. The patients admitted to the hospital will be again turfed quickly to specialists (again with little or no cognitive workup). The workup is completed in the hospital and again there is no follow up available for these patients.
And then again to paraphrase, as Hunter Thompson would say "Then theres the downside".
The cost of this horrific system is that we can't afford it as a nation. Lets see: a) increasing numbers of boomers, increased life expectancy, increased demands by patients for what they believe is a free commodity, increased defensive medicine, increased obesity and health adverse behavior, etc. etc. etc.
The behaviorists, (BF Skinner et al) have shown (you know it the scoop, reward reinforces behavior, punishment etc) Any system that does not change the behavior of a patient in taking care of themselves, seeking care, purchasing care, etc. is doomed to failure. Unless medicine in the US is not changed to a true free market, where prices are posted for everything, patients bear more costs and choose based on cost thus changing their behavior , where true competition occurs and costs decreased due to market forces, where the fix is not in to artifically support the charges of hospitals, pharmaceutical companies and yes even doctors. Where we work to reform the out of control disability system. Where the malpractice debacle is ended. When medical school can actually teach docs to be clinicians again instead of docs who can't treat without testing. Where we as a society realize that a safety net is needed for those that can truly not take care of themselves, but realize that a substantial percentage of disabled are NOT. Where the epidemic of narcotics on demand for any discomfort is considered "standard of care" is ended.
In other words, blah, blah, blah, until medicine is truly a free market in its purest sense, we will never get any of these problems resolved. NEVER! Because of all the vested interests in the industry, it is unlikely to happen. If you can tell me another way to resolve this let me know.
In the meantime, like the Dude in the Big Lebowski, I'm fixing myself a White Russian.
Another category for the question: I will selectively see only those low risk medicare patients. This reduction in medicare fees will necessitate only seeing those patients that do not have much risk involved in their treatment nor require significant time.
Its not the 21% cut stupids. Its their control over your profession that sucks.
Even after the cut is reverted, you will still be subjected to all the nonsense terms and conditions and regulations and requirements.
Man evolved from chimpanzee. Doctors evolved from ostrich.
In fact, 21% cut will help more doctors to realize what is keeping them unhappy. Its not about money folks. Its about being happy. You are not going to take one single dime with you to your grave.
I am sending all of my Medicare patients to their congressman's and senator's office to get care. Perhaps they can figure out how to provide adequate care for less tham it costs to provide the care.
sleepdoc,
Last time I checked we have a Democrat/Socialist/Communist President, Democrat controlled Senate, and a Democrat controlled House. Beck, O'Reilly, and Rush are not making policy, the Democrats are in charge now. Please direct your anger in the right direction. I'm not happy with any of them now, so don't call me an idiot right winger or a stupid tea bagger. Read the comments and facts on Bunning before you spout your drivel. Thanks for playing......
Depending on your market, it could be the best business opportunity you will ever have in your life. If I were one of the only 2 endocrine in my service area, this is what I will do:
I will stop seeing pt of the lowest paying insurance (if it is medicare, so be it) I will hire a staff and give her a car. She will go to each such pt home and will bring them to my competitors doors and give them free breakfast at Danny's coupon if they agree to become pt of that practice. Overwhelm my competitor with low paying pt -- better paying pt will get poor service -- they will flock to my practice. My income will go up while s/he drowns in loss makers.
I know it is done. One of my friend was choked out by a competing large group practice with this method.
Again the AMA sold us out. Did the executives at the AMA take any cuts in pay. Everyone should op out of the AMA it is a worthless self serving organization that does nothing for its members except collect fees to line their own tills.
Sermo Doc 98 Internal Medicine Posted Feb 27, 2010 at 7:48 AM Here's the deal with Bunning....
Last week the Dems and the Repubs amazingly had worked out a BIPARTISAN jobs bill...(improbable, I know).
All the leadership had agreed as had the members of the relevant committees.
Part of this bill was another non-permanent Medicare patch.
This agreement was made public.
Then democratic leadership pulled the rug out and decided to scrap the agreement and make their own bill....largely on the fear that in the Fall, the Republican challengers in their districts would point to the jobs bill as another example of their legendarily profligate spending.
And so the Republicans they made the deal with are miffed.
So they are going to make the Dems to everything the hard way...for a while.
Bottom line: both sides are playing "Chicken" with this issue.
why not a 21% cut on the allowable charges by drug companies? or a forced 21% cut on the cost of other medical devices produced by enormously profitable companies like j and j, synthes, etc. how about a 21% tax or forced reduction against lawyers who sue health care providers and hospitals...how about 21% cut on the lawmaker's salaries who continue to waste the country's time arguing without progress...but a 21% cut for the Americans who worked and learned tirelessly through high school and college just to be accepted into medical schools, then individually spent over $100,000 to study for 4 years in order to enter training programs to work 80 hours per week at less than minimum wage...i realize this is preaching to the choir, and that most of America continues to think that doctors are wealthy complainers...but where should we really make these web posts so that others could read our comments...instead of all of these sermo comments being read by only other doctors?
Unfortunately I cannot act against this. At least not now. My practice is almost 100% Medicare patients. If I stop seeing Medicare patients I would have to close the shop. I cannot afford it. The patients would go to someone else who would continue to take Medicare. It would be possible only in one instance: if a big majority of other PCPs in my area would do the same. But it won't happen. We are not united.
Drivelistic (yep I made that word up) left wing nut jobs are just as bad in my book as far right wing teabaggers.
I'd prefer the middle of the road. If we truly had a real checks and balance system in these United States, I would not be as worried as I am today.
What branch of the Government can give Congress/Senate a cut in salary? Why is there not a check/balance system in place that holds these nutjobs in washington salarys constant. They are in Washington to work "for the people." Shouldn't they do that out of the goodness (LOL um that is extreme sarcasm) in their own hearts (again sarcasm no heart there).
Honestly, if they get free health care in Washington for the rest of their lives, shouldn't the rest of us possibly get the exact same free health care? I for one say take away the friggin free health care from any president or congressperson. It is stupid to give them free health care in a capitalistic society.
Wow, I feel better getting that off my chest. Now I get to relax for 5 minutes...
Great comment Sermo Doc 93 - you're talking about real reform. We can accomplish this in micro-cosmic fashion - in communities and States - but the Fed Gummint won't let us do that, because they can't control the plan(s).
Again we are the low hanging fruit for the massive business that we support. Give the power of the premiums to the consumers. They have been brainwashed into thinking that the bureaucracy and politicians are responsible for their healthcare. They complain about any copayments or deductibles but have no complaints about driving expensive vehicles or taking expensive luxurious vacations.
Good. I hope Medicare gets cut 99% so that doctors finally wake up and stop colluding with a completely dysfunctional healthcare system. We need to get the government out of the business of legislating and paying for our healthcare.
"Ask not what your country can do for you. Ask what you can do for yourself."
Thanks for the great comments everyone. It is great to see physicians starting to wake up and realize what is happening all around them. During a week where Anthem felt justified standing in front of a congressional hearing, defending 39% premium increases and record profits for 2009, it is a bit surreal to see this cut taking effect. Until physicians take the initiative and start acting proactively, we will always be taken advantage of.
The point of this post is to emphasize that we are seeing a trend here. This has been playing out for a long time and will continue to play out, until physicians start showing some initiative. I knew with 100% certainty that the AMA would screw physicians when I understood their business model and that they were getting the vast majority of their $300 million dollars in revenue from CPT codes (less than 10% comes from membership dues).
As angry as tort reform (or the lack there of) makes me, I am far more concerned about another trend......states quietly starting to tie physician licenses to participation in Medicare/Medicaid. Before you think my concerns are unfounded.........
A BILL IN FRONT OF THE MASSACHUSETTS LEGISLATURE AIMS TO TIE PHYSICIAN LICENSE ELIGIBILITY TO PARTICIPATION IN THE STATE'S MEDICAID PROGRAM ( click here www.mass.gov
My point is that physicians need to take decisive action now, because it is getting harder and harder to do so. Over a year ago, we saw this coming and started investing heavily in the tools and material we knew physicians would need. If you haven't taken a look, please consider checking out the Practice Management Exchange on Sermo. There is plenty of discussion on different business models and accredited courses for learning how to switch to cash practice or concierge.
Click here to go to the PME (Practice Management Exchange) md.sermo.com
our academic colleagues could have a huge impact on all of this. they could all simultaneously do a press conference stating they are no longer accepting any plans including medicare and state the reasons why. no one would shut them down, their patients would not leave( would they inundate the private practitioners- not likely), and the issue would be out there.
even though the academics are somewhat insulated from all this as they are salaried, they do understand that if more money came into their practices that more equipment could be bought, salaries and incentives could be put into place and recruitment would improve. now we just need to convince them of the tremendous clout they have.
Sermo Doc 109 General Surgery
There is great potential for this to be a blessing in disguise. Let's make sure it is! We all whine in the lounge, never banding together to exert the influence we have as the true providers of health care. Stop seeing Medicaire patients now! Think of the extra time at home or in your office reading, relaxing and not jumping through silly government documentation rules(just there so they can fine us thousands of dollars for innocent errors), that take up more and more time. Forget the money lost in the short term. If we do not stop this here, all payors will continue to turn the screws- they do not care about our success or failure, they just consider how to get their little worker bees to provide care at the lowest possible reimbursement. Wake up, this perpetual decrease in payment will continue to deteriorate until we take firm action. Think in the long term.
Buffet98: The tail is wagging the dog. "Last time I checked we have a Democrat/Socialist/Communist President, Democrat controlled Senate, and a Democrat controlled House. Beck, O'Reilly, and Rush are not making policy, the Democrats are in charge now" is just what I am talking about. The Democrats are so disorganized that the MORONS on the right control the show. WAKE UP!!!!! It is the tea baggers and the right wing nuts that are the problem. There are NO facts to check about Bunning, he stopped the legislation for jobs, military, health care etc. He is a selfish ignorant ex-ballplayer who got hit on the head one too many times.
@Sermo Doc 8: re: "unnecessary testing=cover your ass testing =er medicine"
1) If you have nothing valuable to contribute to the discussion, then don't contribute 2) I hope tearing down the colleagues (whom everyone in this thread has suggested will be stuck doing YOUR job for YOUR patients after everyone opts out) makes you feel better; but it makes you as much (or more) of the overall problem as the government 3) Unless you NEVER consult any other medicine subspecialty on ANY patient in your practice, never order an echo (just use your stethoscope), never order a chest xray (just auscultate and percuss), never order CT (just do a physical exam)..then you are doing it too sooooo...get over yourself. 4) Define "unnecessary". 5) And finally...my snotty comment of the response (since I was up all night seeing ER patients and intermittently listening to the whining of the internist about admitting the 2 admissions out of the 30 patients I treated) you might want to check out your glass house...karma is a B**ch. I am glad to talk to you with 3 or 4 patients at 6am but it is just as easy to wake you up 4 times between 1 and 5am...I'm up...
I retired 5 years ago at age 65-66. I felt that I still was capable for practicing quality, up to date medicine in my subspecialty. One of the factors in my deciding to retire was that I was sick and tired of the yearly SGR driven Medicare fee Russian roulette game, Yes, the politicians usually rescinded the cut and gave us a token 1 or 2% increase, but this was not enough to cover increased practice costs and inflation.
Are "we" going to rescued again? I don't know. I do know that two of my former associates in my former subspecialty division will bail out if they don't. This is one way of controlling costs. Chase out older doctors; cut down care availability; and then when the patients can't be seen in a timely fashion, blame the doctors. This is political cynicism that only Congress and the administration can get away with. The media will, of course, blame Medicine, the doctors, and the insurance companies and will let Washington get away with this.
Is there an answer? No, I don't think so. Doctors are so diverse in their views; so divided in their political philosophy; and so convinced they they won't be sacrificed for the "public good" that the only historical analogy that comes to my mind is the situation of German Jewry in the 1930s. "They're not serious. They really can't mean what they're saying." We all know what happened then. Sermos numbers are too small to make a difference. And, the AMA which only represents a minority of doctors - well, we know what we can expect from them.
To paraphrase Walt Kelley in the old Pogo cartoon strip (or Shakespeare), "The fault lies not in our stars, but in ourselves."
Sermo Doc 72's petition idea would be a good test to
1. codify goals and complaint
2. see if we can get our s..t together on the most basic of lists
3. whether we are willing to attach our names to any argument( to see if we have any balls whatsoever)
Without true Physician Leadership there is no ownership and control. Without real action in the short term we are losing so many battles that the war ( loss of physician leadership in health care) may soon be lost.
The result of chaos is either things re-organize to a higher level of efficiency or they self destruct. I am fearful the latter is more likely than the former if physicians remain inactive.
Those who think reversal of 21% cut will bring them to paradise, think again - they dont have money and they will keep finding ways to put pressure on physician pay - in form of RACcoons, audits, denials, no COLAs and so on.
"White Out Washington!!!" Take our white coats to to DC!!! I am a physician in Tampa, FL I will be contacting local Hillsborough County Leaders about organizing a work stoppage. Other groups have done this successfully in the past -- ER Docs in West Virginia for fair malpractice rates and in New Jersey on the recent past come to mind. We need to act now!!! White Out!!!
I have long believed that our only way to a decent future was to form a union or better yet a guild. As a family physician in private practice for almost 30 years now I have felt that not only the AMA but My own AAFP has miserably failed to protect my ability to earn a fair living commensurate with the skills, hard work and responsibility I shoulder every day. The answers will not come from the evil clowns in Washington . You want to deal with the insurers you better have clout and we have none right now. Years ago, after several misguided attempts deal with the Medicaid program in Florida gave up and have not accepted any Medicaid in more than a decade. I can see the same happening with Medicare and Tricare but who does that leave as a patient base and what insurances do they have? The answer is the usual suspects, BCBS, Aetna, United Health Care and other assorted thieves. These guys play hardball and without the clout of a large well organized organization fronting us they 'll eat us for lunch every day.We need a Guild/Union and we need to hire the most ruthless junk yard dog attorneys to negotiate on our behalf and make the insurers and the government offers they can't refuse. I'd rather man a free clinic for emergencies during a strike for a week or a month than keep working for the insurers and the government like I am now. It's time to act not beg.
Sermo Doc 111 has mistaken my post as a criticism of er docs. it is the system that i am critical of. as an er doc i cover myself with many tests. i xray anything that hurts etc. i must do it to cover my malpractice self. much of it is unnecessary. emtala helped ruin er medicine.
This proves that our organizations have failed us . The AMA is worthless at best harmfull to our cause at least. We have to band together to protect ourselves and our patients. If we dont we all will suffer.
I'm certain that you recall that our support for the Medicare part D legislation was obtained by appending a short-term Medicare fix to the bill. We either were for the bill or suffered financial harm. I sincerely doubt that politicians will easily give up the ability to hijack our support by passing a permanent SGR fix. The best we can hope for is a temporary fix.
I will not comment on the asinine decision to eliminate the consultation codes.
Since the already paltry Medicaid reimbursement is linked to Medicare fees, we will no longer be able to afford to see any Medicaid patients. Furthermore, we will have to reduce or eliminate the charitable cases we treat.
In my experience private insurers will follow suit and reimbursement by them will also be cut. l propose the following: We bill every patient an "administration fee" for each visit to cover the overhead. Also, fees will be charged for every form we have to fill out.
Agree strongly with Sermo Doc 73 and others. As of Monday, everyone in practice who accepts Medicare should simply observe a "moratorium" (certainly not an illegal "strike"!) and have our employees call every non-urgent patient and state that "as of today, the government is delaying payment of all your fees for at least the first 1 1/2 weeks and has decided that I have to accept a 20 % lower fee. Unfortunately, I have to pay my bills this month so I will need to postpone all appointments for my Medicare patients until I know when and what I will be paid". If enough docs actually did this (thereby accepting a voluntary, instead of involuntary, decrease in cash flow for at least a few weeks, maybe there would be an outcry from all of our patients who would actually be as anxious about their entitlements as we are about our livelihood, maybe there would be some news coverage and SOMEONE in Washington, might just pay some attention. Some of us have just gone ahead and opted out but, for those of us who can't, it may be "survival of the loudest".
Well Sermo Doc 27 you can have all of my Medicare patients and practice all the evidence based medicine on them that you can handle. Please keep your self-loathing to yourself.
Daniel,
I embrace the idea of concierge practices but if participation in Medicaid is required for licensure what good does it do to change to a concierge service. One could of course provide two-tiered service (Medicaid being seen by one of the new "Dr. Nurse Practitioners" or limit one's practice to non-covered services.) I'd like to know because even though I am the sole breadwinner in my family I'll starve before I'll submit to that B.S..
My primary care group (the largest on our county) will stop accepting new Medicare patients Monday, and if the cuts stick, terminate care for 25-50% of the existing patients and require all new patients with commercial plans to sign up for our retainer offering. We have a leaflet ready explaining the reasons why and how to contact our Congressman and Senators.
If Licensure is tied to Medicaid and Medicare participation I doubt that would withstand a challenge in the Courts - the Constitution holds that contracts have to be entered into voluntarily. If States do pass this then physicians should consider withdrawing their labor until it is removed, should work pretty quickly. You can't be punished for not working.
I for one am glad the cuts will happen. For so long we have allowed ourselves to become groveling slaves to the medicare system. Now there will be enough people to break free and go back to a more fee for service system. With huge numbers not taking medicare, we might finally be able to do this. Before, those that didn't take medicare lost out to the majority that did. I still would not charge much to my elderly patients, and will even do work for free, but I will save money by not having to employ people just to get my money from the system. I think people will be surgprised how little we actually charge for our services.
I was at my bar tonight, doing owner duties, and I ran into a couple of surgeons I work with. The 21% medicare cuts came up for a prolonged discussion. I put to them, that lt would be like my bar charging $10 for a beer, but the Feds then telling me that by law, I could only charge $1.50 for the same beer to anyone over the age of 65. The problem is that the glass of beer costs $5, $1.5 for the actual cost of the beer, and then all the extra costs amortized into each glass, that come from the actual running of a business(leases, utilities, employee salaries, etc). Any business would be quickly bankrupt with this type of pricing in their business model, yet this is exactly the business model all of us physicians are have crammed down our collective throats. To boot, this simple son of a bitch in the White House then has the gall to say we can make up for the cut by working harder and seeing more patients. Stunning you can get elected President of the United States, and be that ignorant of even the most basic of business concepts. Losing money on every transaction, but making up for it on volume didn't work out so well for GM or Chrysler did it? The really galling aspect of it all, is that Obama and company have no problem playing on our natural sympathies for our patients, and you see that in many of the posts above, in that any action we take, "punishes" those over 65.
I have news for you all: you can't take care of anyone if you can't keep the doors open. These cuts, especially in the segments of medicine, IM and FP especially, that are heavily dependent on medicare moneys, are going to put many of these docs underwater financially.
I am betting that there will be some form of rescue over the next two weeks, as the anger I have seen here and among my colleagues in my community is frightening. Docs I have never, and I mean NEVER seen angry, I have seen spitting mad this past week. Something new is in the wind, something I have not ever seen in attitudes. Going to be an interesting week this week. Good luck to us all, we are going to need it.
Whenever I try to understand any complex system, and health care is one. I look at extreme models at both ends.
Model # 1-everyone has healthinsurance. As an friend of mine says eloquently "There is an unlimited demand for a free commodity". I can only see people consuming more and more of cognitive and procedural services if there is little cost to the patient. Imagine this model with any commodity (food, gas, oil). It is clear that the demand would increase and would be impossible to cover long term by "the government" ie the taxpayers. An example seen daily in my clinic is that everyone will sign up for a screening colonoscopy if it is a covered benefit by their healthplan. If it is not a covered benefit, or if it is a Medicare patient who has had a screening colonoscopy within the restricted time guidelines and "wants another to be sure they don't have colon cancer", they rarely will pay out of pocket for physician and facility fee (I have had one patient in 23 years sign an Advanced Beneficiary Notice for a non covered Medicare procedure and pay for it out of pocket). They do not perceive colonoscopy to be worth the money that I and/or the facility would charge.
Model # 2-No one has health insurance; ie everything has to be on a cash basis. The market would have to respond. i guarantee that if I lost patients because another doc could perform the same cognitive services and/or procedures I could at a lower cost, then my choice would be to compete or not by equaling or matching cost. That, cruel as it may sound is how a true free market works. Not only does it lower costs, it may change behaviors (smoking, obesity, etc.) that may effect the patient (in the pocketbook) Yes it would close lots of hospitals, close some doctor's offices, cut the income to pharmaceutical manufacturers, cause consolidation of existing hospitals/ambulatory centers/imaging centers, etc) It may or may not actually decrease physician's income.
Now I know that people would point out that model #2 would fail in markets without competition. Care for emergencies would be another issue (I think TRUE emergencies would be budgetable). Redefining the truly disabled and care for the truly indigent would still be doable. But someone tell me how can we control costs and budget healthcare long term. The responsibility has to be put on the patient. The only pressure to change patient behavior is economic. I am in the camp of the behaviiorists. Study behavior modification and you will effectively control healthcare costs and improve morbidity and mortality in this country.
The only solace I have is that I am so certain in this belief that only wholesale change in our system to one where we focus on only one thing-the patient's healthcare consuming behavior is the ONLY SOLUTION. It allows me to believe strongly (hopefully not rationalize) that anything else is a bandaid on this system. Cutting 21% isn't going to work, not cutting 21% isn't going to work, adding another 21% or 221% aint gonna work. The system is inherently flawed.
So live within your means, cut your expenses, require less money to live on, simplify, etc., because the system as it stands is untenable without major modifications. And lets be realistic, they are so many consticuencies (I am sure that is misspelled) that would be effected by a FREE MARKET HEALTH PLAN, insurance companies, hospitals, big pharma, medical equipement providers, state and local government and yes even doctors (the least of all the players don't you think?) that it is unlikely to happen.
So in keeping with the serenity prayer and (.....and the wisdom to know the difference between things that you can change and not change) (paraphrased)
Nihilistic? Fatalistic? Maybe, But realistic ultimately.
If I stopped seeing Medicare patients on Monday some other docs in town will see them. I will lose 40% of my collections and will go out of business. The only way to survive is go with the flow...
sunny- if you (or your competitor) are losing money on medicare, you may want to have your medicare pt give a free ride to your competitor's doors. Dump that business on your competition. Let him/her drown in money losing business. That will bring better paying business to you as they find it is poor quality work there.
When you calculate cost of providing business, dont go by the common fallacy "Oh, I am getting at least something instead of sitting, doing nothing" . No - there are real costs involved in seeing a pt - lease, staff, utility, liability risk etc. And dont forget, time away from your kids is very expensive.
My practice style is such that I will make money at medicare rate even after 21% cut. But as Sermo Doc 93 said, system is inherently flawed and is doomed to fail with or without cuts. I can go down the whirlpool with the system or I could find an alternative.
"In the next 48 hours, the US health care system will suffer an earthquake of the magnitude that was just experienced in Chile. Understand that many primary care physicians already limit the number of Medicare patients they see, because their practices would not be solvent if they saw more. Imagine what would happen if that part of their practice now reimbursed 21% less. Access to health care for the large and growing Medicare population will be dramatically limited, creating the Emergency that the President needs in order to pass his health care bill." from: caps.fool.com
GutDoc (with 2 Ts :-) has said some very powerful analysis. Lets think over it.
A communist healthcare in a capitalist country is doomed to fail. We have unlimited consumption by the communist process that is unchecked due to American style of lawsuit fear and is fueled by capitalist style of greed from direct to TV ads, fake research results, frivolous lawsuits, over-utilization bringing more money to docs and their hospitals etc etc.
Can I live with a complete socialist system? sure I can. Will it be perfect? No, it will not. Will it be good for the country? No. Final result is either collapse of the empire or severe rationing dictated by computer generated algorithms.
Can I live with complete capitalist system? yes, I can. Will it be perfect? No. Will it be good for the country? yes, but at the cost of appearing to be ignoring some patients.
"He gives his patients an itemized receipt with all the necessary codes and tells them to send it in to their dental insurance. Whatever they get from their insurance is between them and the insurance company and he has nothing to do with it. Why is it that people seem to think that medical care should be free and yet they happily (or unhappily) seem willing to pay the market price for veterinary or dental services?"
Because the veterinarian's customers aren't paying $1000 per month in premiums every month. People (including me) feel that they have already paid enough for their healthcare. Put it another way, if you were paying $1000/month for your "car upkeep and repair" insurance, wouldn't it irritate you to get a $300 bill?
The root of all evil is the insurance system.
And I like the idea of a cash-only system, and let patients work it out with their "insurance" company.
"The "ordering of unnecessary tests" canard is mostly BS that is reflexively uttered by laymen and physicians alike only because it is endlessly repeated by the pro-"health care reform" crowd. How many of YOU order unnecessary tests or, God forbid, surgeries? And, if you think you may have at one time, HOW OFTEN? Can any of you, as individual doctors, say: "Oh, yes, I order unnecessary tests, studies, etc everyday--- I couldn't do my practice without them"? Again, BS!"
Me! There have been plenty of times when I order a test that I wouldn't order on myself or my family, simply because I'm trying to make a patient happy (read: so she/he won't sue me if something goes wrong. Oh wait! I'll get sued anyway. "Nothing personal")
Sermo Doc 104: I should have been more specific. The 3rd-pary payer system is the root of all evil. I wasn't attempting to sing the praises of gov'ment medicine.
Couldn't read it all. Am in Colorado on a trip paid for over a year ago.
Panicking of course, as I can do nothing.
Not making a living now. A friend with us says that Obama considers doctors as the enemy. She is not a doctor .
will try to find a job as I need to survive. Husband will stay in practice. A stockbroker friend once jokingly offered me a job as an assistant. Am a financial idiot, but used to working long hours. I think he's already hired someone, though.
Maybe I could work weekends at Target. There is one near the house.
Am depressed at the moment, no chocolate, no where to get any.
Maybe the world will stop and I won't have to go home to struggle with finances.
Churchill- there is a RMCF outlet in that tiny mall close to the airport in Breckenridge, just before the city bypass meets on highway.... and then Silverthorne mall is not too far .... get your resuscitation fast...... call 911 and demand to be taken there as you can not breath without chocolate
Low overhead is the key ..... could also think of adding extra charges ..... depending on demand/supply in your market
Opt out of Medicare, cancel commercial contracts and practice a cash for medical care practice. That is the most cost-effective and ethical way to practice medicine. My practice was 67% Medicare when I opted out in 2001. Today (9 years later and still cash only), Medicare patients represent 50% of my patients. They contract with me outside of Medicare and do not get reimbursed for my very affordable charges. Good medicine is worth good money. Don't sell yourself into slavery and then whine about it. Get out of slavery. See www.northernurology.com for the story, under articles. We can control our practices. We just have to take the reins away from the third party slaveSermo Doc 44s and work for our customers/patients.
I work in an emergency room, and I don't have any options, however, I am scared what my hospital's fate will be. Iowa ALREADY is reimbursed 51st of the 50 states per Medicare patient (Puerto Rico does better also), and our population is primarily Medicare. Rural (as well as urban) Iowa had better plan on getting their care in Illinois, Nebraska, Minnesota or Missouri because Iowa's hospitals won't be able to afford to stay open. Not that anyone in Washington really cares, since we don't have a huge voting population like New York.
I can't really opt out as our practice is almost fully referral based, so myself and our group is essentially stuck, unless our referral base changes, which will probably not happen. This will probably translate into a 15% overall cut. Maybe we should just pay 21% less rent and taxes...
If Congress and/or the President do not stop these cuts we are all in trouble.
1. The docs will not be able to keep their offices open to take care of patients 2. Increasing rules and regulations require expensive staff members to get things done for patients 3. Increasing costs for food, electricity, emr systems, etc, will make it difficult for us to survive.
Perhaps, they will understand, or the system will collapse....
wlbug.. Your estimation of cuts neeeded is very low. You have to do a more accurate analysis or assume at least 40% decline in income to be on the safe side. All other costs of doign business will either stay the same or go up. Unfortunately it will mean masive staff reduction and reassignment of duties. If you have a neighbouring office, consider shared employes for4-6 hours/d. Take more time off. Luckily with ID your staffing must already be very small.
How many of you think that your pay rate will go up over the next 2-3 years??? Insurance revenue is down, CMS is probably bankrupt (or will be soon). If you are going to make 120k anyway, why to make it while eating shit. Why not to enjoy practicing medicine the way it should be?
Transition away from 3rd party system. It will take some planning and time. Time to start is now so that you can be independent in 2-3 years. If you wait for the cuts to actually materialize, you will find yourself panicking when it comes. Transition can not be done in a week or a month.
It's hard to change to private insurances when your practice is based on home bound patients. My plan B is aesthetics. I am sure I will be making money out of that and then I could continue with the home visit practice.
Also, we will be socialized we like it or not. Medical care is astronomical due to the money the insurance companies are making off of us. This is very sad.
It is interesting for years we have slaved over learning how to adhere to the cpt codes/rules/regulations, all the while "worrying" about if we will be audited. You follow one rule, there are 5 definitions/interpretations that result, and therefore you Underbill to avoid the concerns or "red flags" of billing for what you actually did. All the while, payment is worse and worse and worse.
Well, now it gets alot easier. I will absolutely be optiong out as of the 17th. We all have no choice. Think about the comparision.....if your practice is 80% medicare, and you no longer accept medicare contracts what happens?????......After 30 days, you are no longer held down and regulated for what you do. The patients will still see you, but now they have a vested interest in the process. They will have to pay to see you, and what is wrong with that. If your fees are reasonable, it works. One reason people can't afford to be seen, is b/c our fees are so eratic as we don't know what the maximum payer will be, therefore it is set a an rediculous number, to avoid being underpaid. Imagine what it will be like when you have ONE fee schedule. you only need on biller, you office finances get easier, and you actually get paid. Interesting concept huh?
Look at what you will be paid right now......Medicare cuts = 21% cut on top of no Cost of living increase. How can anyone even consider that, and feel they can't opt out? If an office visit for a complicated patient was paid at $80, now you will get $63. extrapolate that for your patient volume. That is worse than Medicaid, not to mention that medicaid will be paid EVEN LESS!!!!!! Come people you CANNOT MAKE THAT UP IN VOLUME. It doesn't make sense.
Congress has pushed the guantlet, now we have to react. We are not punishing anyone, lets be clear. The elderly need to be made aware of what is being done to their healthcare. Think about it....Toyota is going through a tough time right now. Do you think you get a Toyota below the cost to make it? Will Toyota sell you a vehicle, at a loss, b/c you need the car or their financial structure is hurting right now? I should say not. What makes you and I any different. Enough with philosophy and altruism, we have now entered the final countdown. Lofty dreams/goals/philosophy do not pay your bills, put your kids through school, pay for your food, or your school loans/debts. You are still held to your debt and responsibilities. Now the elderly will be too. We did not do it, and we should not take the blame for a legislatively driven/gov't related fiasco that has now been bestowed upon us.
Opt out. I suspect, when people have no choice they will pay, just like their auto bills, food bills, heating/home etc. If they don't pay, they don't get the service. There will be needs for us, and we will survive but only stronger, as the influence over us will be no longer. I have had several patients with and without medicare/insurance whom stated they had no money to pay, I then simply told them to call me when they could put a down payment on the procedure.....Every one returned withing 2 days with >$500 to put down. If you are valued, they will pay. By definition, medicare devalues you and I, therefore it is more than a loss now.
Politicians are about to give us all a 21 % pay cut , effective tomorrow- March 1st- and there's plenty more where that came from.
Even if the current Medicare pay cut happens to be "rescinded" or "delayed" this week....or month...or year with additional providers taxes or concessions of some kind by doctors, hospitals, etc, it will not be indefinitely- and cannot be forever.
This country - and its doctors- have been on a collision course with reality for a long time......
This is not about Democrats vs. Republicans.....
The same Washington bureaucrats who paid you generously in the past - are about to crucify us all on the altar of Public Health Care Need.
Do you want to continue getting paid- instead of paying- to provide medical goods and services to seniors?
1) I think we should make permanent changes to our practices until the whole SGR is scrapped and something workable happens. However, I have such a bad taste in my mouth right now regarding every aspect medicine and politics I may just make some permanent changes even if they fix the Medicare problem. (ie, cash only)
2) Who cares if another doctor is willing to see all the Medicare patients, let them deal with 8 problems per visit and get paid 60 + dollars for a 99214, they'll only be able to see 10-12 patients / day at that rate. This will leave the cash paying patients and better insured patients to the rest of us who are smart enough not to work for less money than it costs to see a patient.
3) Please don't blame one political party or another. I remember that republicans had control of Congress, Senate, and White House, where was tort reform then? Where was the SGR fix? Where was any major changes other than the prescription plan for Medicare? And now the dems are doing what the dems always do, try and fix everything w/ government. It comes down to this, WE need to make the changes and make people, government follow us, not the other way around.
4) We are one part of the reason why the cost of medicine is skyrocketing but we aren't the only source. Think about every job, chair, desk, phone, facility, etc that is used to make one thing happen in medicine. The transfer of money from the patient to the doctor/facility, etc. The middle man is creating the "Huge Sucking Sound" of the cost of medicine. Example: A 50 something year old Vice Pres of United Health Care take an early retirement for 40 + million dollars. If you don't feel that sort of thing generates wasted medical costs I'm sorry for your naivitee.
5) I run my own clinic for the time being, what makes my business work, cash, CASH IS KING. I'm not working in that vain yet, but it's looking very appealing at this point. It' s either do something drastic or just quit the damn profession.
6) Patients I doubt will help us very much. I'm not very impressed with the general population out there. I think the average IQ is slipping. There is a reason why we are physicians and so many people are not! I had a patient actually ask me this question today. Does your hospital charge for MRI's?
Let's all take a deep breath, hug our families, work less hard and more inteligently and let the electorate do what needs to be done, fire the whole mess of them in D.C. and start over. When our representatives are there for us and not themselves, that's when D.C. will start working for us.
Junk the People magazine, Reader's Digest, Sports Illustrated, etc in your waiting room.
Buy a box of these booklets for patients-and friends. I did. It's about a buck a piece.
As a radiologist, I figured it makes more sense to give them out to referring docs of all specialties and let primary care docs- who have a personal relationship with patients -distribute them directly.
No, I don't get any royalties......No..... I 'm not "GETTING PAID BY BIG PUBLISHERS -IF YOU FOLLOW THE MONEY " as some wack-a-doodle is likely to suggest.....
Believe it or not, the booklet does a terrfic job of making a complicated topic very accessible to a layperson of average intelligence. It does a great job of explaining the problems in the US health care system - and how we got there incrementally- in plain , basic language that any interested, curious- and intellectually honest- layperson of average intelligence will be able to comprehend.
You don't need a PhD in Economics (....which is an impediment to mental clarity....) to understand it- just common sense. It's written for the Joe the Plumbers out there.
It also describes some concrete, practical solutions - real ones- not the crap coming out of Washington.
1- Its not about pay **rate**, its about pay *control* that I have problem with. As long as this dynamic is in place, we will be subject to these experiences.
2- If you avoid 21% cut now, do you think your pay cuts will not come in different forms in future? Medicare is not going to get richer. In fact, they are planning to add more drug benefits.
Throw away yoke of 3rd party system, release your energy and passion and dedicate it to what you went to medical school for.
I will stop taking new medicare patients as of the end of the week. The government is NOT going to balance the medicare system on the back of my bankrupt practice.
As a pediatricain I am glad I don't have to direcly deal with Medicare but I know as Medicare reimbursements go down so will the private payers. At this rate I may have to return to my previuos profession. My income is not much above what pharmacists make so that may be where I have to end up if continuing as a pediatrician is not financially viable. (I certainly like being a pediatrician more than I did as a practing pharmacist.)
I have not been taking new medicare patients for quite some time. Now, I wil just stop seeing medicare all together. The government has made it easy for me. About how to turn this all around, I am less hopeful. The citizens of this country must step up and "take back the nation." The problem, "you don't need intelligence to vote and procreate". Scary, scary thought because we are in the situation we are because of whom "we" voted into office!
My solo FP practice opted out of Medicare this year, and made available to patients 3 options to continue with privately contracted care to avoid this coming debacle in the availability of MDs available to supervise the patients' care. We have chosen to charge a limited up front package fee that includes all visits for the calendar year, with a free preventive service (and no scheduling fee for this) that is chosen by the patient at the doctor's recommendation (like an EKG or PFT), and a nominal fee to schedule each visit (forfeited by patients that don't show up).
This ends up costing the patient less than basic cable would for a year's service, and much cheaper than most cell phone plans. We are charging much less than Mayo Arizona's $1500 package, which I believe includes one comprehensive visit and 3 follow-up visits (and no free preventive tests, I believe). Another option with us is to pay a smaller up-front fee, and get 50% off our fee schedule prices, with a scheduling fee still charged for visits when appointments are made. Final option for people who visit less often is to pay our discounted same day cash price with no up-front or scheduling fees, but still a signed contract fully informing our patients that we send no billing to Medicare, and so no secondary payers can be billed. To our surprise over two thirds of our patients recognized that one of these was a good plan for them and their doctor.
Direct doctor contracting with monthly fees in the range of cable bills would probably work for most primary care providers, though we chose to go lower for our ESTABLISHED patients. We still have not opened the doors to NEW Medicare patients with a similar plan, though we could at any time. You do have to notify CMS at least 30 days prior to the start of the next quarter, I believe, to "opt out", and it does need to be for a 2 year minimum.
Many of out patients were informed IN ERROR, by CMS staff that if they saw me after we opted out, then their prescription med costs, and referrals, and tests ordered at other facilities would not be covered. The patients could ask to speak to a supervisor and then would sometimes get the correct information that this was not CMS policy unless a physician was under sanction.
This type of plan could be made available for a robust public option plan patient, or perhaps eventually other public plan patients, and WOULD DEFINITELY HAVE TO NOT BE SUBJECT TO THIRD PARTY REVIEW, to be viable, and not be subject to outfits like the infamous Recovery Audit Contractors, who now are free to target every US MD who receives Medicare dollars, and who are paid a bonus to find any conceivable reason to deny payment, I believe.
Instead a doctor could not only VOLUNTARILY choose to accept a certain NUMBER of contract patients, perhaps from a database listing patient basic health demographics, including what their main medical care needs are at present, but doctors could also CHOOSE patient TYPES (Peds, or "no Peds", etc.) that they felt comfortable with. They could also possibly CHOOSE to invite a case manager into the office to work with the patient and the doctor as part of a health care team, to reach identified goals in managing chronic diseases like asthma, or diabetes, with bonuses to the doctor and case manager, and perhaps lower medicine copays for the patient for generic meds, when identified goals are reached. North Carolina has a program called CommunityCare, that already does this for Medicaid patients, AND HAS A HISTORY OF SAVING THE STATE MILLIONS OF DOLLARS.
After initiating the simple direct doctor contracting option for primary care, then we can build on that to start a new plan for specialists, for which contracting and medical care quality bonuses takes more work to calculate.
Most docs would favor steady payments, no third party sanctions, bonuses for a job well done that includes the patient and other team members, that at the same time has NO incentives for over-utilization. If we are brave enough to take on these contracts, let's see if the government is brave enough to cut out the health care PARASITES.
We are already doing it directly with patients. TRY IT, if you can.
excellent model John This shows how affordable outpt care can be if we get rid of 3rd party shackles unfortunately, politicians can not allow this b/c politics is all about control. However, natural flow of events may take us to the point where most market is served in this model.
Yesterday I got a fax from the AMA with information on this coming Medicare cut. The letter at least said we had until March 17 to withdraw from Medicare for this year. But there was no sample resignation letter to submit.
I also realized another sad reality yesterday. Many insurance companies base their doctor fee schedules on what Medicare pays. So if the 21% cut goes through, will this just be the beginning of rollbacks in our fees from private plans also??
Sermo Doc 7-- To paraphrase Chuck Schumer during the HC Summit last Thursday--
'...the patient gets a bill for $4000.00 from his doctor and realizes that during his admission the doctor stood at his hospital door and waved a hello....'
The lifetime politicians have GOT TO GO. Vote with your feet in November.
The Congress had a year to override the 'temporary measures' which have gotten us to this point. It isn't one senator's bad choice, it's one representative body's ignorance and thoughtlessness. Count them- 538 in the House and 100 in the Senate, and seemingly few bright bulbs among them.
He wants Reid to bring forth and pass the bill extending Medicare til end of this year, without 21% cut, instead of extending for 30 days. Reid says Bush ended 'Pay Go'. Slow as molasses as Rome Burns.
These 2 guys are personal friends, so seeing them go at each other underscores the drama of this legislation.
I saw CNN criticizing Bunning. They mentioned how construction jobs, COBRA, road etc will impact and that contractors stopped working yesterday.
No mention of physician pay cut or that pt will get hurt or that physicians are saying no to medicare. Amazing. They still believe physicians will take cuts as just another chump change and that patient will have no problem. ........ and saddest part is that they might be right.
Sermo Doc 144 : I will start a new post on opting out of medicare with specific information. I would like to know if you how many days before effective day of opt out you gave notice, with the subsequent inevitable question : how much money did you have to pay for the 5% retroactive to opt out notice date. In addition, is your practice your only source of income ? I have seen doctors encouraging others for cash only , when themselves have other sources of income, and are at a --close to retiring-- age. I think that only doctors that have their practices as their only source of income could encourage others to go cash only ( if they are doing it themselves ).
The answer is simple. All doctors, across the board,need to be unavailable for 5 days. Only then will the congress and public realize that no one can do what we can do. Let physicians assistants take care of acute abdomens, obstructive uropathies and critical care medicine. Get the point.
Bill proposed in senate ....... now to postpone through Oct 1st
My response: Yawn
I am done with Medicare. Postponing to Oct 1st means only 1 thing ..... that now I have got some more time to plan things accordingly. ..... but out I am ...... no question about that.
I would, however, offer the cautionary example of a group of highly trained professionals, working a complex job under a great deal of pressure, who felt themselves inadequately reimbursed and withdrew their services, believing them so essential that such an action would lead to their victory.
They were fired en masse, to the general applause of the Republican Party and the right, and the indifference of most of the public. They were called air traffic controllers.
My point being that unless we ally ourselves with patients, and are seen as supporting their interests, and that of the country at large, as well as our own, we're doomed to fail. Again, as I always say when I advance this view, don't mistake me for holding our discontents trivial. I'm talking politics here, as those who would exploit and marginalize us are.
I agree with Sermo Doc 81. We can't sustain the current hodgepodge of insurances that leaves a quarter of our citizens without health care, while over-paying all the middlemen that don't actually provide a service.
There are only two possible sustainable solutions:
1. Assume that health-care is a "privilege," earned by paying cash for the service, like every other industry (e.g. plumbers, grocers, etc.) or
2. Assume that health-care is a "human right", and that our government is obligated to protect that right by organizing the provision of services, like every other service (police protection, fire, military protection, etc.)
It's obvious to me that government-organized health care is the only way to ensure that every citizen is covered, just as every other civilized country has done. If you're not in favor of that, then you're not in favor of making sure everybody can get health care. There's no other way. Short of that, 21% Medicare cuts or not, all us doctors will just be arguing over the crumbs.
Oh, really????
After the annual song and dance about the Medicare cut, that is always, always stoppd seconds before going through, we have the same dranma again?
Yawn. believe it when I see it.
And if I see it, I will drop Medicare.
A loss in income of around 20 % wil hopefully make more of us think about making a step forward and moving to cash medicine and balance billing.
And dropping Medicare and moving to blanace billign and cash practice is something that horrifies politicians and the AARP. Therefore, they will work diligently to stop the cut/
We actually have a win - win.
If the cut goes through, we win politically
If the cut does not go through, hey, it's the same old, same old.
So, I prefer not to do anything, smile and wait
I agree with the balance billing idea. Medicare should be like a PPO. You can either agree to their terms and be a perfered provider and get more patients or if you don't opt in the patient should be able to use the Medicare and pay the balance as though you were a non-prefered PPO provider.
Sermo Doc 152: the general public is not on our side. They note our $200,000 average yearly salary, our virtual guarantee of employment, our increasing distance from patients, and easily caricature us as driving our BMWs from our kids' private schools to our investment adviser to our country club, without noting that we work our butts off after assuming huge debts, and that many of the changes they dislike in doctor-patient relationships are imposed on us rather than our choice.
There are reasons for this, not the least of which is that it serves the interests of those who would control the sixth/seventh of the economy that constitutes health care without interference from a potential alliance of physicians and patients. We need to fight that.
This will be a cause of major turmoil in medicine if it stands. Many of our older collegues will retire and younger physicians will find other ways to support their family.
Many physicians will drop Medicare and unfortunately, those medicare recipients who thought they were paying into a system to take care of them during their retirement years will find they have been lied to. These are our parents and they will not get what they worked so hard for - security. When we finally retire, will there be anyone to provide us with the quality care we now provide for our patients?
This just in -So we have been another one month reprieve in the fee cut till April 1. Very convenient I'd say because the final date to withdraw this year from Medicare is still March 17, when we will not know what really is going to happen with our fees. Are we being played for fools or what????
Guess I've got to see if I can get the 10% disability I need for VA health care, as it's clear there's gonna be no docs left to see me! (Go for it!) The current government is doing everything they can to destroy our country, and we all-- Docs, NRA (I'm a life member), liberterians, talk radio fans, etc-- all of us who think the Constitution is a good idea still-- need to get together, tolerate our differences, and save our land.
Sermo Doc 148,
The Public remembers the lifestyle of older Docs when they were the Top Dogs in their communities and lived in royal style on the top of the hill.
Times have changed, Docs are struggling, but the people still remember the way it used to be. It'll take a lot of time and energy to change our public image.
Sermo Doc 104 - that is a very very important point that we cannot emphasize enough. It seems to take 20 years for any idea to go from reality to public awareness
abc: as many have pointed out, a 20% drop in reimbursement would result in a lot more than a 20% drop in income! That's what I try to drive home to my patients. When I show them the quick math with fixed overhead, they realize that it's a big drop.
I picture the scenario as such: Oblamah pushes the bill through via reconciliaiton. He has played the "I am trying but your not card" to make it appear that he is coming half way, when in fact the bill he presents is the same. It has the same special interest exceptions, and the same structure for you and I. It is once that goes through, that the cuts happen. It is the only way he can justify cutting the fees without mass exodus. Once the bill passes, opting out at that time, would be very difficult, as the verbage is very specific in relation to what care is given and by whom. Pay will be based on the gov't option, and will be uniform for all carriers and fixed at 103-110% of medicare. The beautifal thing is that CBO will set the fees/worth/indications.
The fundamental problem is not Medicare. It is not Medicaid. It is not the 21% cut. It is not the SGr formula. It is not any of those things.
The fundamental problem is not even government.
The fundamental problem is people. People are naturally inclined to be envious, to want more than they have, and to try to get it at as low a cost to themselves as possible. Thus, when socialist (Demopublicans and Republocrats alike) politicians offer "an advance auction of stolen goods" (H.L. Mencken), if there are more "benefitees" than there are victims of the theft, guess what will happen. They will elect Robin Hoods, who will steal from those who have to give to those who don't.
Medicare is an example of this type of scheme - a Ponzi of the highest order, along with Social Security and numerous other programs enforced by the truly evil among us.
There is a way out. Withdraw. Do not participate. In any of these things. Starve the beast. Cut your income. Cut your taxes thereby. Do business with those you know, and only them, and use a medium of exchange other than fiat paper.
Withdraw your participation from these monstrous schemes, and they will collapse. They only live because you feed them.
I continue to be astounded by opinions posted here, such as that of Sermo Doc 149 above (only the latest), that somehow gives a pass to government perfidy, and would instead entrust it with ALL control of medical care. Are these people insane? Are they so ignorant of history? Are they simply stupid? Or are they a part of the evil cabal?
>And the cuts would not even be an issue if it wasn't for the Republicans supporting them. Want to avoid the cuts? Allow for health care reform. <
This comment is proof positive of physician stupidity. You can still be book smart and be so stupid that you can't tell your ass from a hole in the ground.
This guy is so stupid his comments would be humorous if not for the fact he is apparently serious.
Just read the Bloomberg article by one of their staff writers about the huge expenditures to keep her husband with metastatic cancer alive for several years with "experimental therapy". We all need a co-pay or "stake in the game". Otherwise it is the attitude that "I want the best (because most/all of it is coming out of someone else's pocket).
Stay of Execution may be at hand. Senate just passed an extension to the fee cut till Oct 1 -the House has to pass this and then Obama must sign into law. Guess we have some time to do some more politicking about the SGR.
My area of medicine (Urgent Care) was an all cash business (14 clinics and 250k pts/yr) until 1993 when my old group signed up with local group health payors. Now there is just not enough money for all of the things that society wants from the health care industry and us. My smaller private practice is steadily drifting back to an cash practice as patients often cannot afford their own health insurance. It is not uncommon now for patients to see us and their copay with their group health insurance is the same as our cash price to see us without insurance.
There is just not enough money. Reimbursment is going to go down. Providers will be going out of business or diversifying even more to survive. It is not inconceivable that providers will be legally mandated to take whatever reimbursement is offered and private practice will be limited or outlawed. There is just not enough money and the needed serives are vital.
I hope that they fail to repeal SGR and that physicans everywhere stop taking medicare patients. It will take this kind of disaster for the house of cards to come crashing down and make people realize the scope of the problems with health care insurance.
www.youtube.com
This means that we continue to lobby, make deals and move forward. Let us not give up. We provide value that Washington needs. Let us not forget this. don't get mad, get even as politicians do.
He was focused on those doctors who pause at the door to say hello to their patients.
Its guys like him who have got to go.
There will be a sign posted at my door on Monday.
I'm sure they will do a quick delaying bill like they always have, but it would be nice to have the payment formulas fixed once and for all.
As was said by many in the armed services, "Bend over and kiss yourself goodby."
Canada, Sweden, US trained MD
In Ontario long ago when faced with the same attitude in government, docs signed and submitted postdated letters of intent to resign from the government health care plan en masse. Suddenly tnat year fee negotiations with government improved.
We may need to do something similar in this country soon.
Medicare is responding as we should expect - balance the medical cost trend with a reduction in unit pricing. We should expect this until we get our act together and actually manage the care of the public appropriately based on evidence AND effectiveness.
yes but WHY did Sen Bunning (and others) vote against it? Because it was included in a bill with a bunch of other crap. It should be addressed separately (but other Senators would not let that happen)
Senator Bunning blocked unanimous consent because he authored legislation in September that repealed the SGR and funded a permanent solution. It never made it to the floor. He, like us, is tired of kicking the can down the road and is forcing a solution, not a patch.
What will it take before every PRACTICING Physician in the US opens the window and shouts "I am mad as hell and I won't take it anymore?"
My senators have both ignored my letters. I guess I have to go door to door in the fall election to get them thrown out but I think they are already headed for disaster (and they know it). Health care "reform" is like some altruistic "quest" for them.
Ah, Sermo Doc 27, just about ALL the things we do in medicine (and the "unnecessary tests") you speak of are driven by liability concerns. Especially in the ER. Its CYA.
And you know it. Send ONE patient home with mittleshmertz pains in the ER and they wind up at another facility with appendicitis- you're screwed. Just about every "cost" in our hospital has some form of liability built into it- THATS what's driving up the costs in healthcare.
the only thing that happens when one group decides to stop seeing a particular class of patient is that the other (more desperate) group starts seeing them instead. and then the first group is sitting there with nothing to do.
think hotels give out rooms on hotwire because they want to? They do it because otherwise they would be losing money. Face it. some money is better than no money...and the market will dictate prices, and there are just too many desperate doctors with too much to lose for any sort of strike or slow down or whatever you call it to seriously work.
the solution is to hire a bunch of MA's, a bunch of NP and increase your patient load to 500% over capacity. Just sign off an their work, hope nothing bad happens and get a canadian work visa just in case something bad happens....
too bad for the doctors. medicare reimbursement stunk anyway and now is has just gotten worse. looks like doctors are expected to work free. good point hkmp5a3 made to Sermo Doc 27. it is just not that simple which is why the government sure does't need to get in on it.
since the government runs medicare and the fees will be $3 less than the 1991 rate wonder what commerical insurance fee for service will look like when they get through with it?
I am a hospital-based pathologist. I would like nothing more than to no longer participate in Medicare but I don't see how I can do that. Does anyone have ideas on how to accomplish that as a hospital-based physician?
As an Infectious Disease Physiican, doing 100% consultative work, I've already been cut about 25% with the loss of consultation codes this year. Another 21% would be ludicrus. It's certainly unreasonable of me to expect that I be additionally remunerated for an extra 3 years of training when any primary care doc can handle what I do.
For those of you that are suggesting a work slow down or strike, it will never happen. Physicians have never been able to join together in significant numbers, for any goal and their organizations are totally impotent.
The bottom line is that medical care is too expensive and the gov't isn't wiling to pay the bill. I suspect in the not too distant future hospitals will be given a DRG sum for each patient admitted and they will determine what the doctors get paid. That should be another bloodbath. Unfortunately the only viable system for the government will be a single payor one where docs are salaried or receive payments determined by the government. If you are nearing Medicare age yourself, you should hope malpractice litigation is still strong so that you have some threat for your caregivers to provide quality care. Notice I didn't say physicians. Our profession sowed the seeds of its own destruction when they hired nurse practioners and physicians assistants and convinced their patients that these caregivers were just as good as the physician.
But the employed ones do not have anything to smile about, because they will be hit by the cut in their salaries; only the best arse-lickers (who go to bed with administrators) will see their income stay the same or drop less....
Finally the 'socialized' medicine arrives in the capitalist US of A --- without the introduction of the new healthcare, DO REALIZE that Obama cannot take blame for that state of affairs - it was coming for several years.
Does anyone have any hard facts about this matter?
Keep your head clear, eyes open, and mind open to options.
Pent up water must find it's lowest level. Have faith in this certainty.
We have until March 17, 2010 to opt out of Medicare enmasse.
Enjoy your Fridays.
I may further my time in purgatory, but remember in war, there is damage.
I do feel sorry for my patients. However, unless they feel my pain they will not get involved in healthcare reform.
The government has forced me to choose between my patients and my family. When I do my "free" paper work at night, my family pays for it. What does the rest of the world say? Oh I know, "its business, not personal."
I am hopeful however, that once these cuts are effected Surgeons will do it for us. If you see some way to coordinate without collusion please let us know. This will end up being legally sketchy, and the Feds will use their power to come down on those they see as leaders of rebellion. That said, it was only the STRIKE of the 1970's that gave us MICRA here in CA. Personally that is the course I favor, and to be honest, even if only some of our partners cooperate it will bring the OR to standstill. It takes the full compliment of people to run things.
So Daniel, I suggest that you use some of the money this site generates and hire some really good lawyers. Find out what we can and cannot do and let the membership know what you find. I agree, it is time to take back the field of medicine from the AMA, the insurers and the Feds!
Also, American docs need to take a lesson from the docs in Australia.
www.abc.net.au
I have a good friend who is an anesthesiologist in New Zealand. He makes much more per hour in the private sector there than private anesthesiologists do in the US. Also, medical malpractice litigation has been outlawed there. Meanwhile, the peer review system takes up the slack by being very strong.
The docs do even better in Australia. In fact many NZ docs have already left for Australia and the trend continues. The government and private insurers actually appreciate the knowledge and skills of physicians and reward them accordingly. BTW, any board certified US doctor can easily work in NZ or Australia.
I've even heard stories of recent U.S. residency grads taking jobs in Canada for more money, better hours and a nicer malpractice climate.
Remember that the 13th Amendment to the U.S. Constitution prohibits slavery and involuntary servitude.
You can't work hard enough to make up for the barrage of cuts in fees. If it's not 22 percent Monday, it's a 35 percent cut in Ambulatory Endoscopy Center fees over the last decade, while hospitals reimbursements have increased, etc.
I suspect primary care private practice doctors will lead the way in closing practices to new patients, if not all Medicare patients. If that happens, specialists will see less Medicare referrals, etc.
Until Seniors beat down legislators' doors when they can't find a doctor, we will get non-negotiable cuts.
You said, "If you see some way to coordinate without collusion please let us know. This will end up being legally sketchy, and the Feds will use their power to come down on those they see as leaders of rebellion"
I had this very discussion with a hedge fund manager from the UK, Michael Hintze, a few years back while heli skiing with him in Las Lenas, Argentina.
He said that the way to get around the collusion or antitrust was to do it all in the open at an academic meeting. Simply have an open forum on the economics and finances of running a medical practice, talk about historic rates and reimbursements in medicine and other fields and show what levels of reimbursements it would take to keep up with the increases seen in dentistry, law, architecture, corporate CEO's etc.
I would think that not all physicians would have to stop seeing Medicare, but if a significant minority were to do so, it would likely cause a gridlock.
And you know what this does? It RAISES the cost of healthcare for everyone, even for Medicare and the Gov't. Hospitals will have all the docs and they charge more as they get better rates from the Gov't. Great job Congress. Way to make health care costs go up.
I beleive it is all part of the Sermo Doc 44 plan to socialze medicine.
Well, I intend to quit Medicare. I do feel for my patients, and I want them to become mobilized and go to their Senators and Representatives. Medicare needs to get out of the price-fixing business.
"We have until March 17, 2010 to opt out of Medicare enmasse."
We don't want to "opt-out." We want to dis-enroll. Then we are not subject to CMS regulations any longer.
Dear President Obama;
I am pleading with you for the sake of my patients, my profession, my employees, and my own family to please help the physicians in this country to continue to do what they do best; care for patients.
I am writing to you because recently The Whitehouse and Congress have embarked on a journey that may mean a certain end to my career and that of many young physicians in this country.
Today, most physicians came to understand that our worst fears will be realized on Monday February 29, 2010, when Medicare reimbursement to doctors will be cut by 21% due to Congressional inaction.
I am a solo primary care physician practicing in a largely rural area with a sizable Medicare population. Most physician practices in my area are comprised of 80-90% of Medicare patients. Commercial health insurers in my area tie what they pay physicians directly to Medicare rates for even the healthiest, youngest non-Medicare patients. As you can see, a 21%decrease in Medicare rates ultimately means a more exaggerated assault to a medical practice's bottom line, along the order of 30-40% reduction in gross revenue.
I often hear people say "oh, doctors make too much money anyway", a statement that reflects the gross misunderstanding of the sacrifice doctors make and how much it costs to maintain a practice and deliver care. For doctors, the biggest expenses of practice, the overhead, are not negotiable. Doctors have no leverage in getting more from insurance companies or cutting our rent, unreasonably high malpractice premiums, cost of complying with unfunded federal and regional mandates, or cutting already meager staff salaries. The ONLY recourse I have is to see more and more patients. I am one person and there is a finite number of patients I can see each day and still do a good service for my patients.
With previous average reimbursement from Medicare and commercial insurers of $75 per office visit, and a monthly overhead (excluding physician salary) of $20,000 in my case, it does not take a lot of effort to see how hard a doctor has to work just to keep the doors open. A 40% reduction in pay will certainly cause many physicians to ponder severe cutbacks or bankruptcy. This may also mean turning away Medicare recipients. In my case, it will likely mean moving out of the area, adding further to the local physician shortage.
If the government is genuine about reforming the physician payment system, it must implement policies that reimburse according to quality, not volume. It must also act to address the primary sources of high healthcare and practice costs---insurance reform and malpractice tort reform. Insurance companies should not be afforded a veil of secrecy and Antitrust protection.
I am not alone in my concerns. Many doctors have chosen early retirement while young students opt out of medical school altogether. Those who choose medicine as a career, more often than not, choose anything other than primary care.
Mr. President, I encourage you to please consider all of the players in the healthcare struggle. There are hundreds of thousands of practicing physicians in the US and only a very small number of them belong to the American Medical Association. If you want to know where doctors stand on the issue of health care reform, ask us, the ones who are there at the frontlines every day, not one who claims to speak for us. Please give us all a voice. You may find greater support if doctors think they are being heard.
Hyperbole only takes away from some of the points you make. While there is undoubtedly waste in the healthcare system (as there is in every other system), it is nowhere near 40%. I would like you to give us the link with this supposed evidence. While it may be an individual's interpretation, there is no evidence to support that high a number.
I cannot speak for all physicians, but I know for a fact that the "unneeded" services I provide are nowhere near 40%. Certainly I have had patients spend a day too long in the hospital or had some tests that others could deem unnecessary, but I have never operated on a patient when it was not absolutely medically indicated.
I do not perform any diagnostic tests in my office, so unlike some practices, I have no incentive to perform unneeded labs, x-rays, EKG's, etc to buff up the bill. While some of this may occur (do you do it in your practice??), I think most physicians do this as a service and convenience for their patients (usually at a discount to hospital or outpatient labs). Maybe you could poll Sermo members to see how many do this strictly for profit.
The "studies" that indicate this level of waste do so by saying there is no randomized evidence that something is helpful and cost effective, therefore it is unnecessary and thus = waste.
Newsflash, most of what we do today is not based in Level I evidence (multiple randomized, controlled studies). To randomize some things would be malpractice and unethical.
We have never randomized:
1. a trial of ruptured appendicitis to see if appendectomy is better than just Tylenol and IV fluids
2. a trial of patients with DKA to see if giving them insulin is better than Snicker bars
3. a trial of gunshot wounds to the abdomen to see if repair of injured bowel is better than prayer and cookies
4. a trial of patients with acute respiratory failure comparing mechanical ventilation to intubation and spontaneous breathing
Although we do not have "PROOF" these treatments are better than some alternatives, I would argue that is not the same as waste. We may ultimately learn that what we assume to be best treatment for a given problem is incorrect, and we should modify our treatment based on that evidence when it becomes available.
There is certainly some need to clean up our act and to do what we can to help control costs, but the fact remains that some of the growth in health care expenditure is due to :
1. More patients living to be older and sicker (patients thoughtful enough to die young are cheap)
2. New technology and drugs that are more expensive
3. Patients and family demanding that everything possible be done regardless of reality of futility
4. More spending at the extremes of life that do not satisfy the criteria of "cost effectiveness"
5. More physicians being graduated from medical schools in the 80's and 90's in an attempt to cure the maldistribution problem
6. New entitlement programs that do not encourage patients to seek care effectively - using the ED instead of a PCP office or clinic.
7. Patients not taking responsibility for their own health as evidenced by our epidemic of obesity, continued high rates of tobacco and ethanol abuse, teenaged pregnancy rates, rates of use of motorcycle helmets and auto seatbelts, etc.
To think that a 21% cut in physician reimbursement will correct these problems is foolish. What is next when this doesn't work, another 50% cut? Common sense measures need to be taken, but this will only impair access for many vulnerable elderly patients and do nothing to lead us to affordable healthcare.
I, too, have never operated on a patient unnecessarily. I, like most of my colleagues, don't derive any financial benefit from ordering labs (since I send out for them, too). I order a test for only two reasons: 1) because the result will determine which course of action I pursue, or 2) because it will prove to future plaintiff's attorney's that I did check that.
NEWSFLASH TO MY COLLEAGUES: There's no need to terminate your contract with Medicare. Simply don't accept new Medicare patients until this is resolved. That's what we are doing starting Monday. Let *them* call their representative. My contract only requires that I accept their *payment* when I see a Medicare patient. No contract requires that I *treat* them...(well, minus EMTALA).
Our gov't won't listen to a few thousand "rich"doctors. They *may* listen to a few *million* average Joe Medicare patients who can't find a doc to see them.
The main reasons for increased medical costs:
1) lifestyle of patients.
2) lifestyle of patients.
3) lifestyle of patients.
4) defensive medicine.
5) increased ability to treat disease(s). <-- engineers call this "a failure of success."
The rest of us, who are in business for ourselves, will run afoul of the Justice Dept if we join in such a discussion.
What we can do, however, is join professional organizations that represent our interests, and NO, I sure as HELL do not mean the AMA.
We DO need to take a stand, whatever we each decide it to be.
Turn Sermo Doc 66's letter to the president into a petition that Sermo members can sign. Present 900,000 signatures to Congress. That would be the best show of strength that a profession which isn't allowed to unionize or fee bargain could demonstrate to the powers that be. Conceptually, work slowdowns, refusal to take new MC patients, and the like, all look good on paper, but most of us seem too ethically bound or financially pressed to refuse care, and others are too oportunistic--there will always be someone around to pick up the slack--which would minimize the desired effect.
What a bunch of whiners.
Let's see what you will really do.
You don't need to strike.
md.sermo.com
Opt-out if you have the testicles
AMA has been kind enough to provide a form
At minimum don't see Medicare unless life and death in March.
You won't get paid for 2 weeks anyway.
You know they are going to do a temporary fix.
Now is the time to start leaning your practice to only a minimal number of medicare even after they come up with a temporary fix.
Most of you are NOT GOING TO DO ANYTHING ANYHOW.
Whiners and losers.
Sorry, but that's what most docs are.
Where's my KY jelly, then at least it won't be so painful to get screwed. Thank You to all the politicians.
Don't know about the rest of you, but I am not a loser. I might whine a little until I get things figured out--because venting helps--but if that's all you do? Looooooserrrrrr.
I do feel for those who are stuck in contracts and/or specialties that do not permit immediate change but, you know what? You do not have to remain in those positions or specialties until the day that you die. Pursue any other goals or interests that you have.
Socialist systems always leave their dependents destitute. Doctors will not be different.....get out/opt out now.
This is so they can verticalize medical care. They want to ship all the medicare patients to future government overseen facilities to control what care they get.
This is the first step in the government controlling what healthcare you (& everyone eventually) get.
The government won't ever tackle trial lawyers (because they are trial lawyers, most of them). So this is their way around it. It doesn't matter if you practice evidence based medicine, or give the best care.
It doesn't matter anymore that medicine was once an art (= dealing with people & their psycho-social problems) & a science (= evidence based medicine).
Its government takeover to force you out of private practice, so they can control people & money.
But, I think Sermo Doc 77 is right. The present administration wants us all to work for the Feds. The Medicare population is where they are starting. TriCare may be the next population to target.
However, I fail to see where they think they are getting the money to do all this...
Paul Ryan is right.
Shame on any and all of you who contribute to the assimilation and bowlderization of our profession by our overweening, socialistic federal government--- contribute to it by your tacit acceptance of their terms and tactics.
Federally configured or sponsored "health care reform" is a big lie, and the tactics being used to force it into existence were well delineated by George Orwell in his prophetic novel, "1984".
I, for one, refuse to play by their rules. Those of you who do, will be swallowed by the Leviathan.
please see this
A side note. Our 23 member group resigned en mass from the AMA yesterday and will be limiting our Medicare practice beginning next week.
You can't make it up in volume.
God bless us all
The time to act is now! Docs4PatientCare is going back to DC on March 24th and 25th. Hal Scherz will post the invitation to ALL of you to join us on Sermo today.
This is very real, and it is time for all physicians to join together in unity to stand up strong for our profession.
Richard A. Armstrong MD FACS
Nothing that has been discussed in the health care reform debate, including the "summit" on Thursday has addressed the root causes of our trouble.
The SGR could be "fixed" for physicians tomorrow by one simple action of Congress and the President. Admit to the American people that the government cannot afford to pay for all of health care and that the demand is bankrupting the country. This is a fact that everyone should know. There is nothing wrong with honesty!
Then, ALLOW balance billing for all medicare services across the board and let the market work it out. Patients and physicians need desperately to be reconnected to the costs of care. The government can't control this. The smart move is to put the control back where it needs to be...with the doctor and the patient!
The governments solution to any problem is to throw money at it regardless of whether it works or is sustainable and regardless of the consequences.
I would agree with the poster above, that this is an overall attempt to "verticalize" medicine. The days of private practice are numbered.
I have not decided what my response will be in reaction to these planned cuts in the short term. In the long term, however, it is clear to me that we are on an unstable path that will lead to dissolution of most of our social "safety net", and a vast reworking of the business of healthcare. Healthcare reform is coming, but it likely will not come about by legislation, but by gradual destruction of the fundamental flaws that underlie our current system.
The citizens of this country must step up and take back the nation. That will require work and sacrifice from all of us. Allowing balance billing in medicare is a quick simple step to begin.
We all know that after some juggling, cuts will be taken back. Even if they are not, I can manage by making changes in the way I work. At the end of the day, life is about being able to live happily and be a productive member of the society. Money is a tool, not the end of it. A career of helping others relieve their pain can be one of the most rewarding way of living. We all know that. This is *the reason* that attracted us to this profession and kept us in it despite all the sacrifices we were asked to make.
Now the realities of life is that we all have real bills and real payrolls that we are responsible for. We cannot continue to fulfill the duties given to us by God if we cannot sustain basic requirements of performing a service.
What is more disgusting (at least to me) is that healthcare of 200 million Americans and almost all the US doctors is being used as a mere pawn in the political game! They are using us for their political leverage!
If I do an analysis of medical profession as a business, it is clear that the fact that our business dynamic can be changed by a stroke of a pen is a bigger negative of this business than poor pay. Walmart works at far far lower profit margin than we do but it has pricing power in its own hands.
I am disgusted at the non-medicine aspects of medical profession. Most of these aspects (CPT, billing etc) serve only one purpose - what is the minimum amount of money that 3rd parties need to pay in order to get us to work. I do not think I came to this profession to do that.
How do we gain a seat at the table?...obviously not through the AMA (they have the highchair in the next room). Unless legislators hear an outcry from their consituents with regard to access despite insurance, they will continue with their plans. Most of us don't have the economic depth to stop seeing new/old patients, so we roll over. I am guilty of this as are my colleagues...I have gotten used to eating on a regular basis and am reluctant to jeopardize that.
We are in an illogical business from the investment that went into becoming a physician, the costs of running a practice, the hours put in weekly, the responsibility assumed, and accepting a fixed income for the last 9 years with Monday's decrease, however transient, looming.
We need a Knight in Shining Armor and the gonads to follow that person's leadership.
.
So, What do we do?
I urge you all to lock yourself alone in a quiet room for a few hours today, free of any other obligation and ponder on this issue. It is *the* time that you need to take a deep breath and decide what you need to do to bring back happiness to your life.
Why did you come to medicine?
What makes you happy?
Why are you not able to get it?
What can you do to bring back happiness in your life?
Now, think over this trade-off:
Would you take all the hassles and distractions that you see today and make 170K?
or
You would rather get rid of all the shackles of 3rd parties and take patient as your only Sermo Doc 44 and make 110K?
Look guys - you are not going to live in a mansion working as a doctor anyway, so why not to live the way that makes you happy?
Life is too short to waste on checking bullets, moving papers around, being on hold on phone or writing nonsense notes just to satisfy idiot CPT coding.
No gravestone will ever say I wish I had more of pre-authorization faxes!
Make a mental image of yourself popping your head out of a 3rd floor window in Bronx and shout "It is my profession and I need it now" or "I am mad as hell and I'm not gonna take it anymore"
-- contd below --
Now the question is how do we take back our profession in our hands so that we do what is right for the patient and not waste our time and energy on dealing with administrative nonsense?
Final answer is going to be unique to every individual and will require great deal of thinking it through and planning.
Change that will help us most is change from a paradigm of
coding-billing-collecting-chasing-accounting-writing off
to one of
collecting-accounting paradigm
Most of our hassles come from 3rd party requirements, insurance contract being the most common one. Finding a way to function without insurance companies is what will help us most. Not everyone can do it, but I dont think continuing to drink free liquor will make us happy in the long run.
There are several models of cash only or cash plus la marquis insurance only models that have been discussed on sermo. If I get time, later today, I will start a thread to discuss all of them at one location. Now, I must get ready - I have a cricket match to play while you suckers try to find who moved your cheese.
Similarly,I have been asked by my lay friends repeatedly, "Do you know what will happen when the Medicare cuts will go into effect?" "Will doctors go on strike?" I tell them (recently turning 50 and after 20 plus years of private gi practice earning me an unofficial degree in perspective) the following:
I reply, "No, but I'm pretty sure". My primary care peers who still see medicare patients will decrease or stop seeing them. An increase in consultation requests to all specialists will increase to "turf these patients". The consultations will be accompanied by little or no records, or better yet, the pseudodocumentation of today's EMR templates which to me are often worse than no records. Direct procedure referrals for EGDs and Colonoscopies will increase again to get these patients out of their offices (if they indeed still see them). Trogolodyte primary care physicians and specialists (me included) who actually still empirically treat patients for their conditions and not order testing will be placed on the endangered species list. The "safety valve" of the ER will be overrun by Medicare patients (already is). Hospitalists/APNS/PAs will admit a greater percentage of these patients because of the path of least resistance. ER docs will find a hard time setting up follow ups with the non-existent PCPs and/or specialists who don't see Medicare or who create barriers to their care. The patients admitted to the hospital will be again turfed quickly to specialists (again with little or no cognitive workup). The workup is completed in the hospital and again there is no follow up available for these patients.
And then again to paraphrase, as Hunter Thompson would say "Then theres the downside".
The cost of this horrific system is that we can't afford it as a nation. Lets see: a) increasing numbers of boomers, increased life expectancy, increased demands by patients for what they believe is a free commodity, increased defensive medicine, increased obesity and health adverse behavior, etc. etc. etc.
The behaviorists, (BF Skinner et al) have shown (you know it the scoop, reward reinforces behavior, punishment etc) Any system that does not change the behavior of a patient in taking care of themselves, seeking care, purchasing care, etc. is doomed to failure. Unless medicine in the US is not changed to a true free market, where prices are posted for everything, patients bear more costs and choose based on cost thus changing their behavior , where true competition occurs and costs decreased due to market forces, where the fix is not in to artifically support the charges of hospitals, pharmaceutical companies and yes even doctors. Where we work to reform the out of control disability system. Where the malpractice debacle is ended. When medical school can actually teach docs to be clinicians again instead of docs who can't treat without testing. Where we as a society realize that a safety net is needed for those that can truly not take care of themselves, but realize that a substantial percentage of disabled are NOT. Where the epidemic of narcotics on demand for any discomfort is considered "standard of care" is ended.
In other words, blah, blah, blah, until medicine is truly a free market in its purest sense, we will never get any of these problems resolved. NEVER! Because of all the vested interests in the industry, it is unlikely to happen. If you can tell me another way to resolve this let me know.
In the meantime, like the Dude in the Big Lebowski, I'm fixing myself a White Russian.
Mark it Zero Dude!
Sermo Doc 93
Its their control over your profession that sucks.
Even after the cut is reverted, you will still be subjected to all the nonsense terms and conditions and regulations and requirements.
Man evolved from chimpanzee.
Doctors evolved from ostrich.
In fact, 21% cut will help more doctors to realize what is keeping them unhappy. Its not about money folks. Its about being happy. You are not going to take one single dime with you to your grave.
Last time I checked we have a Democrat/Socialist/Communist President, Democrat controlled Senate, and a Democrat controlled House. Beck, O'Reilly, and Rush are not making policy, the Democrats are in charge now. Please direct your anger in the right direction. I'm not happy with any of them now, so don't call me an idiot right winger or a stupid tea bagger. Read the comments and facts on Bunning before you spout your drivel. Thanks for playing......
Depending on your market, it could be the best business opportunity you will ever have in your life.
If I were one of the only 2 endocrine in my service area, this is what I will do:
I will stop seeing pt of the lowest paying insurance (if it is medicare, so be it)
I will hire a staff and give her a car.
She will go to each such pt home and will bring them to my competitors doors and give them free breakfast at Danny's coupon if they agree to become pt of that practice.
Overwhelm my competitor with low paying pt -- better paying pt will get poor service -- they will flock to my practice.
My income will go up while s/he drowns in loss makers.
I know it is done. One of my friend was choked out by a competing large group practice with this method.
Posted Feb 27, 2010 at 7:48 AM
Here's the deal with Bunning....
Last week the Dems and the Repubs amazingly had worked out a BIPARTISAN jobs bill...(improbable, I know).
All the leadership had agreed as had the members of the relevant committees.
Part of this bill was another non-permanent Medicare patch.
This agreement was made public.
Then democratic leadership pulled the rug out and decided to scrap the agreement and make their own bill....largely on the fear that in the Fall, the Republican challengers in their districts would point to the jobs bill as another example of their legendarily profligate spending.
And so the Republicans they made the deal with are miffed.
So they are going to make the Dems to everything the hard way...for a while.
Bottom line: both sides are playing "Chicken" with this issue.
I'd prefer the middle of the road. If we truly had a real checks and balance system in these United States, I would not be as worried as I am today.
What branch of the Government can give Congress/Senate a cut in salary? Why is there not a check/balance system in place that holds these nutjobs in washington salarys constant. They are in Washington to work "for the people." Shouldn't they do that out of the goodness (LOL um that is extreme sarcasm) in their own hearts (again sarcasm no heart there).
Honestly, if they get free health care in Washington for the rest of their lives, shouldn't the rest of us possibly get the exact same free health care? I for one say take away the friggin free health care from any president or congressperson. It is stupid to give them free health care in a capitalistic society.
Wow, I feel better getting that off my chest. Now I get to relax for 5 minutes...
BOs**t doesn't care about Doctors.
"Ask not what your country can do for you. Ask what you can do for yourself."
The point of this post is to emphasize that we are seeing a trend here. This has been playing out for a long time and will continue to play out, until physicians start showing some initiative. I knew with 100% certainty that the AMA would screw physicians when I understood their business model and that they were getting the vast majority of their $300 million dollars in revenue from CPT codes (less than 10% comes from membership dues).
As angry as tort reform (or the lack there of) makes me, I am far more concerned about another trend......states quietly starting to tie physician licenses to participation in Medicare/Medicaid. Before you think my concerns are unfounded.........
A BILL IN FRONT OF THE MASSACHUSETTS LEGISLATURE AIMS TO TIE PHYSICIAN LICENSE ELIGIBILITY TO PARTICIPATION IN THE STATE'S MEDICAID PROGRAM ( click here www.mass.gov
My point is that physicians need to take decisive action now, because it is getting harder and harder to do so. Over a year ago, we saw this coming and started investing heavily in the tools and material we knew physicians would need. If you haven't taken a look, please consider checking out the Practice Management Exchange on Sermo. There is plenty of discussion on different business models and accredited courses for learning how to switch to cash practice or concierge.
Click here to go to the PME (Practice Management Exchange)
md.sermo.com
Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.
even though the academics are somewhat insulated from all this as they are salaried, they do understand that if more money came into their practices that more equipment could be bought, salaries and incentives could be put into place and recruitment would improve. now we just need to convince them of the tremendous clout they have.
There is great potential for this to be a blessing in disguise. Let's make sure it is! We all whine in the lounge, never banding together to exert the influence we have as the true providers of health care. Stop seeing Medicaire patients now! Think of the extra time at home or in your office reading, relaxing and not jumping through silly government documentation rules(just there so they can fine us thousands of dollars for innocent errors), that take up more and more time. Forget the money lost in the short term. If we do not stop this here, all payors will continue to turn the screws- they do not care about our success or failure, they just consider how to get their little worker bees to provide care at the lowest possible reimbursement. Wake up, this perpetual decrease in payment will continue to deteriorate until we take firm action. Think in the long term.
1) If you have nothing valuable to contribute to the discussion, then don't contribute
2) I hope tearing down the colleagues (whom everyone in this thread has suggested will be stuck doing YOUR job for YOUR patients after everyone opts out) makes you feel better; but it makes you as much (or more) of the overall problem as the government
3) Unless you NEVER consult any other medicine subspecialty on ANY patient in your practice, never order an echo (just use your stethoscope), never order a chest xray (just auscultate and percuss), never order CT (just do a physical exam)..then you are doing it too sooooo...get over yourself.
4) Define "unnecessary".
5) And finally...my snotty comment of the response (since I was up all night seeing ER patients and intermittently listening to the whining of the internist about admitting the 2 admissions out of the 30 patients I treated) you might want to check out your glass house...karma is a B**ch. I am glad to talk to you with 3 or 4 patients at 6am but it is just as easy to wake you up 4 times between 1 and 5am...I'm up...
Are "we" going to rescued again? I don't know. I do know that two of my former associates in my former subspecialty division will bail out if they don't. This is one way of controlling costs. Chase out older doctors; cut down care availability; and then when the patients can't be seen in a timely fashion, blame the doctors. This is political cynicism that only Congress and the administration can get away with. The media will, of course, blame Medicine, the doctors, and the insurance companies and will let Washington get away with this.
Is there an answer? No, I don't think so. Doctors are so diverse in their views; so divided in their political philosophy; and so convinced they they won't be sacrificed for the "public good" that the only historical analogy that comes to my mind is the situation of German Jewry in the 1930s. "They're not serious. They really can't mean what they're saying." We all know what happened then. Sermos numbers are too small to make a difference. And, the AMA which only represents a minority of doctors - well, we know what we can expect from them.
To paraphrase Walt Kelley in the old Pogo cartoon strip (or Shakespeare), "The fault lies not in our stars, but in ourselves."
1. codify goals and complaint
2. see if we can get our s..t together on the most basic of lists
3. whether we are willing to attach our names to any argument( to see if we have any balls whatsoever)
The result of chaos is either things re-organize to a higher level of efficiency or they self destruct. I am fearful the latter is more likely than the former if physicians remain inactive.
commercial insurance rates are fixed at some percentage of medicare so even pediatric reembursement will go down
www.mass.gov
Daniel
I will not comment on the asinine decision to eliminate the consultation codes.
Since the already paltry Medicaid reimbursement is linked to Medicare fees, we will no longer be able to afford to see any Medicaid patients. Furthermore, we will have to reduce or eliminate the charitable cases we treat.
Do they realize the harm they are doing?
I embrace the idea of concierge practices but if participation in Medicaid is required for licensure what good does it do to change to a concierge service. One could of course provide two-tiered service (Medicaid being seen by one of the new "Dr. Nurse Practitioners" or limit one's practice to non-covered services.) I'd like to know because even though I am the sole breadwinner in my family I'll starve before I'll submit to that B.S..
If Licensure is tied to Medicaid and Medicare participation I doubt that would withstand a challenge in the Courts - the Constitution holds that contracts have to be entered into voluntarily. If States do pass this then physicians should consider withdrawing their labor until it is removed, should work pretty quickly. You can't be punished for not working.
I have news for you all: you can't take care of anyone if you can't keep the doors open. These cuts, especially in the segments of medicine, IM and FP especially, that are heavily dependent on medicare moneys, are going to put many of these docs underwater financially.
I am betting that there will be some form of rescue over the next two weeks, as the anger I have seen here and among my colleagues in my community is frightening. Docs I have never, and I mean NEVER seen angry, I have seen spitting mad this past week. Something new is in the wind, something I have not ever seen in attitudes. Going to be an interesting week this week. Good luck to us all, we are going to need it.
Model # 1-everyone has healthinsurance. As an friend of mine says eloquently "There is an unlimited demand for a free commodity". I can only see people consuming more and more of cognitive and procedural services if there is little cost to the patient. Imagine this model with any commodity (food, gas, oil). It is clear that the demand would increase and would be impossible to cover long term by "the government" ie the taxpayers. An example seen daily in my clinic is that everyone will sign up for a screening colonoscopy if it is a covered benefit by their healthplan. If it is not a covered benefit, or if it is a Medicare patient who has had a screening colonoscopy within the restricted time guidelines and "wants another to be sure they don't have colon cancer", they rarely will pay out of pocket for physician and facility fee (I have had one patient in 23 years sign an Advanced Beneficiary Notice for a non covered Medicare procedure and pay for it out of pocket). They do not perceive colonoscopy to be worth the money that I and/or the facility would charge.
Model # 2-No one has health insurance; ie everything has to be on a cash basis. The market would have to respond. i guarantee that if I lost patients because another doc could perform the same cognitive services and/or procedures I could at a lower cost, then my choice would be to compete or not by equaling or matching cost. That, cruel as it may sound is how a true free market works. Not only does it lower costs, it may change behaviors (smoking, obesity, etc.) that may effect the patient (in the pocketbook) Yes it would close lots of hospitals, close some doctor's offices, cut the income to pharmaceutical manufacturers, cause consolidation of existing hospitals/ambulatory centers/imaging centers, etc) It may or may not actually decrease physician's income.
Now I know that people would point out that model #2 would fail in markets without competition. Care for emergencies would be another issue (I think TRUE emergencies would be budgetable). Redefining the truly disabled and care for the truly indigent would still be doable. But someone tell me how can we control costs and budget healthcare long term. The responsibility has to be put on the patient. The only pressure to change patient behavior is economic. I am in the camp of the behaviiorists. Study behavior modification and you will effectively control healthcare costs and improve morbidity and mortality in this country.
The only solace I have is that I am so certain in this belief that only wholesale change in our system to one where we focus on only one thing-the patient's healthcare consuming behavior is the ONLY SOLUTION. It allows me to believe strongly (hopefully not rationalize) that anything else is a bandaid on this system. Cutting 21% isn't going to work, not cutting 21% isn't going to work, adding another 21% or 221% aint gonna work. The system is inherently flawed.
So live within your means, cut your expenses, require less money to live on, simplify, etc., because the system as it stands is untenable without major modifications. And lets be realistic, they are so many consticuencies (I am sure that is misspelled) that would be effected by a FREE MARKET HEALTH PLAN, insurance companies, hospitals, big pharma, medical equipement providers, state and local government and yes even doctors (the least of all the players don't you think?) that it is unlikely to happen.
So in keeping with the serenity prayer and (.....and the wisdom to know the difference between things that you can change and not change) (paraphrased)
Nihilistic? Fatalistic? Maybe, But realistic ultimately.
Sermo Doc 93
if you (or your competitor) are losing money on medicare, you may want to have your medicare pt give a free ride to your competitor's doors. Dump that business on your competition. Let him/her drown in money losing business. That will bring better paying business to you as they find it is poor quality work there.
When you calculate cost of providing business, dont go by the common fallacy "Oh, I am getting at least something instead of sitting, doing nothing" . No - there are real costs involved in seeing a pt - lease, staff, utility, liability risk etc. And dont forget, time away from your kids is very expensive.
My practice style is such that I will make money at medicare rate even after 21% cut. But as Sermo Doc 93 said, system is inherently flawed and is doomed to fail with or without cuts. I can go down the whirlpool with the system or I could find an alternative.
from: caps.fool.com
A communist healthcare in a capitalist country is doomed to fail. We have unlimited consumption by the communist process that is unchecked due to American style of lawsuit fear and is fueled by capitalist style of greed from direct to TV ads, fake research results, frivolous lawsuits, over-utilization bringing more money to docs and their hospitals etc etc.
Can I live with a complete socialist system? sure I can.
Will it be perfect? No, it will not.
Will it be good for the country? No. Final result is either collapse of the empire or severe rationing dictated by computer generated algorithms.
Can I live with complete capitalist system? yes, I can.
Will it be perfect? No.
Will it be good for the country? yes, but at the cost of appearing to be ignoring some patients.
Because the veterinarian's customers aren't paying $1000 per month in premiums every month. People (including me) feel that they have already paid enough for their healthcare. Put it another way, if you were paying $1000/month for your "car upkeep and repair" insurance, wouldn't it irritate you to get a $300 bill?
The root of all evil is the insurance system.
And I like the idea of a cash-only system, and let patients work it out with their "insurance" company.
No, it's Big Govt and ever-growing Entitlement Programs!
Me! There have been plenty of times when I order a test that I wouldn't order on myself or my family, simply because I'm trying to make a patient happy (read: so she/he won't sue me if something goes wrong. Oh wait! I'll get sued anyway. "Nothing personal")
How effective were you and/or SERMO in getting Congress to fix the SGR problem?
Panicking of course, as I can do nothing.
Not making a living now. A friend with us says that Obama considers doctors as the enemy. She is not a doctor .
will try to find a job as I need to survive. Husband will stay in practice. A stockbroker friend once jokingly offered me a job as an assistant. Am a financial idiot, but used to working long hours. I think he's already hired someone, though.
Maybe I could work weekends at Target. There is one near the house.
Am depressed at the moment, no chocolate, no where to get any.
Maybe the world will stop and I won't have to go home to struggle with finances.
Go back to sleep!!!!
there is a RMCF outlet in that tiny mall close to the airport in Breckenridge, just before the city bypass meets on highway.... and then Silverthorne mall is not too far .... get your resuscitation fast...... call 911 and demand to be taken there as you can not breath without chocolate
Low overhead is the key ..... could also think of adding extra charges ..... depending on demand/supply in your market
1. The docs will not be able to keep their offices open to take care of patients
2. Increasing rules and regulations require expensive staff members to get things done for patients
3. Increasing costs for food, electricity, emr systems, etc, will make it difficult for us to survive.
Perhaps, they will understand, or the system will collapse....
Insurance revenue is down, CMS is probably bankrupt (or will be soon).
If you are going to make 120k anyway, why to make it while eating shit. Why not to enjoy practicing medicine the way it should be?
Transition away from 3rd party system. It will take some planning and time. Time to start is now so that you can be independent in 2-3 years. If you wait for the cuts to actually materialize, you will find yourself panicking when it comes. Transition can not be done in a week or a month.
Start planning now.
Also, we will be socialized we like it or not. Medical care is astronomical due to the money the insurance companies are making off of us. This is very sad.
Well, now it gets alot easier. I will absolutely be optiong out as of the 17th. We all have no choice. Think about the comparision.....if your practice is 80% medicare, and you no longer accept medicare contracts what happens?????......After 30 days, you are no longer held down and regulated for what you do. The patients will still see you, but now they have a vested interest in the process. They will have to pay to see you, and what is wrong with that. If your fees are reasonable, it works. One reason people can't afford to be seen, is b/c our fees are so eratic as we don't know what the maximum payer will be, therefore it is set a an rediculous number, to avoid being underpaid. Imagine what it will be like when you have ONE fee schedule. you only need on biller, you office finances get easier, and you actually get paid. Interesting concept huh?
Look at what you will be paid right now......Medicare cuts = 21% cut on top of no Cost of living increase. How can anyone even consider that, and feel they can't opt out? If an office visit for a complicated patient was paid at $80, now you will get $63. extrapolate that for your patient volume. That is worse than Medicaid, not to mention that medicaid will be paid EVEN LESS!!!!!! Come people you CANNOT MAKE THAT UP IN VOLUME. It doesn't make sense.
Congress has pushed the guantlet, now we have to react. We are not punishing anyone, lets be clear. The elderly need to be made aware of what is being done to their healthcare. Think about it....Toyota is going through a tough time right now. Do you think you get a Toyota below the cost to make it? Will Toyota sell you a vehicle, at a loss, b/c you need the car or their financial structure is hurting right now? I should say not. What makes you and I any different. Enough with philosophy and altruism, we have now entered the final countdown. Lofty dreams/goals/philosophy do not pay your bills, put your kids through school, pay for your food, or your school loans/debts. You are still held to your debt and responsibilities. Now the elderly will be too. We did not do it, and we should not take the blame for a legislatively driven/gov't related fiasco that has now been bestowed upon us.
Opt out. I suspect, when people have no choice they will pay, just like their auto bills, food bills, heating/home etc. If they don't pay, they don't get the service. There will be needs for us, and we will survive but only stronger, as the influence over us will be no longer. I have had several patients with and without medicare/insurance whom stated they had no money to pay, I then simply told them to call me when they could put a down payment on the procedure.....Every one returned withing 2 days with >$500 to put down. If you are valued, they will pay. By definition, medicare devalues you and I, therefore it is more than a loss now.
Politicians are about to give us all a 21 % pay cut , effective tomorrow- March 1st- and there's plenty more where that came from.
Even if the current Medicare pay cut happens to be "rescinded" or "delayed" this week....or month...or year with additional providers taxes or concessions of some kind by doctors, hospitals, etc, it will not be indefinitely- and cannot be forever.
This country - and its doctors- have been on a collision course with reality for a long time......
This is not about Democrats vs. Republicans.....
The same Washington bureaucrats who paid you generously in the past - are about to crucify us all on the altar of Public Health Care Need.
Do you want to continue getting paid- instead of paying- to provide medical goods and services to seniors?
Please see the rest of the post here:
md.sermo.com
2) Who cares if another doctor is willing to see all the Medicare patients, let them deal with 8 problems per visit and get paid 60 + dollars for a 99214, they'll only be able to see 10-12 patients / day at that rate. This will leave the cash paying patients and better insured patients to the rest of us who are smart enough not to work for less money than it costs to see a patient.
3) Please don't blame one political party or another. I remember that republicans had control of Congress, Senate, and White House, where was tort reform then? Where was the SGR fix? Where was any major changes other than the prescription plan for Medicare? And now the dems are doing what the dems always do, try and fix everything w/ government. It comes down to this, WE need to make the changes and make people, government follow us, not the other way around.
4) We are one part of the reason why the cost of medicine is skyrocketing but we aren't the only source. Think about every job, chair, desk, phone, facility, etc that is used to make one thing happen in medicine. The transfer of money from the patient to the doctor/facility, etc. The middle man is creating the "Huge Sucking Sound" of the cost of medicine. Example: A 50 something year old Vice Pres of United Health Care take an early retirement for 40 + million dollars. If you don't feel that sort of thing generates wasted medical costs I'm sorry for your naivitee.
5) I run my own clinic for the time being, what makes my business work, cash, CASH IS KING. I'm not working in that vain yet, but it's looking very appealing at this point. It' s either do something drastic or just quit the damn profession.
6) Patients I doubt will help us very much. I'm not very impressed with the general population out there. I think the average IQ is slipping. There is a reason why we are physicians and so many people are not! I had a patient actually ask me this question today. Does your hospital charge for MRI's?
Let's all take a deep breath, hug our families, work less hard and more inteligently and let the electorate do what needs to be done, fire the whole mess of them in D.C. and start over. When our representatives are there for us and not themselves, that's when D.C. will start working for us.
This booklet is must-read for doctors - and for patients seeking to understand who screwed up the US Health Care system- and how- and how to fix it:
Why Health Care Costs So Much: Government's Real Role:
www.alethospress.com
On Sermo here:
md.sermo.com
My suggestion:
Junk the People magazine, Reader's Digest, Sports Illustrated, etc in your waiting room.
Buy a box of these booklets for patients-and friends. I did. It's about a buck a piece.
As a radiologist, I figured it makes more sense to give them out to referring docs of all specialties and let primary care docs- who have a personal relationship with patients -distribute them directly.
No, I don't get any royalties......No..... I 'm not "GETTING PAID BY BIG PUBLISHERS -IF YOU FOLLOW THE MONEY " as some wack-a-doodle is likely to suggest.....
Believe it or not, the booklet does a terrfic job of making a complicated topic very accessible to a layperson of average intelligence. It does a great job of explaining the problems in the US health care system - and how we got there incrementally- in plain , basic language that any interested, curious- and intellectually honest- layperson of average intelligence will be able to comprehend.
You don't need a PhD in Economics (....which is an impediment to mental clarity....) to understand it- just common sense. It's written for the Joe the Plumbers out there.
It also describes some concrete, practical solutions - real ones- not the crap coming out of Washington.
More info here:
md.sermo.com
1- Its not about pay **rate**, its about pay *control* that I have problem with. As long as this dynamic is in place, we will be subject to these experiences.
2- If you avoid 21% cut now, do you think your pay cuts will not come in different forms in future? Medicare is not going to get richer. In fact, they are planning to add more drug benefits.
Throw away yoke of 3rd party system, release your energy and passion and dedicate it to what you went to medical school for.
This ends up costing the patient less than basic cable would for a year's service, and much cheaper than most cell phone plans. We are charging much less than Mayo Arizona's $1500 package, which I believe includes one comprehensive visit and 3 follow-up visits (and no free preventive tests, I believe). Another option with us is to pay a smaller up-front fee, and get 50% off our fee schedule prices, with a scheduling fee still charged for visits when appointments are made. Final option for people who visit less often is to pay our discounted same day cash price with no up-front or scheduling fees, but still a signed contract fully informing our patients that we send no billing to Medicare, and so no secondary payers can be billed. To our surprise over two thirds of our patients recognized that one of these was a good plan for them and their doctor.
Direct doctor contracting with monthly fees in the range of cable bills would probably work for most primary care providers, though we chose to go lower for our ESTABLISHED patients. We still have not opened the doors to NEW Medicare patients with a similar plan, though we could at any time. You do have to notify CMS at least 30 days prior to the start of the next quarter, I believe, to "opt out", and it does need to be for a 2 year minimum.
Many of out patients were informed IN ERROR, by CMS staff that if they saw me after we opted out, then their prescription med costs, and referrals, and tests ordered at other facilities would not be covered. The patients could ask to speak to a supervisor and then would sometimes get the correct information that this was not CMS policy unless a physician was under sanction.
This type of plan could be made available for a robust public option plan patient, or perhaps eventually other public plan patients, and WOULD DEFINITELY HAVE TO NOT BE SUBJECT TO THIRD PARTY REVIEW, to be viable, and not be subject to outfits like the infamous Recovery Audit Contractors, who now are free to target every US MD who receives Medicare dollars, and who are paid a bonus to find any conceivable reason to deny payment, I believe.
Instead a doctor could not only VOLUNTARILY choose to accept a certain NUMBER of contract patients, perhaps from a database listing patient basic health demographics, including what their main medical care needs are at present, but doctors could also CHOOSE patient TYPES (Peds, or "no Peds", etc.) that they felt comfortable with. They could also possibly CHOOSE to invite a case manager into the office to work with the patient and the doctor as part of a health care team, to reach identified goals in managing chronic diseases like asthma, or diabetes, with bonuses to the doctor and case manager, and perhaps lower medicine copays for the patient for generic meds, when identified goals are reached. North Carolina has a program called CommunityCare, that already does this for Medicaid patients, AND HAS A HISTORY OF SAVING THE STATE MILLIONS OF DOLLARS.
After initiating the simple direct doctor contracting option for primary care, then we can build on that to start a new plan for specialists, for which contracting and medical care quality bonuses takes more work to calculate.
Most docs would favor steady payments, no third party sanctions, bonuses for a job well done that includes the patient and other team members, that at the same time has NO incentives for over-utilization. If we are brave enough to take on these contracts, let's see if the government is brave enough to cut out the health care PARASITES.
We are already doing it directly with patients. TRY IT, if you can.
This shows how affordable outpt care can be if we get rid of 3rd party shackles
unfortunately, politicians can not allow this b/c politics is all about control. However, natural flow of events may take us to the point where most market is served in this model.
I also realized another sad reality yesterday. Many insurance companies base their doctor fee schedules on what Medicare pays. So if the 21% cut goes through, will this just be the beginning of rollbacks in our fees from private plans also??
To paraphrase Chuck Schumer during the HC Summit last Thursday--
'...the patient gets a bill for $4000.00 from his doctor and realizes that during his admission the doctor stood at his hospital door and waved a hello....'
The lifetime politicians have GOT TO GO.
Vote with your feet in November.
The Congress had a year to override the 'temporary measures' which have gotten us to this point. It isn't one senator's bad choice, it's one representative body's ignorance and thoughtlessness. Count them- 538 in the House and 100 in the Senate, and seemingly few bright bulbs among them.
The world won't stop, but it did shift on it's axis as a result of Chile quake.
Mother Nature isn't happy.
I wish you luck.
He wants Reid to bring forth and pass the bill extending Medicare til end of this year, without 21% cut, instead of extending for 30 days.
Reid says Bush ended 'Pay Go'.
Slow as molasses as Rome Burns.
These 2 guys are personal friends, so seeing them go at each other underscores the drama of this legislation.
Two old goats.
No mention of physician pay cut or that pt will get hurt or that physicians are saying no to medicare.
Amazing.
They still believe physicians will take cuts as just another chump change and that patient will have no problem. ........ and saddest part is that they might be right.
My response:
Yawn
I am done with Medicare. Postponing to Oct 1st means only 1 thing ..... that now I have got some more time to plan things accordingly. ..... but out I am ...... no question about that.
I would, however, offer the cautionary example of a group of highly trained professionals, working a complex job under a great deal of pressure, who felt themselves inadequately reimbursed and withdrew their services, believing them so essential that such an action would lead to their victory.
They were fired en masse, to the general applause of the Republican Party and the right, and the indifference of most of the public. They were called air traffic controllers.
My point being that unless we ally ourselves with patients, and are seen as supporting their interests, and that of the country at large, as well as our own, we're doomed to fail. Again, as I always say when I advance this view, don't mistake me for holding our discontents trivial. I'm talking politics here, as those who would exploit and marginalize us are.
There are only two possible sustainable solutions:
1. Assume that health-care is a "privilege," earned by paying cash for the service, like every other industry (e.g. plumbers, grocers, etc.) or
2. Assume that health-care is a "human right", and that our government is obligated to protect that right by organizing the provision of services, like every other service (police protection, fire, military protection, etc.)
It's obvious to me that government-organized health care is the only way to ensure that every citizen is covered, just as every other civilized country has done. If you're not in favor of that, then you're not in favor of making sure everybody can get health care. There's no other way. Short of that, 21% Medicare cuts or not, all us doctors will just be arguing over the crumbs.
After the annual song and dance about the Medicare cut, that is always, always stoppd seconds before going through, we have the same dranma again?
Yawn. believe it when I see it.
And if I see it, I will drop Medicare.
A loss in income of around 20 % wil hopefully make more of us think about making a step forward and moving to cash medicine and balance billing.
And dropping Medicare and moving to blanace billign and cash practice is something that horrifies politicians and the AARP. Therefore, they will work diligently to stop the cut/
We actually have a win - win.
If the cut goes through, we win politically
If the cut does not go through, hey, it's the same old, same old.
So, I prefer not to do anything, smile and wait
There are reasons for this, not the least of which is that it serves the interests of those who would control the sixth/seventh of the economy that constitutes health care without interference from a potential alliance of physicians and patients. We need to fight that.
This will be a cause of major turmoil in medicine if it stands. Many of our older collegues will retire and younger physicians will find other ways to support their family.
Many physicians will drop Medicare and unfortunately, those medicare recipients who thought they were paying into a system to take care of them during their retirement years will find they have been lied to. These are our parents and they will not get what they worked so hard for - security. When we finally retire, will there be anyone to provide us with the quality care we now provide for our patients?
I certainly hope so...
besides Medicare people will wake up and realize that they paid for decades into a Ponzi scheme called social security.
The Public remembers the lifestyle of older Docs when they were the Top Dogs in their communities and lived in royal style on the top of the hill.
Times have changed, Docs are struggling, but the people still remember the way it used to be. It'll take a lot of time and energy to change our public image.
Won't the boomers be mad when they learn Congress stole all the money for their healthcare.
Agree with abc
abc: thank you
It is coming, but not right now.
I picture the scenario as such: Oblamah pushes the bill through via reconciliaiton. He has played the "I am trying but your not card" to make it appear that he is coming half way, when in fact the bill he presents is the same. It has the same special interest exceptions, and the same structure for you and I. It is once that goes through, that the cuts happen. It is the only way he can justify cutting the fees without mass exodus. Once the bill passes, opting out at that time, would be very difficult, as the verbage is very specific in relation to what care is given and by whom. Pay will be based on the gov't option, and will be uniform for all carriers and fixed at 103-110% of medicare. The beautifal thing is that CBO will set the fees/worth/indications.
The fundamental problem is not even government.
The fundamental problem is people. People are naturally inclined to be envious, to want more than they have, and to try to get it at as low a cost to themselves as possible. Thus, when socialist (Demopublicans and Republocrats alike) politicians offer "an advance auction of stolen goods" (H.L. Mencken), if there are more "benefitees" than there are victims of the theft, guess what will happen. They will elect Robin Hoods, who will steal from those who have to give to those who don't.
Medicare is an example of this type of scheme - a Ponzi of the highest order, along with Social Security and numerous other programs enforced by the truly evil among us.
There is a way out. Withdraw. Do not participate. In any of these things. Starve the beast. Cut your income. Cut your taxes thereby. Do business with those you know, and only them, and use a medium of exchange other than fiat paper.
Withdraw your participation from these monstrous schemes, and they will collapse. They only live because you feed them.
I continue to be astounded by opinions posted here, such as that of Sermo Doc 149 above (only the latest), that somehow gives a pass to government perfidy, and would instead entrust it with ALL control of medical care. Are these people insane? Are they so ignorant of history? Are they simply stupid? Or are they a part of the evil cabal?
<b>www.lewrockwell.com
www.zerohedge.com
globaleconomicanalysis.blogspot.com
tickedoffdoc.blogspot.com</b>
They are stupid.
Bring on the cuts! The sooner, the better!!
This comment is proof positive of physician stupidity. You can still be book smart and be so stupid that you can't tell your ass from a hole in the ground.
This guy is so stupid his comments would be humorous if not for the fact he is apparently serious.
There is just not enough money. Reimbursment is going to go down. Providers will be going out of business or diversifying even more to survive. It is not inconceivable that providers will be legally mandated to take whatever reimbursement is offered and private practice will be limited or outlawed. There is just not enough money and the needed serives are vital.