How Sup Court decision to pass Affordable Healthcare Act will affect Rad Onc?

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Originally Posted by SimulD

Question:

Why should any physician own any equipment that they can self-refer to? I went to advocacy day, and lobbied for closure of the Stark loophole. But then, I thought about it. The incentive is still to over treat, no matter what specialty owns the linac. I'm just saying, if we studied fractionation patterns at academic centers vs. freestanding centers, we might be a little embarrassed at what we find...

Couldn't agree more with you. The problem is that regardless of who owns the equpment, if it is a private entity (physician, private equity group, etc.) there will always be pressure placed and incentives given to the treating physicians to maximize return on investment. How do we eliminate this to practice medicine in an ethical and evidence based manner without eliminating the private model? I know a lot of private groups that do but every 10 that act the right way 1 or 2 aren't and they set the tenor for this discussion.

Originally Posted by wagy27

Couldn't agree more with you. The problem is that regardless of who owns the equpment, if it is a private entity (physician, private equity group, etc.) there will always be pressure placed and incentives given to the treating physicians to maximize return on investment. How do we eliminate this to practice medicine in an ethical and evidence based manner without eliminating the private model? I know a lot of private groups that do but every 10 that act the right way 1 or 2 aren't and they set the tenor for this discussion.

And allowing only government entities to own these machines would likely mean other sets of problems for us. For example, the essential erosion of the private practice model, us eventually working for the government, governmental red-tape in trying to set up a new much needed centers somewhere, etc. We need to police ourselves. It's our responsibility to maintain the highest standards and respect for our field and our patients. The more we can do this and show the rest of medicine and payors this (that we can regulate our field, eliminate waste, practice ethically, not abuse our own radiation centers), the more political capital we will have when it comes time to policy, public health issues. Someone has to lead this initiative, and it really needs to be us.

Originally Posted by FractionJackson

How do you think this ruling will affect the landscape of Radiation Oncology?

Like all other physicians the reimbursement will go down. You will make less. It will take longer to pay off your school loans. I am mid-latter 40's and still paying school loans. When was the last time you documented an ophthalmic exam for you diabetic patients? Osama says you have to or your "grade" (and pay) will be reduced. More minutia on the way...

Unfortunately, given the nature of this forum, you are already "in the system" and have too much invested to change professions (as do I). However, "the brightest of the next generation" is unlikely to go into medicine. I have dissuaded my children from medicine and the majority of you will too. Google "doctors company" and you will find 90% of MD's do not recommend their children enter medicine. I recommend those of you who can abandon it to do so and the others head towards a track of administration, as the hospitals are the ones who benefit most from Obamacare. The goal is to ultimately force all physicians to become hospital employees and later to be government employees. "Get out while you can" is my advice. No longer can any doc hang his name on a shingle and make it...

Most of you don't realize this because you are unlikely to own a home yet but, unfortunately, those who take care of you when you are old will be paid less than plumbers, unless the government takes that over also...

BTW, if you are interested in "cradle to grave" government healthcare look at Spain and Greece...

Originally Posted by SimulD

Question:

Why should any physician own any equipment that they can self-refer to? I went to advocacy day, and lobbied for closure of the Stark loophole. But then, I thought about it. The incentive is still to over treat, no matter what specialty owns the linac. I'm just saying, if we studied fractionation patterns at academic centers vs. freestanding centers, we might be a little embarrassed at what we find...

I agree with you that there will always be an incentive to treat. Even in my residency I occasionally saw the chair gently ask why we didn't have more people on treatment. Community hospitals with machine ownership are similar. Thus, short of govt owned linacs (which would certainly limit access to care), there is no way to avoid this.

IMO the urology model is different. While a radonc owner may have an incentive to treat, this is mitigated/limited by the need to actually see the patient. Thus the referral system provides somewhat of a safeguard against overtreatment. When the urologist owns the machine, then refers to the radonc employee, this is lost.

sneakybooger, first off you calling obama osama is extremely offensive and repulsive, but really tells us more about your IQ than the president. Secondly, the reason you're still paying off school loans into your mid-late 40's is because you have no idea how to manage your money, how do you like DEM apples?

Yeah, comparing the president to one of the world's worst terrorists probably not the most effective way to make an argument. Sort of like when make a Hitler comparison, you've lost the argument... Sort of like the people who said W was the stupidest man alive. You've already lost, buddy...

Anyway, I don't mean to quibble, but this ownership thing is like the fox telling the wolf, "No, no, let me guard the hen house, I'm more trustworthy." You're right, though, government ownership has its own issues. I like community models, for some reason when many institutions own and the distribution is to a vast swath, it feels like there isn't as much pressure to treat or hyperfractionate or treat patients at multiple centers without being on site.

Originally Posted by SimulD

Anyway, I don't mean to quibble, but this ownership thing is like the fox telling the wolf, "No, no, let me guard the hen house, I'm more trustworthy." You're right, though, government ownership has its own issues. I like community models, for some reason when many institutions own and the distribution is to a vast swath, it feels like there isn't as much pressure to treat or hyperfractionate or treat patients at multiple centers without being on site.

Agreed. I think that's where the multi-specialty models make sense (and by multi, I mean more than 2 aka rad oncs and urologists). Adequate technical reimbursement has allowed XRT to reach a wide swath of population around the country. One has to wonder if the government would be as efficient in deploying those resources.

I think the multi-specialty model has its merits. However, many have their physicians on a base salary with production based incentives based on RVUs, etc. Much of what would increase your RVUs also increases their technical revenues. Even in the absence of production based bonuses, your ability to negotiate a salary is going to be based to some degree on the profitability of your department. Thus there is probably always some incentive to treat (or overtreat). A multispecialty model makes the relationship less distinct, but it still exists.

Originally Posted by RadRadRad

Thus there is probably always some incentive to treat (or overtreat).

The only real way to prevent over-utilization is to drop reimbursement by fraction and replace it with reimbursement by case. It's coming eventually . . .

Interesting article in Red Journal this month about how a large practice with academic and community sites utilized fractionation schemes for bone metastases (at UPMC). Community sites gave more fractions (i.e. >5 fx). They cost a lot more, too (they go into numbers in the article). Bu,t when they had peer-review and clinical pathway implementation, their fractionation decreased to 1-5 fractions. From what I remember there, there was financial incentives to be "pathway compliant", so maybe this made up for the loss of money from doing 40 Gy in 16 for a hip met.

http://www.redjournal.org/article/S0...329-3/abstract

Originally Posted by Gfunk6

The only real way to prevent over-utilization is to drop reimbursement by fraction and replace it with reimbursement by case. It's coming eventually . . .

Yep. Similar to a medicare-DRG model of reimbursement that happen now for inpatients

Originally Posted by medgator

Yep. Similar to a medicare-DRG model of reimbursement that happen now for inpatients

Yikes that would mean that all care for a given pt (surgery, chemo and XRT) would be bundled together for a given case

I guess with socialized medicine this is possible

Originally Posted by napoleondynamite

Yikes that would mean that all care for a given pt (surgery, chemo and XRT) would be bundled together for a given case

I guess with socialized medicine this is possible

I've asked people involved in the legislation process on my state about this an haven't been able to get a good answer about who would then decide who gets what. I've heard physicians compare this to tossing raw meat in the middle of hungry dogs, and to be honest, it doesn't seem far from the truth.

Originally Posted by Sheldor

I've asked people involved in the legislation process on my state about this an haven't been able to get a good answer about who would then decide who gets what. I've heard physicians compare this to tossing raw meat in the middle of hungry dogs, and to be honest, it doesn't seem far from the truth.

Well, I shudder to think what would happen when you compare our political clout to the other specialties involved.

You know, I wonder if with ACA on the table if academic jobs will become even more competitive? Something comforting about not having to worry quite as much about all this crud.

Originally Posted by napoleondynamite

Well, I shudder to think what would happen when you compare our political clout to the other specialties involved.

You know, I wonder if with ACA on the table if academic jobs will become even more competitive? Something comforting about not having to worry quite as much about all this crud.

When will we know about reimbursement changes? and will it ever be fixed or will it constantly change?

This scenario really puts a damper on being a doctor.

I still don't know why nursing salaries are not being slashed first, since they are a far bigger contributing factor to healthcare costs. It seems that as docs, most people are just laying down and taking it.

Originally Posted by DrAwsome

When will we know about reimbursement changes? and will it ever be fixed or will it constantly change?

This scenario really puts a damper on being a doctor.

I still don't know why nursing salaries are not being slashed first, since they are a far bigger contributing factor to healthcare costs. It seems that as docs, most people are just laying down and taking it.

There are a LOT of expenses in healthcare that are greater than that spent on physician reimbursements. Unfortunately, politically physicians are low hanging fruit because of old perceptions of doctors as golf playing part time workers.

An anecdotal rage story: My sister-in-law got her B.S.N in three years, and now works as a nurse. She currently makes $60 per hour, and works two 12 hour shifts per week with full benefits for the family with no deductible. Thats right. $75,000 per year with full health coverage for the family, working 24 hours a week. Admittedly, not all nurses make that much money, but its enough to make your blood boil slightly.

The one word answer to your actual question is: unions. That is why nurses salaries aren't the ones being talked about.

Originally Posted by DrAwsome

When will we know about reimbursement changes? and will it ever be fixed or will it constantly change?

This scenario really puts a damper on being a doctor.

I still don't know why nursing salaries are not being slashed first, since they are a far bigger contributing factor to healthcare costs. It seems that as docs, most people are just laying down and taking it.

There is no permanent 'fix' to reimbursements. There are competing interests, competing ideas, and competing solutions. There always have been and always will be. If you want to learn about reimbursement changes that may be come in the future, you may want to look at some of the global payments/ACO models being developed in Massachusetts. Unfortunately, radiation oncology doesn't fit neatly into a lot of these traditional models, so it may be a while before we see any major changes in radiation oncology is my guess.

I think a certain uncertainty has always been a part of the medical profession - it shouldn't put a 'damper' on being a doctor IMO. If you look back to the 1960s, the medical profession as a whole (including the AMA) was staunchly against the creation of Medicare and believed it would put an end to medicine in the United States as we know it. This is an exciting time for health care if you want to be part of changes that, from a non-financial point of view anyways, may move away from a pure fee-for-service system and towards a greater emphasis on quality care. Of course, we have to be constantly on guard to ensure that these changes are done with physician input and as favorably to physicians as possible...

Also, its well documented that doctors and their prescription pads are the greatest drivers of health care costs. We are the ones who order all the imaging services, procedures, and prescriptions. Its not nursing salaries by a far shot. Playing pure turf politics is dangerous for physicians, from a political point of view. While I agree that nursing salaries are probably higher than warranted, it is also true that nurses are in high demand/low supply and nurse salaries are largely dependent on what institutions/hospitals pay them. Even aside from their political/union powers, it is a lot more difficult to target nursing salaries through insurance/government policy than it is physician reimbursements.

The best solution, I think, is to ensure that our professional societies are constantly part of the conversation to ensure that new models are developed with physician input. Physicians need to take the lead in finding cost savings, as some physician groups through ACO models and others already have.

Originally Posted by radninja

There is no permanent 'fix' to reimbursements. There are competing interests, competing ideas, and competing solutions. There always have been and always will be. If you want to learn about reimbursement changes that may be come in the future, you may want to look at some of the global payments/ACO models being developed in Massachusetts. Unfortunately, radiation oncology doesn't fit neatly into a lot of these traditional models, so it may be a while before we see any major changes in radiation oncology is my guess.

I

I spoke with the woman, who is a good friend, in charge of planning and implementing an ACO model of physician reimbursement and it was a very interesting conversation. I asked her point blank how a field such as Radiation Oncology would fit in. She was baffled, and truly did not know. Who will determine who gets what? Won't this incentivise med/oncs to offer rad onc referral less often? Etc. Etc.

Point being, while I agree that we don't fit in neatly, I'm hoping that it goes the way you say, rather than them just cramming rad oncs in anyway.

My biggest concern is that in the leap away from fee-for-service, which likely incentivizes over treatment, it seems as though we are going the complete other direction and choosing a method that encourages under treatment. I don't know the answer, but I'd much rather it be somewhere in the middle both as a patient and a physician.

Originally Posted by Sheldor

There are a LOT of expenses in healthcare that are greater than that spent on physician reimbursements. Unfortunately, politically physicians are low hanging fruit because of old perceptions of doctors as golf playing part time workers.

An anecdotal rage story: My sister-in-law got her B.S.N in three years, and now works as a nurse. She currently makes $60 per hour, and works two 12 hour shifts per week with full benefits for the family with no deductible. Thats right. $75,000 per year with full health coverage for the family, working 24 hours a week. Admittedly, not all nurses make that much money, but its enough to make your blood boil slightly.

The one word answer to your actual question is: unions. That is why nurses salaries aren't the ones being talked about.

And why are we not doing anything about this? Dont you think that this is something that as doctors we should address? Nurses are the only health care professionals who are not salaried, yet they are the lowest level of healthcare professional. If it boils your blood sufficiently, why not do something about it?

Why are we not unionizing and striking and demanding what we deserve? Nurses do it. So should we. Who sets the rates for what nurses make? If a nursing association can set the rates for what they make why cant we?!

The minute we are forced to unionize, the minute we are de-professionalized. Lobby, self regulate, be activist, but lets not be assembly line workers or nurses. Coming from Detroit, I've seen the devastation of an industry due to the often capricious and divisive nature of union workers. And, for a private practice physician, who exactly is management/ownership? I may swing left, but the moment we start paying dues to have some union boss negotiate for my less hardworking or less competent "teamsters", I'll be more disappointed in medicine than ever before.

Originally Posted by SimulD

The minute we are forced to unionize, the minute we are de-professionalized.

Interesting... Are docs in Canada unionized? How would you view them?

You believe? Do a google search. They are not unionized. I view them favorably. Canadian medical schools are harder to get into them than ours.

They may not use the brand "unions," but the provincial medical societies are responsible for negotiating salaries for each respective province' physicians in Canada. Sounds pretty union-ish to me.

However, I 100% agree that unions are not the way to go. Which is why health care should remain in the private sector rather than be socialized. In a socialized system we'd have no choice but to unionize and negotiate terms with the government. Next thing you know we're taking to the streets like in France because we're working more than 30 hours a week.

Organizing as independent practice associations do is not the same as unionization. Canadian docs don't function like the Teamsters. Doctors in Charlotte, for example negotiate in large groups but is not like a union.

I think it's a splitting-hair distinction. When you have an organization negotiating your salary, vacation time, benefits, etc, well, that is exactly what a union does..even the teamsters. If the government is not only the insurer but also your employer, you will think about your medical organization in a different light.

I think that is clearly distinct from your Charlotte example where docs band together to negotiate with individual insurance companies. They aren't negotiating their entire package with ONE company, that is a different animal IMO.

Socialized medicine is inevitable only if physicians allow it to come to pass. There are many who think as you do, including the AMA. And if enough physicians agree or stay silent then it will. But there are groups who see this outcome as less than ideal and are working to prevent it, such as D4PC.

Clearly, most believe the current situation untenable. Physicians will have to choose sides. Unfortunately, this appears to be coming sooner rather than later.

Originally Posted by Gfunk6

Socialized medicine in the US is inevitable. Reduced reimbursement for specialists is inevitable. Our current system simply cannot be sustained. For universal coverage you either have to massively increase taxes, drastically cut reimbursements or some of both.

As physicians, we can accept this inevitability, participate in the discussion and mold policies a bit more in our favor *OR* you can live in a fantasy land where you can bury your head in the sand and have our future soley dictated by government beuracrats and insurance companies.

Originally Posted by temujim

Socialized medicine is inevitable only if physicians allow it to come to pass. There are many who think as you do, including the AMA. And if enough physicians agree or stay silent then it will. But there are groups who see this outcome as less than ideal and are working to prevent it, such as D4PC.

Clearly, most believe the current situation untenable. Physicians will have to choose sides. Unfortunately, this appears to be coming sooner rather than later.

I think we are really on the same side of this issue. Just because I think socialized medicine in inevitable, it doesn't mean I think we should do nothing about it . Delay, delay, delay is the name of the game. Our participation in organizations such as ASTRO is important to achieve this end.

Originally Posted by medgator

I don't think the country was ready for that. It would not have been politically viable for him or his party. The moderate democrats would haven't gone for it. Remember, the ACA ('obamacare') passed with slim majorities in both houses without a single republican vote of support.

I think it is pretty clear in the shady way this law was passed, the country was not ready for it either. Bribes to individual states and senators, written by lobbiests, passed under obscure rules after Senate lost 60. SS, Medicare, and Medicaid passed with bipartisan support. This law will always be tainted in a large portion of peoples mind because it was passed in such an unusual way with so little pubic support. This law had bipartisan opposition in the House and cost democrats the House in one of the hugest turn around ever. Many moderate democrats did not go for Obamacare. None of that happened after Medicare and SS, which the public generally supported.

Originally Posted by jimbobb23

I think it is pretty clear in the shady way this law was passed, the country was not ready for it either. Bribes to individual states and senators, written by lobbiests, passed under obscure rules after Senate lost 60. SS, Medicare, and Medicaid passed with bipartisan support. This law will always be tainted in a large portion of peoples mind because it was passed in such an unusual way with so little pubic support. This law had bipartisan opposition in the House and cost democrats the House in one of the hugest turn around ever. Many moderate democrats did not go for Obamacare. None of that happened after Medicare and SS, which the public generally supported.

Sorry to be silly, but public vs. pubic. But I agree!

Originally Posted by jimbobb23

I think it is pretty clear in the shady way this law was passed, the country was not ready for it either. Bribes to individual states and senators, written by lobbiests, passed under obscure rules after Senate lost 60. SS, Medicare, and Medicaid passed with bipartisan support. This law will always be tainted in a large portion of peoples mind because it was passed in such an unusual way with so little pubic support. This law had bipartisan opposition in the House and cost democrats the House in one of the hugest turn around ever. Many moderate democrats did not go for Obamacare. None of that happened after Medicare and SS, which the public generally supported.

The fact that Medicare/Social Security was passed on a more bipartisan basis than the ACA I think speaks more to a difference in the political climate and not because the ACA was shady. Probably better suited for a political science forum, but there used to be liberal and conservative republicans, liberal and conservative democrats. Look to most laws enacted before the 1980s and you'll see many more bipartisan laws. For better or for worse is a matter of personal opinion, but 1980s-present has shown a greater consolidation in power in the two parties, which has led to where we are today. Its important to realize that not everyone was on board with Medicare (see: Ronald Reagan - one of the most vocal opponents of Medicare/Social Security and hero of the modern republican party).

The reality is that much of the ACA is similar to what the Republicans proposed in the 1990s in opposition to the Clinton effort and it very much resembles the bipartisan health care law in Massachusetts under Romney (the main difference is the issue of federalism -- not any real policy).

Ultimately, Presidents have tried and failed at health care reform that insures all Americans for decades, so I think its unrealistic for people to claim they should have waited on health care reform 'until the country was read' -- because for the tens of millions of people this law will benefit, they really could not wait.

Originally Posted by radninja

Ultimately, Presidents have tried and failed at health care reform that insures all Americans for decades, so I think its unrealistic for people to claim they should have waited on health care reform 'until the country was read' -- because for the tens of millions of people this law will benefit, they really could not wait.

The problem is, based on what I have read so far, is how we pay for those people to benefit. Increased taxes on higher earners is how as well as penalties to businesses that opt out of providing coverage. Seems like you're robbing peter to pay paul in this situation under the guise of they have more so we can take more.

Originally Posted by wagy27

The problem is, based on what I have read so far, is how we pay for those people to benefit. Increased taxes on higher earners is how as well as penalties to businesses that opt out of providing coverage. Seems like you're robbing peter to pay paul in this situation under the guise of they have more so we can take more.

The president gave his assurance that this act would be deficit neutral, and nay, would actually save the taxpayers real money. No one thinks that he would have lied about such a thing, right?

Originally Posted by Mandelin Rain

The president gave his assurance that this act would be deficit neutral, and nay, would actually save the taxpayers real money. No one thinks that he would have lied about such a thing, right?

My internet sarcasm meter isn't great so I can't tell if you're being facetious. Medicare was touted similarly when LBJ signed it back then. Of course, average life expectancy was 68 at that time.

Creating a large entitlement and saying it lowers the deficit (or at most is neutral) sounds like eating a serving of fat-free deep-fried oreos. Only time will tell if the CBO (congressional budget office) was correct in their assumption. Wagy27 is correct. The plan is paid for via surcharges on individuals making >$200K a year who will pay more into medicare, and more on their investments and interest income.

Originally Posted by medgator

My internet sarcasm meter isn't great so I can't tell if you're being facetious. Medicare was touted similarly when LBJ signed it back then. Of course, average life expectancy was 68 at that time.

Creating a large entitlement and saying it lowers the deficit (or at most is neutral) sounds like eating a serving of fat-free deep-fried oreos. Only time will tell if the CBO (congressional budget office) was correct in their assumption. Wagy27 is correct. The plan is paid for via surcharges on individuals making >$200K a year who will pay more into medicare, and more on their investments and interest income.

It was certainly saracasm. Being "deficit neutral" was also conditional on the doc-fix never being renewed, and all Medicare physician reimbursement dropping by 30% overnight.

Of course, that didn't happen, and likely (please God) won't happen. So yes, we'll be the ones paying the difference anyway.

Originally Posted by bigkahunaburger

sneakybooger, first off you calling obama osama is extremely offensive and repulsive, but really tells us more about your IQ than the president. Secondly, the reason you're still paying off school loans into your mid-late 40's is because you have no idea how to manage your money, how do you like DEM apples?

K, I graduated with $175,000 in school debt, a family, and a home. I just hired a new grad who had $250,000 in school loans. Mine is the same story of med school debt that the vast majority of my colleagues tell. How much school loan debt do you think a medical student will graduate with after 8-9 yrs of med school/residency?

I am just trying to help you, K. It's called tough love. I love the practice of medicine, but not the business of medicine.


Did you Google "Doctor's Company"? Download and read the pdf. Only 11% of 5000 MD's would recommend medicine as a career for their children. Here is the link in case you had trouble finding it ( although as smart as you are you probably already knew all about it):

http://www.thedoctors.com/KnowledgeC.../CON_ID_004672



Here is something else to think about:



Why does an MRI in USA cost $1200 and in Europe it is $250?

Do you think this is gonna a bad year to get a job-- academic or private? Pay cuts + universal healthcare + I didn't train at MSK/MDA/joint center== uncertain future + no job for me!

Don't worry too much! You worked so hard, it will work out. Maybe a bit flat, but there is still a lot of demand for us and the projections show we will be in need for years to come. Im hoping astro lobbies hard and gets those cuts to come down a bit. That will happen in late fall. Once it does, groups will have less uncertainty.

Originally Posted by BraggPeak

Do you think this is gonna a bad year to get a job-- academic or private? Pay cuts + universal healthcare + I didn't train at MSK/MDA/joint center== uncertain future + no job for me!

We thought the same way a few years ago when healthcare reform was passed in 2009. 2010 had a lot of jobs out there. There is still demand for our services, albeit you may not get the perfect combo of 1) location 2) job quality/satisfaction and 3) income that you'd like. It's a good rule of thumb that you end up having to take a hit somewhere in those three areas.

Thanks. When I email programs about potential jobs, the responses I get are either 1) no response or 2) check back in the fall. I guess it's pretty early still for 2013 jobs.

Originally Posted by BraggPeak

Thanks. When I email programs about potential jobs, the responses I get are either 1) no response or 2) check back in the fall. I guess it's pretty early still for 2013 jobs.

For some of the bigger groups, they get a better picture of what they need 6 months out. You'll have a year to go at this point, but it's certainly reasonable to start making first contacts leading up to the initial meetings at ASTRO.

Originally Posted by SneakyBooger

K, I graduated with $175,000 in school debt, a family, and a home. I just hired a new grad who had $250,000 in school loans. Mine is the same story of med school debt that the vast majority of my colleagues tell. How much school loan debt do you think a medical student will graduate with after 8-9 yrs of med school/residency?

I am just trying to help you, K. It's called tough love. I love the practice of medicine, but not the business of medicine.


Did you Google "Doctor's Company"? Download and read the pdf. Only 11% of 5000 MD's would recommend medicine as a career for their children. Here is the link in case you had trouble finding it ( although as smart as you are you probably already knew all about it):

http://www.thedoctors.com/KnowledgeC.../CON_ID_004672



Here is something else to think about:



Why does an MRI in USA cost $1200 and in Europe it is $250?

Physician services historically have represented 20% of medical costs in the country. About half of that 20% can be lopped off as overhead fees. So, physician take-home pay generally represents about 10% of medical costs in this country. Of the other 90%, about 80% is at least indirectly controlled by physicians (medical imaging, drug prescriptions, treatment costs, etc) and the rest is considered administrative costs, which physicians have no control over.

The ACO model is predicated on the fact that physicians can control costs. Physicians are rewarded for cutting costs and hitting key quality measures. And the ACO model, as written in in the ACA/Obamacare and implemented by the HHS requires that a majority of the board of the ACO be made up of physicians. I think this is an excellent opportunity for the physician community to take back the reins and play a larger role in the control of health care both to our own and to our patients' benefit.

Of course for rad onc, it is still not really clear yet how we will play into this new model. Nonetheless, here are some resources some AMA friends provided me with details on ACOs and such and the role physicians can play: http://www.ama-assn.org/ama/pub/abou...esources.page?

Originally Posted by Mandelin Rain

The president gave his assurance that this act would be deficit neutral, and nay, would actually save the taxpayers real money. No one thinks that he would have lied about such a thing, right?

FYI, the president was correct when claiming that the ACA is budget neutral (or actually reduces the deficit) according to the CBO (nonpartisan final authority on such matters recognized by both dems and republicans)

Here are two CBO reports from earlier today laying it out in more detail:
http://cbo.gov/publication/43471
http://cbo.gov/publication/43472

Originally Posted by radninja

FYI, the president was correct when claiming that the ACA is budget neutral (or actually reduces the deficit) according to the CBO (nonpartisan final authority on such matters recognized by both dems and republicans)

Here are two CBO reports from earlier today laying it out in more detail:
http://cbo.gov/publication/43471
http://cbo.gov/publication/43472

The CBO analysis of cost savings has been found to be flawed. The biggest issue was double-counting medicare savings. Conveniently this occurred after the ACA was passed by both houses and signed by the president.

http://www.forbes.com/sites/gracemar...al-disaster/2/

http://www.csmonitor.com/Business/Do...er-it/(page)/2

http://dmarron.com/2012/05/09/the-fi...uble-counting/

Over the long-term, does it make sense for an entitlement to be deficit-neutral or reducing? Medicare is a prime example of something that started out as a good idea, but became more unsustainable as people's lifespans have increased. When LBJ created medicare, the average lifespan was only 68. Now it's in the late 70s.

Originally Posted by medgator

The CBO analysis of cost savings has been found to be flawed. The biggest issue was double-counting medicare savings. Conveniently this occurred after the ACA was passed by both houses and signed by the president.

http://www.forbes.com/sites/gracemar...al-disaster/2/

http://www.csmonitor.com/Business/Donald-Marron/2012/0509/What-is-medicare-double-counting-and-why-are-budget-experts-fighting-over-it/(page)/2

http://dmarron.com/2012/05/09/the-fi...uble-counting/

Over the long-term, does it make sense for an entitlement to be deficit-neutral or reducing? Medicare is a prime example of something that started out as a good idea, but became more unsustainable as people's lifespans have increased. When LBJ created medicare, the average lifespan was only 68. Now it's in the late 70s.

Should we not create certain standards of care a la Canada and other countries with "socialized medicine" where after certain ages, certain services are no longer available? Clearly it's something we have not wanted to do, but we are spending billions of dollars in people's last few years of life, with little to show for it. Isn't it in Canada and GB where patients 65+ don't get dialysis, surgeries, etc, for example? Curving end of life is necessary if we are to cut costs. Otherwise we are simply hacking away at doctor salaries for little to no real savings otherwise.

Originally Posted by radninja

FYI, the president was correct when claiming that the ACA is budget neutral (or actually reduces the deficit) according to the CBO (nonpartisan final authority on such matters recognized by both dems and republicans)

Here are two CBO reports from earlier today laying it out in more detail:
http://cbo.gov/publication/43471
http://cbo.gov/publication/43472

The ultimate garbage in, garbage out situation. All the CBO can do is calculate a number based on assumptions an figures that it's given. Guess who controls those assumptions?You understand that the AMA is lobbying for a permanent fix to the SGR, such that one key assumption that the Obama administration fed the CBO can't possibly come true (and still hasn't, and likey never will).

Originally Posted by medgator

The CBO analysis of cost savings has been found to be flawed. The biggest issue was double-counting medicare savings. Conveniently this occurred after the ACA was passed by both houses and signed by the president.

http://www.forbes.com/sites/gracemar...al-disaster/2/

http://www.csmonitor.com/Business/Do...er-it/(page)/2

http://dmarron.com/2012/05/09/the-fi...uble-counting/

Over the long-term, does it make sense for an entitlement to be deficit-neutral or reducing? Medicare is a prime example of something that started out as a good idea, but became more unsustainable as people's lifespans have increased. When LBJ created medicare, the average lifespan was only 68. Now it's in the late 70s.

The Medicare "double-counting" claim has been along for a long time. The 'trust fund' for Medicare Part A does not exist anywhere on the books, thus the CBO counts those Medicare savings as cutting the deficit. This would not be true of social security, for example, because all money in social security has to stay inside the social security trust fund --- it can't be used for another purpose. That's why the CBO still says it will cut the deficit (and that repealing it will increase the deficit). But yes, I still think the Administration is being completely disingenuous when they claim that it extends the length of Meidcare AND cuts the deficit in the same sentence. They're have an out on what's just a technicality.

Regardless, the ACA does indeed cut the deficit in the long term. The CBO says it would cut around $1 trillion from the deficit in the second decade of the law (http://www.washingtonpost.com/blogs/...able-care-act/)

In a traditional sense, yes entitlement programs would increase the defecit; however, the cost saving mechanisms the law puts in place, the taxes on pharma/medical device/tanning/1% on high income/etc, and the reduced Medicare spending on hospitals/Medicare Advantage will save money in the long run. However you look at it, it does save money in the long run. Dems I'm sure will claim that ACOs, IPAB, etc will save more money than the CBO claims and republicans will claim it will save less, but the CBO is the authority on this.

Just as I would trust clinical trials, meta-analysis, and high profile research papers when I provide patient care over anecdotal claims on the internet, I tend to trust the CBO on these matters too.

Originally Posted by radninja

The Medicare "double-counting" claim has been along for a long time. The 'trust fund' for Medicare Part A does not exist anywhere on the books, thus the CBO counts those Medicare savings as cutting the deficit. This would not be true of social security, for example, because all money in social security has to stay inside the social security trust fund --- it can't be used for another purpose. That's why the CBO still says it will cut the deficit (and that repealing it will increase the deficit). But yes, I still think the Administration is being completely disingenuous when they claim that it extends the length of Meidcare AND cuts the deficit in the same sentence. They're have an out on what's just a technicality.

Regardless, the ACA does indeed cut the deficit in the long term. The CBO says it would cut around $1 trillion from the deficit in the second decade of the law (http://www.washingtonpost.com/blogs/...able-care-act/)

In a traditional sense, yes entitlement programs would increase the defecit; however, the cost saving mechanisms the law puts in place, the taxes on pharma/medical device/tanning/1% on high income/etc, and the reduced Medicare spending on hospitals/Medicare Advantage will save money in the long run. However you look at it, it does save money in the long run. Dems I'm sure will claim that ACOs, IPAB, etc will save more money than the CBO claims and republicans will claim it will save less, but the CBO is the authority on this.

Just as I would trust clinical trials, meta-analysis, and high profile research papers when I provide patient care over anecdotal claims on the internet, I tend to trust the CBO on these matters too.

Just as clnical trials have flaws (hmm.ESPAC 1 come to mind), so to does the CBO as previously noted, Just because something is labeled as the clinical trial, or the budget assessment doesnt mean that it shouldn't be evaluated before accepting as dogma.

Debating the merits/flaws of Obamacare, whether it's budget neutral or budget busting has one problem. No matter what people say, you will not convince a supporter to change her mind or a person who hates the law to start supporting it. It's not the plan, people are just tribal. If a Republican developed the plan (as they created the individual mandate), liberals would say its cruel to force people to buy insurance.

So, it's more useful to talk about how we will operate under the framework of the law. It's going to be upon us to prove that are services are valuable an worth the money by integrating quality assessments of what we do and to show data indicating how cost effective we are. For example, RT is more cost effective than Tamoxifen for breast cancer in terms of numbers needed to treat, yet we are constantly being forced out of the game, while no one makes a peep about Tam.

Reading the law, it seems like much of our future research should be about comparative effectiveness and QOL to prove our worth and keep our codes getting reimbursed.

Now that the election is over and the political composition of the Presidency, House and Senate are virtually unchanged, ASTRO has put out a post-election analysis here.

The bottom line,

They think Congress will probably put a 3-12 month "temporary" delay to the planned 27% Medicare SGR reimbursement cut. Of course this will continue to drive up the deficit and absolutely maintain the status quo. ASTRO doesn't think it is very likely that a long-term compromise will be reached.

In the meantime, ASTRO is pushing for alternative reform measures like ending self-referral which should help put a dent in federal healthcare spending and, hopefully, help shield our specialty from deeper cuts.