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How do you think this ruling will affect the landscape of Radiation Oncology?
How Sup Court decision to pass Affordable Healthcare Act will affect Rad Onc?
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I think it will be a disaster. The only real specialties that are safe are those that can charge cash and don't need a hospital to provide services. Given that it's cheaper for many employers to simply pay the penalty "tax" than provide coverage, I would not be surprised if employers dropped employees left and right, which means the end of insurance, and more people covered under the gov. I think we have essentially just become a single payer system. Who in their right mind would cover their employees when it can simply pay a penalty and save thousands?
How much do you think medicare/medicaid will reimburse for services when they have no competition for private insurance?
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This is a complex and politically divisive topic.
However we must learn to adapt. On one hand, I think it will be good for patients who can get more reasonable insurance rates. Also, it will prevent people from not getting insurance, becoming catastrophically ill, then getting the govt to pick up the tab. Having kids stay on their parent's policy until age 26 will also help.
It's interesting Obama didn't go for the single payer system but instead mandated that people buy a private insurance product. Better to have more private insurance in the mix rather than Medicaid/Medicare rates for everyone.
However we must learn to adapt. On one hand, I think it will be good for patients who can get more reasonable insurance rates. Also, it will prevent people from not getting insurance, becoming catastrophically ill, then getting the govt to pick up the tab. Having kids stay on their parent's policy until age 26 will also help.
It's interesting Obama didn't go for the single payer system but instead mandated that people buy a private insurance product. Better to have more private insurance in the mix rather than Medicaid/Medicare rates for everyone.
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But that's the thing-employers currently provide private insurance, not the gov. A lot of employers will likely decide that it's more financially viable to simply pay a penalty than insure their employees. So realistically, less and less employers will offer insurance and more people will depend on the gov. for insurance which means less reimbursements to hospitals and docs for more work. Not to mention the medicolegal situation is worse than in any other country on the planet.
D
deleted4401
Totally divisive topic and there will be partisan opinions on whether or not this is good for the economy or employment or whatever, but strictly for radiation oncology, this is what I see:
Short term: More people insured is good for us. Most rad-oncs take uninsured people b/c we feel bad, so this could be helpful. Less people getting kicked off for pre-existing conditions helps us, as well, as far as dealing with insured patients. I think as far as private insurers vs Medicare rates: that totally depends on where you live. Some places private insurers pay 70-80% of "usual and customary" fees set by CMS/Medicare and in other areas it's 130-150% of Medicare rates. For us, the age 26 thing won't help at all - less than 0.1% of our patients are that age.
Long term: no matter what, specialists are going to take a hit. It's going to happen. We'll be targets, too, but it has nothing to do with ObamaCare. The nation is going broke. Health care costs are approaching 20% of GDP. Physician reimbursements appear to low-hanging fruit, so they'll go ahead and grab it, while finding out there is very little in terms of overall savings. There is a provision stating that insurers have to spend X amount on actual medical care rather than administrative costs/advertising, and because that could decrease shareholder value, premiums may raise or reimbursements could fall.
I don't think in the short term much will happen to us. In fact, for people in places where private insurers pay more than Medicare, there may be a short term gain, b/c of more insured people. But in the long term, it's not what 9 people in black robes decide that will fundamentally decide what happens to us. It's up to Medicare/CMS.
And this is really complicated stuff, but if the employers don't cover their employees, the point of the tax (which is $2000/employee for every employee after the first 30-50 depending on the situation), the scaled subsidies, and the insurance exchanges is that people will have access to and be responsible to buy their own health care, and I like the idea of that. It's not that if your employer doesn't cover you, you get covered by Medicare/Medicaid. In fact, that is completely wrong. The point is, if you make enough money and don't have employer provided health care, you have to buy it on your own. If they don't want to buy insurance, that's fine, you get fined $695.
-S
Short term: More people insured is good for us. Most rad-oncs take uninsured people b/c we feel bad, so this could be helpful. Less people getting kicked off for pre-existing conditions helps us, as well, as far as dealing with insured patients. I think as far as private insurers vs Medicare rates: that totally depends on where you live. Some places private insurers pay 70-80% of "usual and customary" fees set by CMS/Medicare and in other areas it's 130-150% of Medicare rates. For us, the age 26 thing won't help at all - less than 0.1% of our patients are that age.
Long term: no matter what, specialists are going to take a hit. It's going to happen. We'll be targets, too, but it has nothing to do with ObamaCare. The nation is going broke. Health care costs are approaching 20% of GDP. Physician reimbursements appear to low-hanging fruit, so they'll go ahead and grab it, while finding out there is very little in terms of overall savings. There is a provision stating that insurers have to spend X amount on actual medical care rather than administrative costs/advertising, and because that could decrease shareholder value, premiums may raise or reimbursements could fall.
I don't think in the short term much will happen to us. In fact, for people in places where private insurers pay more than Medicare, there may be a short term gain, b/c of more insured people. But in the long term, it's not what 9 people in black robes decide that will fundamentally decide what happens to us. It's up to Medicare/CMS.
And this is really complicated stuff, but if the employers don't cover their employees, the point of the tax (which is $2000/employee for every employee after the first 30-50 depending on the situation), the scaled subsidies, and the insurance exchanges is that people will have access to and be responsible to buy their own health care, and I like the idea of that. It's not that if your employer doesn't cover you, you get covered by Medicare/Medicaid. In fact, that is completely wrong. The point is, if you make enough money and don't have employer provided health care, you have to buy it on your own. If they don't want to buy insurance, that's fine, you get fined $695.
-S
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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 in the short term, I agree with SimulD. It will create a more captive "paying" population for us as we do see provide indigent care in many of our practice settings (academic, to community/rural PP). The concern I have is that the cost issue in healthcare has not been solved by this legislation at all. If anything, the ACA has essentially put more air in the healthcare bubble, and unfortunately, it's going to be very ugly when it pops.
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Here's ASTRO's official position. As others stated, probably no short term effects.
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You make no sense, right now it wouldn't cost anything for employers to not insure their employees; and they still offer insurance because it's a benefit they'll provide to keep those employees. So what you're saying is that in the future when the employers will get fined for not providing insurance, fewer employers will cover their employees?
I'm happy this law passed. It sickens me when I see a patient with cancer who can't get radiation because of lack of insurance.
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It's different, because right now insurance companies run on a profitable manner. Why do you think they have all these restrictions on pre-existing conditions, age until kids can stay on their parents insurance, etc? I'm not saying it's right, I'm saying that this is how insurance companies make their money. Many will likely run on an unprofitable/less profitable margin and will likely cut reimbursements big time. Maybe you like working for 150k after 13 years of education, but like someone else said, most of us did not sign up to be a martyr. I find it sad that our profession is seen as so worthless to the point that nurses and PA's get paid the same or more than many of our colleagues.
The law has a provision requiring the medical loss ratio to be at least 85%. What this means is that health insurance companies have to use 80-85% of the money they receive in premiums on actual medical services - primarily paying doctors and hospitals.
In theory, this would only incentivize insurance companies to work the system by increasing reimbursements to physicians and thus increasing the absolute value of the 85% (thus leaving more in absolute terms in the leftover 15% for the insurance companies). Its probably not going to work this way in actuality, but claims that insurance companies are going to drop reimbursement rates for physicians because of the ACA make no sense and are based in zero truth. CBO reports and other non-partisan sources noted no drop in reimbursements to physicians as a direct result of the law. Besides, with the millions of new Americans added to the insurance payrolls due to the mandate, the insurance industry actually (somewhat grudgingly) supported the health care law as a whole.
Hey, I want to be reimbursed too and I'm not martyr, but I the legislation simply will not do many of the things that some of its detractors claim it will.
There are other parts of the law may have negative consequences for physicians (such as the IPAB), but I think on the whole, 95% of the law is positive for our patients and the future of the practice of medicine. I think the ASTRO piece posted by Gfunk is spot-on about the benefits of the law and also the ways in which we as a profession can ensure that it is implemented well.
In theory, this would only incentivize insurance companies to work the system by increasing reimbursements to physicians and thus increasing the absolute value of the 85% (thus leaving more in absolute terms in the leftover 15% for the insurance companies). Its probably not going to work this way in actuality, but claims that insurance companies are going to drop reimbursement rates for physicians because of the ACA make no sense and are based in zero truth. CBO reports and other non-partisan sources noted no drop in reimbursements to physicians as a direct result of the law. Besides, with the millions of new Americans added to the insurance payrolls due to the mandate, the insurance industry actually (somewhat grudgingly) supported the health care law as a whole.
Hey, I want to be reimbursed too and I'm not martyr, but I the legislation simply will not do many of the things that some of its detractors claim it will.
There are other parts of the law may have negative consequences for physicians (such as the IPAB), but I think on the whole, 95% of the law is positive for our patients and the future of the practice of medicine. I think the ASTRO piece posted by Gfunk is spot-on about the benefits of the law and also the ways in which we as a profession can ensure that it is implemented well.
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Obviously, many things in play now. With the new law passed,the concept of employers offering health insurance to their employees is an interesting one, and it's tough to tell how things will go. The health insurance exchanges that the states/fed gov't will set-up will (theoretically) offer different types of plans of different cost/coverage (there will be a set of basic coverage requirements) in an effort to uncouple insurance from employment/employer status. How much will these plans cost? Low cost plans can definitely compete with current plans to lower costs, in order to better compete for individual and employer market share. There's this thought that employers want the best employees to work for them, and offering them good benefits is part of that attractive package - this is true now, but with the job shortage even a good employee can't exactly be picky. It may indeed be cheaper for certain employers to pay the fine, or they may resort to including the health insurance benefits but with lower salaries/vacation/bonus. Let's see.
One of the next questions after today's ruling is how Medicaid will expand. Fed gov't is offering a lot of money, enough for the states (who are already financially pressed) to chip in after the 3 years? With an additional 17 million people (I think that was the number) to be covered under Medicaid, how will hospitals/providers react? Medicaid is already an unpopular insurance among providers...
Lazers: I'm right there with you that I am very happy that our cancer patients will get coverage. Since companies can't look at pre-existing conditions, cancer survivors and those with the complex co-morbidities also have an opportunity to purchase health insurance at a fair rate, if not coupled with their employee. However, there's a lot of cost here, so costs have to be cut from somewhere else. Physician reimbursements have had downward pressure for a long time, and it'll continue. Aside from the ACA, have you guys been following MedPAC (Medicare Payment Advisory Committee) recommendations? These guys recommended a 5.9% cut x 3 years (close to >20% with inflation, etc) in Medicare reimbursement fees for all specialists fees across the board. The only ones untouched are primary care fields (however, inflation eats into these guys as well). These cuts are just for the next 3 years then they are supposed to stay frozen. However, what will be the mode of care delivery then? ACO? Medical homes? Some other kind of hospital-physician-payer relationship? Single payer (ahem, who knows, though doubtful)? Medicare is looking into prospective payment models (i.e. pay by the diagnosis instead of fee-for-service) for cancer hospitals too. Oncology has not yet been included in the ACO model, but its an ever-evolving landscape.
Today's ruling is about getting more patients into the risk pool by paying into the system. Hopefully, this will help in covering those patients who require substantial services but don't pay into the system at all. (And thanks to EMTALA, hospitals must stabilize/ doctors must treat then ship out to your nearest public hospital.) Today's ruling doesn't enforce some kind of a reduction in remibursement etc. But, the big change that will effect you, me, patients, other specialists, and primary care physicians will come in many different ways, including the future waves of novel, innovative care models that look to cut costs tremendously without changing quality one bit.
That ASTRO link was great, and having more patients covered (even if by a tax) is a good thing. I'm sure ASTRO and all of the medical societies will be watching closely and hopefully working together to make sure that these patients get care and integrated into the system.
One of the next questions after today's ruling is how Medicaid will expand. Fed gov't is offering a lot of money, enough for the states (who are already financially pressed) to chip in after the 3 years? With an additional 17 million people (I think that was the number) to be covered under Medicaid, how will hospitals/providers react? Medicaid is already an unpopular insurance among providers...
Lazers: I'm right there with you that I am very happy that our cancer patients will get coverage. Since companies can't look at pre-existing conditions, cancer survivors and those with the complex co-morbidities also have an opportunity to purchase health insurance at a fair rate, if not coupled with their employee. However, there's a lot of cost here, so costs have to be cut from somewhere else. Physician reimbursements have had downward pressure for a long time, and it'll continue. Aside from the ACA, have you guys been following MedPAC (Medicare Payment Advisory Committee) recommendations? These guys recommended a 5.9% cut x 3 years (close to >20% with inflation, etc) in Medicare reimbursement fees for all specialists fees across the board. The only ones untouched are primary care fields (however, inflation eats into these guys as well). These cuts are just for the next 3 years then they are supposed to stay frozen. However, what will be the mode of care delivery then? ACO? Medical homes? Some other kind of hospital-physician-payer relationship? Single payer (ahem, who knows, though doubtful)? Medicare is looking into prospective payment models (i.e. pay by the diagnosis instead of fee-for-service) for cancer hospitals too. Oncology has not yet been included in the ACO model, but its an ever-evolving landscape.
Today's ruling is about getting more patients into the risk pool by paying into the system. Hopefully, this will help in covering those patients who require substantial services but don't pay into the system at all. (And thanks to EMTALA, hospitals must stabilize/ doctors must treat then ship out to your nearest public hospital.) Today's ruling doesn't enforce some kind of a reduction in remibursement etc. But, the big change that will effect you, me, patients, other specialists, and primary care physicians will come in many different ways, including the future waves of novel, innovative care models that look to cut costs tremendously without changing quality one bit.
That ASTRO link was great, and having more patients covered (even if by a tax) is a good thing. I'm sure ASTRO and all of the medical societies will be watching closely and hopefully working together to make sure that these patients get care and integrated into the system.
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D
deleted4401
I don't usually waste a post to cheerlead, but the last two were great. Curious to hear fact based/evidence based comments from detectors of the law, rather than the typical sky is falling conversation. Honestly, I just don't see this hurting docs or patients. I do see it costing more, but it costs more to insure more people.
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I think this was one of the best posts of the day thus far. Thank you.
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In other words, we get hit from all sides! What can we do to have a more stable situation, and to not get screwed from all angles?
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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.
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Re: How are we going to pay for this?
Great points, and all of these will hit greater scrutiny now that the SCOTUS upheld the constitutionality of the core insurance mandate (aka healthcare/insurance tax). I didn't mention it yesterday since we were talking about the constitutionality of the ruling and how it would affect our patients, but I definitely have a big problem with how this expansion of insurance coverage is to be paid for. First, the gov't is going to put up $1 trillion more to help with the expansion of medicaid, helping to set-up the health insurance exchanges, and other costs. This trillion is coming from higher taxes for the wealthy, penalties, and fees (on hospitals, for example). If you make >$200k individual or >$250k married filing jointly you'll have to pay about ~1% more. Savvy investor and looking to make gains through the market? (Remember, this does include the elderly who are hoping to ride out their retirement with the interest/capital gains on their nest egg.) In these cases, at least a 2-3% (estimated at ~3.8% on a portion of this income as of now) increase in tax (maybe more).
If you've been counting on that medical flex spending account, it's likely that your max pre-tax dollars that go into it will not be $5000 (well, that limit was specific to my plan) but rather $2500 now (therefore increasing the amount you pay in taxes). As wagy mentioned, if the employer's cost for the employee's health insurance is > ~$10,000/yr (one way the fed govt defines cadillac insurances) there will be a tax on this plan. In essence, they want individuals and employers to choose lower cost insurance plans, which means possibly higher costs to the consumer via copays, deductibles, limitations on certain types of coverage, lower reimbursements to providers --> thereby decreasing the pot of healthcare money. If employers wish to keep providing these higher cost insurance plans, that extra tax to the employer will be funneled back into the federal govt system. The fed gov't is really hoping that this health insurance exchange creates a highway for *reasonably priced* insurances.
The next 1.5 years will be about reshaping the provisions in the law. However, the costs that wagy mentioned are potentially just a starting point, since the penalty employers or individuals need to pay for not getting insurances isn't a lot. This penalty needs to be able to sink its teeth ever deeper in order for there to be an incentive to actually buy the insurance; otherwise, its like adding a tax on more Americans that is supposed to go towards the health care pot. Add on top of that the fact that SCOTUS said that its unconstitutional for fed govt to basically "force" states into or out of medicaid (by threatening to withhold the large sums of money). If less states opt for this option of expanding state medicaid, then that means less people to be enrolled into medicaid (with current estimates, this could include 17 million new people). If there's less people in the medicaid or private insurance systems (since they opt'ed to pay the penalty), all of that means less people than we originally thought would be paying into the system --> which means that fed govt will likely need to increase more taxes to generate revenue to pay for the provisions of the law.
The end game looks like downward pressure on physician reimbursement (see my MedPAC comment above) and higher taxes for the wealthy. Supposedly more people will be taxed for health care, but when close to the majority of Americans do not pay into the tax system (income, etc due to many many reasons), a disproportionate amount of taxing will fall to the wealthy, who Democratic governments feel can and should pay higher taxes. I try to be as centrist as possible, and look fairly at the arguments, but its certain that taxes on the so called wealthy will increase under the current government. The thing is, doctors in general are in a precarious financial situation. We have huge debts that we carry into our 40's (maybe even 50's) and our main asset to our families is our ability to earn a larger salary, which continues to be eaten away by lower reimbursements and higher taxes.
What can we do? Honestly, becoming adept at the legislative/lobbying process can help and finding ways for the medical societies to band together. We're so busy with everything we're doing that adding another time killer to our schedules is not ideal. But voicing the concerns of physicians to your local lawmakers (your US House of Rep, even state lawmakers) is important, and if done in the right way, can help. Getting rid of the SGR, not taking a 20% cut to reimbursements over 3 yrs (MedPAC), and not increasing taxes are things we could all hope for. Support the medical societies who are helping in these efforts, and if you know of fellow rad onc residents who are interested in these things, encourage them!
Great points, and all of these will hit greater scrutiny now that the SCOTUS upheld the constitutionality of the core insurance mandate (aka healthcare/insurance tax). I didn't mention it yesterday since we were talking about the constitutionality of the ruling and how it would affect our patients, but I definitely have a big problem with how this expansion of insurance coverage is to be paid for. First, the gov't is going to put up $1 trillion more to help with the expansion of medicaid, helping to set-up the health insurance exchanges, and other costs. This trillion is coming from higher taxes for the wealthy, penalties, and fees (on hospitals, for example). If you make >$200k individual or >$250k married filing jointly you'll have to pay about ~1% more. Savvy investor and looking to make gains through the market? (Remember, this does include the elderly who are hoping to ride out their retirement with the interest/capital gains on their nest egg.) In these cases, at least a 2-3% (estimated at ~3.8% on a portion of this income as of now) increase in tax (maybe more).
If you've been counting on that medical flex spending account, it's likely that your max pre-tax dollars that go into it will not be $5000 (well, that limit was specific to my plan) but rather $2500 now (therefore increasing the amount you pay in taxes). As wagy mentioned, if the employer's cost for the employee's health insurance is > ~$10,000/yr (one way the fed govt defines cadillac insurances) there will be a tax on this plan. In essence, they want individuals and employers to choose lower cost insurance plans, which means possibly higher costs to the consumer via copays, deductibles, limitations on certain types of coverage, lower reimbursements to providers --> thereby decreasing the pot of healthcare money. If employers wish to keep providing these higher cost insurance plans, that extra tax to the employer will be funneled back into the federal govt system. The fed gov't is really hoping that this health insurance exchange creates a highway for *reasonably priced* insurances.
The next 1.5 years will be about reshaping the provisions in the law. However, the costs that wagy mentioned are potentially just a starting point, since the penalty employers or individuals need to pay for not getting insurances isn't a lot. This penalty needs to be able to sink its teeth ever deeper in order for there to be an incentive to actually buy the insurance; otherwise, its like adding a tax on more Americans that is supposed to go towards the health care pot. Add on top of that the fact that SCOTUS said that its unconstitutional for fed govt to basically "force" states into or out of medicaid (by threatening to withhold the large sums of money). If less states opt for this option of expanding state medicaid, then that means less people to be enrolled into medicaid (with current estimates, this could include 17 million new people). If there's less people in the medicaid or private insurance systems (since they opt'ed to pay the penalty), all of that means less people than we originally thought would be paying into the system --> which means that fed govt will likely need to increase more taxes to generate revenue to pay for the provisions of the law.
The end game looks like downward pressure on physician reimbursement (see my MedPAC comment above) and higher taxes for the wealthy. Supposedly more people will be taxed for health care, but when close to the majority of Americans do not pay into the tax system (income, etc due to many many reasons), a disproportionate amount of taxing will fall to the wealthy, who Democratic governments feel can and should pay higher taxes. I try to be as centrist as possible, and look fairly at the arguments, but its certain that taxes on the so called wealthy will increase under the current government. The thing is, doctors in general are in a precarious financial situation. We have huge debts that we carry into our 40's (maybe even 50's) and our main asset to our families is our ability to earn a larger salary, which continues to be eaten away by lower reimbursements and higher taxes.
What can we do? Honestly, becoming adept at the legislative/lobbying process can help and finding ways for the medical societies to band together. We're so busy with everything we're doing that adding another time killer to our schedules is not ideal. But voicing the concerns of physicians to your local lawmakers (your US House of Rep, even state lawmakers) is important, and if done in the right way, can help. Getting rid of the SGR, not taking a 20% cut to reimbursements over 3 yrs (MedPAC), and not increasing taxes are things we could all hope for. Support the medical societies who are helping in these efforts, and if you know of fellow rad onc residents who are interested in these things, encourage them!
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Nice line GFunk! Physicians love the fantasy land and the feeling of sand in their ears. We've got to get involved to discuss the policies and have a seat at the table. There's no healthcare without docs (ahem, although the armies of NPs, CRNAs are coming), and if we focus together, we can help get healthcare to more Americans and mold the policies to make sure that corporate america and the US govt don't run every aspect of our system.
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And this is one of my big problems too! If we all worked French hours (35/hr), with no debt, and minimal liability, I would be ok with decreased reimbursement. But it's not just that! It's the nationalized healthcare without any of the protections! We work twice what docs in Canada, France, etc. work, with all the debt, and none of the legal protections! Further, WE get taxed to death. How long can they squeeze us?
I don't think it's too much to ask to get fair compensation. Every other field does, including nurses, CRNA's etc. Why are THEIR services so valuable, but as doctors, we are worthless? It's like the twighlight zone. It seems like for every other industry, there is money except for healthcare, which is one of the most important ones. Someone please explain that to me.
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And this is why we should be involved. Very involved. It's incredibly easy, especially for residents, to have an impact within your state medical societies. Go for it!
D
deleted4401
Aside: Canadian doctors work hours like us and make just as much money as American doctors, more in some cases. Dirty little secret that nobody seems to know. Just ask them... They removed their salary caps. It's a pretty good gig up North. Looked into work there, but needed a fellowship to even be considered.
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Just curious, why did you need a fellowship to be considered?
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I actually know very well one of the big public health docs in Canada - someone who has spear headed many of the healthcare reforms and has been a physician advocate. Canadian doctors are pretty happy it seems. They have a stable, known income (vs us - unstable, who knows what income will be next yr). The docs there have even gone on strike in the past for reimbursement issues, and they enter into collective bargaining agreements every year. For instance, all of the physicians in Toronto will get together to negotiate fees with the government. Of course, there's a back and forth, and with the glum fiscal outlook right now, the gov't in Canada wants to cut their salaries. However, their physicians are much more cohesive than we are in the US, and that can certainly help when negotiating. In the US, we're basically made up of hundreds of small businesses (of private practices) that are each negotiating separately with the insurance companies, and we basically don't negotiate the set medicare rates at all.
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How do we get politically involved? And when can we as an overall profession make ourselves stronger?
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First of all make sure you are a member of the AMA. Your institution will probably pay for it. Secondly reach out to your state medical society and find out who your resident and fellow section person is- Then get hooked in.
PM me with your state, and I can probably make some connections for you.
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Yes, I find it very ironic when people talk about nationalized health care and salaries, with Canada being a prime example. Internists are making 300k, rads in the 400k range, even with national healthcare! We definitely need to unionize and use their example I think. We need to come together and NEGOTIATE a salary we are happy with, not just accept whatever the gov will give us. I don't see why we have such a double standard here. How do we start this process though-start a petition? Get a facebook page going to get support amongst each other? We gotta do something. Further it's sad but I don't think this helps patients either in the long run. Nothing will change for the better. More taxes, less services.
D
deleted4401
Yeah, I'm trying to figure out how to get involved. Tough thing is AMA supported this health care bill, and I'm not sure if I do or will. They sort of spoke as the "voice of doctors", but don't represent even half of us. What do the State Medical Societies do? I've looked into that, as well, but don't seem to see many events/conferences/activism. Rymd - let me know if you anything for MD/VA/DC.
Yeah - so the big cities in Canada (Toronto/Montreal/Vancover) won't even hire Canadian trained rad-oncs unless they get a fellowship, so they come to the US for a year and then go back. I don't know why. They didn't give a good explanation.
-S
Yeah - so the big cities in Canada (Toronto/Montreal/Vancover) won't even hire Canadian trained rad-oncs unless they get a fellowship, so they come to the US for a year and then go back. I don't know why. They didn't give a good explanation.
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Simul- For you it'll be the YPS- the young physician section. (a ton of acronyms) I'll get you some info after the weekend.
You are right that the AMA supported this health care bill. There is a ton of background, though in the end it was sit at the table, or be eaten. The AMA chose the lesser of two evils (according to some)...
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Yea, I'm looking to get very involved now that residency is (finally) starting.
The AMA is a great potential resource, and we should try to continue to be involved. However, as we all know, the AMA has lost a lot of support among physicians. As the AEI fellow Dr. Scott Gottlieb reflected, historically AMA made 2 "faustian" agreements: 1) They said OK to managed healthcare in the 90's, as long as the AMA could help decide how the pot of money was split up between specialties/physicians. 2) They backed the healthcare bill, but in the end underestimated the fact that a large part of the insurance expansion would be MEDICAID and not the higher paying private insurers. But the AMA will be only as strong as its supporters, so if we know what we want to do, the AMA can be an organization we can work with to get there. However, I must say that during this last year, I've been trying to get more involved with AMA at the national level and the resident and fellows section coordinators have not been as helpful - would appreciate any advice rymd!
State medical societies can be a great venue as well, but depends on the state in terms of resident participation. I'm in a state where the state medical society is VERY strong, with a lot of political clout. I'm definitely hoping to get involved as much as I can...
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The best way to get involved in the AMA is through your state society. The leadership positions within the AMA-RFS are really divided up at the meetings... which you can attend as a delegate from your state society! That really is your key.
Please PM may with any specific questions, we can probably work with ARRO to get you hooked in.
I think its important to be cognizant of the fact that despite some Canadian physicians making more than their US counterparts, that it the exception, not the rule. You will find some physicians taking in $1 million/year in Canada, you will also find that in the US. On average, US physicians (and especially specialists) do out-earn their physician counterparts throughout the world. Physicians also generally fall in the higher income brackets, and thus physicians in Cananda and Europe pay higher taxes than we do.
Here's an article on the issue: http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-other-countries-make/
So, our take home pay is much higher than most anywhere else in the world.
That being said, physician reimbursements are not the reason that US health care costs so much. Physician reimbursements are about 20% of health care costs, and after overhead costs that physicians have to pay, its more like 10%. Cutting physician reimbursement is the "easy" solution, but it isn't an effective solution.
You want to have a voice? Join the AMA. And don't just join the AMA, donate to the AMA's PAC and donate to your specialty society's PAC.
I think the AMA was spot on for supporting PPACA because it achieved 80-90% of our goals despite it not addressing malpractice and having a few other flaws. It will help our patients and the profession of medicine immensely at a relatively low cost. I don't agree with all the ways its paid for either, but it FAR better than what the status quo was before. Talk to the AMA DC office. The AMA changed A LOT to make it much more favorable towards physicians.
Don't support AMA positions? Join the AMA and influence it! The AMA is a democratic organization and the House of Delegates makes policy in a democratic way. The fact is that the AMA is the most influential physician society in the country. If you don't like what's happening, you can take advantage of the AMA's immense influence to change that.
Here's an article on the issue: http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-other-countries-make/
So, our take home pay is much higher than most anywhere else in the world.
That being said, physician reimbursements are not the reason that US health care costs so much. Physician reimbursements are about 20% of health care costs, and after overhead costs that physicians have to pay, its more like 10%. Cutting physician reimbursement is the "easy" solution, but it isn't an effective solution.
You want to have a voice? Join the AMA. And don't just join the AMA, donate to the AMA's PAC and donate to your specialty society's PAC.
I think the AMA was spot on for supporting PPACA because it achieved 80-90% of our goals despite it not addressing malpractice and having a few other flaws. It will help our patients and the profession of medicine immensely at a relatively low cost. I don't agree with all the ways its paid for either, but it FAR better than what the status quo was before. Talk to the AMA DC office. The AMA changed A LOT to make it much more favorable towards physicians.
Don't support AMA positions? Join the AMA and influence it! The AMA is a democratic organization and the House of Delegates makes policy in a democratic way. The fact is that the AMA is the most influential physician society in the country. If you don't like what's happening, you can take advantage of the AMA's immense influence to change that.
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I think the biggest problem is the lack of security in reimbursement and that it keeps changing. Why can't they stick to a certain rate and keep it frozen at that rate, not changing constantly? Also I don't see why our salaries get cut when nurses salaries have increasingly gone up, with nurses in places like Kaiser making 54$/hour, CRNA's making more than many primary care docs, and so forth. Shouldn't those costs be reigned in? Clearly if the pie is getting smaller, it should start where the pie matters less and work up.
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It seems to me that ASTRO, while small, seems to care greatly about the future of radiation oncology and medicine in general. Compared to other societies they seem to have done a decent job at protecting the field as a whole thus far. Perhaps rather than the AMA it would be better to focus funds and time on strengthening ASTROs PAC?
Another huge problem is the fact that hospitals (and other ancillary healthcare facilities) are hiring NPs and PAs to stand in for physicians in order to "cut costs." Using NPs and PAs does indeed save the hospital money, in fact it might even generate more revenue because NPs and PAs call more consults and order more tests/scans... but in the end this substantially drives up overall healthcare costs for the nation as a whole.
*Disclaimer: I have nothing against NPs and PAs when utilized appropriately*
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I'm sorry, I have to take issue with this bit of hyperbole. I think folks out there in the general public (i.e. our patients) would be pretty appalled to hear physicians equating making "only" 150k with martyrdom, especially during a time of economic turmoil. Martyrdom means that you willingly DIE for a greater purpose; pushing a Lexus instead of a Benz hardly qualifies. Let's take a step back and remember that we are incredibly lucky to be physicians, to have a job that makes a meaningful difference in people's lives while being (relatively) well compensated in the process. If the main reason you're in medicine is to make money, you're in the wrong field my friend.
Specialists have traditionally been so well compensated in the US not because they/we bring that much more inherent value to the health care system than other providers, but because our pay has been artificially inflated by an unsustainable fee-for-service model of health care. Does anyone really think that a radiation oncologist making $450k contributes 3 times as much to the public's well being than a primary care doc making $150k? Not to mention the fact that the primary care doc probably works more hours doing what most of us think of as a decidedly crappier job. But, as many have noted, this fee-for-service model is going to end one way or another and specialists' salaries are inevitably going to fall. We can complain about being martyrs, or we can engage in the process of reform to ensure that our patients' needs are being met by the new system. If, when the dust settles on reform, I end up making "only" $150k I will accept the change as a necessary part of a sustainable health care model; I hope most of my colleagues do the same.
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Clearly use of the word "marty" is hyperbole, but I don't think thats reason to dismiss the argument.
However, using 150k as an actual number to debate, I think clearly it is far too low for a residency that takes 5 years post graduation to complete. For those of us with very high student loans, starting a career at 35 with no savings, lost earnings since your early twenties, a small amount of consumer debt and a first mortgage in student loans 150K just isn't worth it, or sustainable.
I agree that we are lucky to be physicians, but it doesn't need to be a crime to want 13 years of education, training and sacrifice to be worth it financially long term. So while I'd like to be able to "accept the change as necessary", it would likely also make it necessary for me to find other employment so that I can afford to pay off loans, send my kids to college and retire someday. Just my 2 cents.
As an addendum: I agree that physicians need to have a greater voice in the changes, and that specialist incomes are going to fall, but knowing that they will fall eventually doesn't mean we need to blindly accept it as necessary when there is SO MUCH other rampant spending that could be cut to the greater benefit of savings in healthcare.
However, using 150k as an actual number to debate, I think clearly it is far too low for a residency that takes 5 years post graduation to complete. For those of us with very high student loans, starting a career at 35 with no savings, lost earnings since your early twenties, a small amount of consumer debt and a first mortgage in student loans 150K just isn't worth it, or sustainable.
I agree that we are lucky to be physicians, but it doesn't need to be a crime to want 13 years of education, training and sacrifice to be worth it financially long term. So while I'd like to be able to "accept the change as necessary", it would likely also make it necessary for me to find other employment so that I can afford to pay off loans, send my kids to college and retire someday. Just my 2 cents.
As an addendum: I agree that physicians need to have a greater voice in the changes, and that specialist incomes are going to fall, but knowing that they will fall eventually doesn't mean we need to blindly accept it as necessary when there is SO MUCH other rampant spending that could be cut to the greater benefit of savings in healthcare.
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I agree with you. But again-why is no one discussing/addressing the fact that nurses are making 80k+ at some places? There are thousands of nurses. why can't their salaries be slashed? That would amount to millions in savings. Why are they paid like this?
And why are residents paid so little? How do we address this? Can we replace the AMA and start a new organization that truly represents us?
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You are so right about this. I mean I still don't understand why our incomes have to fail. Like I have said sooo many times, why aren't nursing/administrator/NP/Pa salaries coming down a great deal first?
Why are we not worth our salaries? Bankers, lawyers, even dentists don't have to deal with this. We are by far one of the most important professions out there!!!
I think we need to unionize and demand fair wages. It seems we keep having intellectual discussions but no actual doing of anything!
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Like others have said, I think its not that 150k is bad money, but for the sacrifice, years of education, hugeee opportunity costs, its not worth it.
Why would it be ok for us to make 150k when nurses make 100k, engineers make 100k, NP/PA make more than that, all with much less effort and cost?
We get paid nothing during residency. We deal with that. Now we don't get paid anything as attendings either?
Are you ok with making the same as the nurses who go home after their shift, or making less than them or CRNA's? I'm not. While I love being a doctor and helping patients I also believe I should be well compensated.
Like Sheldor said, many people are finishing long residencies at mid 30s, with lots of student loans, well over a decade than most people finish training, etc.
Are we saying that nurses and midlevels are more important than us since they get better well compensated then? If there are going to be cuts, then I think the first to be cut are those who are not essential, and to bring wages to a more "normal" distribution. I don't feel that I should be making 150k when the PA makes the same and the nurse makes 100k.
And as I have said before, I personally have no loans, and have a business that makes more than I would make in medicine, and my husband works and makes 6 figs. I would be happy to provide free care and to not turn someone away just because they could not pay. My dad was a doc, in another specialty, and I never saw him turn someone away just because of pay. But at the same time, in general, it does not mean that I don't want to be well compensated.
While my friends were having fun, I was studying my butt off for the MCAT, to get through pre-reqs, to get through med school, and the steps, and so on. I will never get that time back. I have post-poned many things in life, as I'm sure many of you have. And while I don't feel that I need to make astronomical amounts of money to be happy and practice and better the lives of my patients, I also feel that all our sacrifice and value needs to be recognized and paid accordingly. Further, I certainly don't think that I should be making the same as midlevels. No way!!!!
Someone please explain to me why there are nursing making 6 figures, and getting paid 40-60$ an hour, making 100-200k, and why there is money for that but not to pay physicians well? I'm very surprised no one is more upset about this, and why we keep just taking it like there is no tomorrow. Nurses, for example, made as much as some PCPs with overtime pay. They have blocked several bills by the White House to stop overtime pay. I ask-why arent nurses salaried employees like many doctors? How is it ok for docs ot take a pay cut but not to for nurses? Why do they work in shifts, but we work 30 hours straight? If no one is bothered by this, again I am shocked. Cutting nurse overtime would likely save billions. Why are these nurses successful in their attempts to block their salary reductions but us, as doctors and as the ones who are the most essential part of the healthcare structure, continuously lose ground? It boggles my mind.
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The nursing lobby is very powerful. Nursing organizations make political donations and public endorsements of candidates. No one wants to cross them. Physicians just don't organize the same way and there aren't as many of us.
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So we just accept it like idiots and they get paid more than us? It is sad that it seems most physicians just lay down and take it. It is this attitude that allows even nurses and everyone else run over us.
If we even just made nurse salaried like normal "professional" jobs, we would save billions. But I guess no one wants to stand up and say hey there is a problem here. So much for political unionizing for us.
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Thanks to everyone who posted a reply to my (apparently more incendiary than anticipated) post. I think folks make a lot of good points. A couple things in response:
1) I do happen to think that radiation oncologists (and specialists in general) should be paid more than 150k, and that we should continue to be compensated better than nurses, PAs, PCPs, etc. But the world is full of highly educated, bright, hardworking people who contribute a ton to society and don't get paid very well in return. Teachers with master's degrees get paid 40-50k for a challenging job that requires long hours. Physics professors (who are the intellectual "cream of the crop" by most measures and spent >6 years in earning a PhD) get paid 80-100k for similarly hard work. Even within radiation oncology, folks in academia take a substantial pay cut compared to PP yet work way harder. The point is that there is only a weak link between income and intelligence/education years/hard work in society in general, and I don't think we as physicians should feel entitled to a particular salary when so many others out there are doing hard work and good work for much, much less. By all means let's advocate for our ourselves as physicians and ensure that we get a fair slice of the shrinking health care pie, but just take a deep breath and realize that nobody reading this post is going to die in penury as a result of a modest pay cut.
2) Yes, nurses do make a pretty decent salary, especially for length of training and hours worked. But even if nursing salaries were identical to physician salaries, I would still choose to be a physician (even with the long training and long hours), mainly because I think being a doc is a way better job! We get to develop great relationships with patients, tackle complex and interesting clinical questions, and generally get mad respect. No code browns, no sponge baths, no getting orders barked at me by entitled physicians. I wonder- how many people on this thread would rather be a floor nurse than a physician given identical pay? Maybe I'm in the minority on this.....
1) I do happen to think that radiation oncologists (and specialists in general) should be paid more than 150k, and that we should continue to be compensated better than nurses, PAs, PCPs, etc. But the world is full of highly educated, bright, hardworking people who contribute a ton to society and don't get paid very well in return. Teachers with master's degrees get paid 40-50k for a challenging job that requires long hours. Physics professors (who are the intellectual "cream of the crop" by most measures and spent >6 years in earning a PhD) get paid 80-100k for similarly hard work. Even within radiation oncology, folks in academia take a substantial pay cut compared to PP yet work way harder. The point is that there is only a weak link between income and intelligence/education years/hard work in society in general, and I don't think we as physicians should feel entitled to a particular salary when so many others out there are doing hard work and good work for much, much less. By all means let's advocate for our ourselves as physicians and ensure that we get a fair slice of the shrinking health care pie, but just take a deep breath and realize that nobody reading this post is going to die in penury as a result of a modest pay cut.
2) Yes, nurses do make a pretty decent salary, especially for length of training and hours worked. But even if nursing salaries were identical to physician salaries, I would still choose to be a physician (even with the long training and long hours), mainly because I think being a doc is a way better job! We get to develop great relationships with patients, tackle complex and interesting clinical questions, and generally get mad respect. No code browns, no sponge baths, no getting orders barked at me by entitled physicians. I wonder- how many people on this thread would rather be a floor nurse than a physician given identical pay? Maybe I'm in the minority on this.....
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While I love being a physician, if the income is the same, I am not sure I would make the same level of sacrifice to become one if I could likewise be in nursing and same the same, and I think others would agree with me. Also, what does it say if nurses and us make the same? Further, if the healthcare pie is shrinking, and as doctors we are willing to take some pay cut, then the same should be expected of nurses. We can save billions by appropriately reducing nursing/midlevel salaries, and if they are anything of what they claim to be, they should be more than happy to do so. Everyone deserves a fair salary, but I think nurses/mid-levels are taking a huge chunk of the pie for a small amount of what they are worth, and I have a problem with that, especially when it comes to reducing my and my colleagues salary. And while myself/the rest of you guys may not be directly affected, our PCP colleagues are bearing huge brunts of the patient load/care and they are not being well compensated, while NP/nurses are leaving at 3pm and making just as much. If that does not create heartburn to at least some of you, I find that we are failing in this respect as a profession.
While compensation is of course not the #1 most important issue to me in being a physician or even a radiation oncologist, I think it is important to stand up for our profession and not just rollover when we face cuts. However, in an environment where there is growing pressure to cut compensation, I think it can be really helpful to be informed of where we should and can cut even in our own profession and thereby influence policy in an informed way.
For example, in radiation oncology, especially since the introduction of IMRT and Protons, rad onc billing codes have been going through the roof. CMS notices this and they will want to decrease reimbursements for radiation services as a result. ASTRO, however, I think has been largely successful in staving away any cuts. In addition, they try to go for targeted cuts.
Because of the exception to the Stark physician self-referral Law, treating radiation oncology as an ancillary service, urologists throughout the country have been opening up their own prostate cancer radiation centers throughout the country. And due to financial incentives, these prostate cancer patients are being treated with IMRT at rates FAR higher than prostate cancer patients anywhere else. And of course, a pretty strong argument can be made that this is not only being driven by financial incentives, but is also actually hurting some patients because low grade prostate cancer patients that otherwise would not need to be treated are being subjected to radiation at higher rates. ASTRO has been trying to fight this by advocating for federal legislation to close this loophole. This would not only be better for patients, but better for radiation oncologists on several levels:
1) Radiation oncologists (or hospitals/academic medical centers) would own the radiation equipment and not physicians from other specialties
2) IMRT, protons, etc would not be used as often if the current financial incentive for urologists was taken away. This would prevent radiation CMS codes from spiking every year, reducing the chance that CMS will cut our rates across the board.
3) Radiation oncologists would be seen by policymakers in a positive light, given this not only protects patients, but also reduces costs. And being seen in a positive light is always a good thing for the treatment of radiation oncologists in future policy.
However, if we want to get this done, we have to contact our own members of congress to push this issue, donate to ASTRO's PAC, etc.
For example, in radiation oncology, especially since the introduction of IMRT and Protons, rad onc billing codes have been going through the roof. CMS notices this and they will want to decrease reimbursements for radiation services as a result. ASTRO, however, I think has been largely successful in staving away any cuts. In addition, they try to go for targeted cuts.
Because of the exception to the Stark physician self-referral Law, treating radiation oncology as an ancillary service, urologists throughout the country have been opening up their own prostate cancer radiation centers throughout the country. And due to financial incentives, these prostate cancer patients are being treated with IMRT at rates FAR higher than prostate cancer patients anywhere else. And of course, a pretty strong argument can be made that this is not only being driven by financial incentives, but is also actually hurting some patients because low grade prostate cancer patients that otherwise would not need to be treated are being subjected to radiation at higher rates. ASTRO has been trying to fight this by advocating for federal legislation to close this loophole. This would not only be better for patients, but better for radiation oncologists on several levels:
1) Radiation oncologists (or hospitals/academic medical centers) would own the radiation equipment and not physicians from other specialties
2) IMRT, protons, etc would not be used as often if the current financial incentive for urologists was taken away. This would prevent radiation CMS codes from spiking every year, reducing the chance that CMS will cut our rates across the board.
3) Radiation oncologists would be seen by policymakers in a positive light, given this not only protects patients, but also reduces costs. And being seen in a positive light is always a good thing for the treatment of radiation oncologists in future policy.
However, if we want to get this done, we have to contact our own members of congress to push this issue, donate to ASTRO's PAC, etc.
D
deleted4401
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...
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...
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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.
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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...
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BTW, if you are interested in "cradle to grave" government healthcare look at Spain and Greece...
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.
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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?
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deleted4401
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.
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.
