Today, Medicine got 21% less worth it.

[southerndoc]

Yea, why don't we just create a special tax for physicians so physicians can pay off the national debt.

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[deleted87716]

Yea, why don't we just create a special tax for physicians

They've actually tried that in California.

As if I needed another reason to not live in California.

 

[bronx43]

I just laugh at all the whining by doctors. How many of these doctors were whining when Bush was passing his mega-tax cuts for teh rich? You know, which include a lot of doctors?

NOw these same doctors are crying about the Medicare cuts...done because of out of control deficits..that are because of tax cuts...that they enjoyed. And of course, they are too greedy to notice the relationship.

"Oh now! My patients can't get a heart cath every year so that I can put a stent they don't need every year!"

Seriously... people watching out for their own financial interest? What a crock! I mean, doctors are clearly the only people who care when their incomes are slashed generously. In no other profession would people be so narrow-minded...

 

[JaggerPlate]

Seriously... people watching out for their own financial interest?

The nerve of some people.

 

[RGMSU]

For physicians, the quest of looking out for our financial interests should always be balanced with a quest of seeking what is best for the patient. That's why a lot of these threads don't make us look very good. I've oscillated back and forth on the issues, but I honestly think it's looking like healthcare reform would be good for patients, good for primary care physicians, and good for the system.

 

[deleted87716]

Update from Kevin Burke of the AAFP:

Last night, the Senate approved the House-passed bill that extends unemployment benefits, COBRA, the SGR and other payment and benefit provisions. The bill funds Medicare payments to physicians at the current rate until March 31. The President immediately signed the bill.

Meanwhile, the Senate is working on another bill that would extend these same benefits for several more months. In the case of the SGR, payments would be extended to October 1 of this year. This bill will likely pass the Senate later this week or early next and would likely be approved quickly in the House.

Most Senators who voted for the legislation cited the difficulties created for the unemployed, but they also heard from a large number of physicians and that made a significant difference in their sense of urgency.

Another Band-Aid, but better than a cut. Pun intended.

 

[VegaSinclair]

There's another post on here today about Obama's recommendations for health care reform including some Republican pointers including tort reform but also addressing Medicare in that the cuts need to be made in reducing fraud in the system and not in the payouts to doctors. Fraud and scams is what should be cut out of any business model. I blame the Medicare system for making fraud easier over private insurance companies. Although there is still fraud happening with private insurance companies or at the very least errors happening in the mass paperwork doctors have to file to insurance companies.

 

[DoctwoB]

There's another post on here today about Obama's recommendations for health care reform including some Republican pointers including tort reform but also addressing Medicare in that the cuts need to be made in reducing fraud in the system and not in the payouts to doctors. Fraud and scams is what should be cut out of any business model. I blame the Medicare system for making fraud easier over private insurance companies. Although there is still fraud happening with private insurance companies or at the very least errors happening in the mass paperwork doctors have to file to insurance companies.

Tort reform was a $50 million budget to try and pilot some methods of reducing malpractice costs. Better than nothing, but not any sort of sweeping change, at least in the short term.

My personal opinion is that to truly offer effective health care reform, Medicare and medicaid should switch from a FFS model to the PPS type model, where physicians receive a set amount for treating a patient with disorder B and complicating factors X,Y, and Z, and private insurers would likely follow suit.

That way, there is no incentive to offer unnecessary tests or over treat/prescribe disorders. There is the problem of this creates an incentive to offer too little care instead of too much, but this could be fixed by offering bonuses for positive outcomes. Obviously things would be a lot more complicated than what I just described, but overall I think its the FFS model that leads to over-utilization and skyrocketing costs without sky-rocketing phsician compensation. And guess what, if we get costs under control, they'll stop clamoring for physician salary cuts and Medicare cuts.

 

[dynx]

I will say, as a general observation, that docs don't have the ba**s to play hard ball. That's why lawyers, politicians, and businessmen get away with roughing docs up. Docs are very quick to come up with excuses as to why they "can't" defend their profession, which is a big part of the reason we've had the downward slide we've had in the past 20 years.

Amen. I've noticed this and I think its a product of the way we're trained. Everyone is afraid to say **** to the resident abusing them as a medical student, the chief abusing them as an intern then the attending abusing them till they're an attending. When they become an attending...thier the big bad dude when dealing with residents and personel, but when the administration or gov. systems come down on them they revert back to what they were trained to do, bend over and assume the position.

I'm at a big name surgery program, we have a "legendary" PD. Everyone is pretty intimidated by this guy. The administration regularly buttf*cks the program and tough guy yells and screams at the secretary giving him the news them proceeds to, in the words of jim Carey "piss and moan like and impotent jerk then take it up the *****". Dude, walk. Take your patients and tell the hospital to go F*ck itself. I mean if these guys cant muster up the cahones to take it to them when they have mansions and cash for thier childrens children allready banked what hope is there for the rest of us coming out?

 

[RGMSU]

Bingo. That style of "teaching" breeds followers, not leaders. It is indicative of the kind of insecure, narcissistic personalities frequently attracted to medicine and the very a**holes who have given us all a bad name with patients and society in general. If physicians were still respected like they used to be, which they're not, nobody would be talking about pay cuts to physicians. Of course, the old country doctor who would sacrifice himself to make a housecall to a patient he had treated for 30 years is kinda gone isn't it. That's the guy patients used to respect. Luckily, I'm at a medical school that is, for the most part, 100% opposite what you describe. We have a faculty member who emails us the night before a major exam to wish us all well. An MD I might add. Go figure.

 

[tibor75]

Seriously... people watching out for their own financial interest? What a crock! I mean, doctors are clearly the only people who care when their incomes are slashed generously. In no other profession would people be so narrow-minded...

And doctors are among those that get paid more, the more they abuse the system.

Ever wonder why doctors are paid like car repair men? Why are surprised when you take your care for a tune-up, and the shop finds about 10 other things wrong that you "HAVE TO FIX OR YOU'RE SCREWED!"

Private practice docs the same. More procedures, more money. Patient care be damned. I've seen it everywhere.

 

[MOHS_01]

And doctors are among those that get paid more, the more they abuse the system.

Ever wonder why doctors are paid like car repair men? Why are surprised when you take your care for a tune-up, and the shop finds about 10 other things wrong that you "HAVE TO FIX OR YOU'RE SCREWED!"

Private practice docs the same. More procedures, more money. Patient care be damned. I've seen it everywhere.

You are the broken clock's prodigal son........

 

[Dr McSteamy]

^ Relocate. Or, start doing botox and facial peels.

undercut the dermatologists right?

does this work well?


you always hear those poorer folks in miami going to unlicensed people for their cosmetic needs...... injecting bathroom silicone caulking into their skin

i figure as long as you don't charge as much as a derm, you can nab these poor folks away from dangerous unlicensed practitioners

 

[Dr McSteamy]

I just laugh at all the whining by doctors. How many of these doctors were whining when Bush was passing his mega-tax cuts for teh rich? You know, which include a lot of doctors?

NOw these same doctors are crying about the Medicare cuts...done because of out of control deficits..that are because of tax cuts...that they enjoyed. And of course, they are too greedy to notice the relationship.

"Oh now! My patients can't get a heart cath every year so that I can put a stent they don't need every year!"

most doctors fall in the upper middle class, so i don't see how the tax cuts benefited them.

the middle class gets ****ed the most.










back to the OP........... you'll have to adjust.

21% cut means........ see pts 21% faster, cut 21% of your crap, or try to bill for 21% more stuff.
think like the big car companies and cut costs.

 

[RGMSU]

There aren't going to be across the board Medicare cuts that stick. I don't know how many times somebody has to post that before anybody listens to it. Assuming the passage of healthcare reform, Medicare cuts will be targeted toward fraud and waste in an attempt to bend the cost curve down for the future so that across the board cuts in Medicare aren't necessary. There has been some talk of Medicare payments to primary care physicians increasing, and there has also been some suggestion of Medicaid reimbursements increasing.

 

[deleted87716]

undercut the dermatologists right?

Actually, I was replying to MOHS_01, who is a dermatologist.

 

[MOHS_01]

There aren't going to be across the board Medicare cuts that stick. I don't know how many times somebody has to post that before anybody listens to it.

Really? And on what higher authority do you have this information? Until Congress votes to that effect that is quite a mouthful.

Assuming the passage of healthcare reform, Medicare cuts will be targeted toward fraud and waste in an attempt to bend the cost curve down for the future so that across the board cuts in Medicare aren't necessary. There has been some talk of Medicare payments to primary care physicians increasing, and there has also been some suggestion of Medicaid reimbursements increasing.

Someone is a wee bit optimistic (at best). Even the advocates of reform are forced to admit that "fraud and abuse", while not an insignificant number, is insufficient to really make a long term difference. High estimates place the number at $100b. Given that our current public sector expenditures top $1T, this little less that 10% would buy us a year or two at best.... and that's assuming that these assclowns can actually manage to "stomp out fraud and abuse -- and all of it -- something that, if it were so easy, they should have been doing all along).

"Bend the cost curve down"? Really? I'm eagerly -- eagerly -- awaiting your explanation on how this will work. Seriously, I want to hear it.

 

[bronx43]

And doctors are among those that get paid more, the more they abuse the system.

Ever wonder why doctors are paid like car repair men? Why are surprised when you take your care for a tune-up, and the shop finds about 10 other things wrong that you "HAVE TO FIX OR YOU'RE SCREWED!"

Private practice docs the same. More procedures, more money. Patient care be damned. I've seen it everywhere.

Ok, I agree that such practices are wrong, along with playing defensive medicine due to fear of frivolous lawsuits.
I was pointing out the naivety of thinking doctors, or any professional, would sit quietly after a large salary cut.

 

[bronx43]

There aren't going to be across the board Medicare cuts that stick. I don't know how many times somebody has to post that before anybody listens to it. Assuming the passage of healthcare reform, Medicare cuts will be targeted toward fraud and waste in an attempt to bend the cost curve down for the future so that across the board cuts in Medicare aren't necessary. There has been some talk of Medicare payments to primary care physicians increasing, and there has also been some suggestion of Medicaid reimbursements increasing.

Whether or not they stick will depend entirely on how many doctors have the cajones to reject patients and go into the red.

And "targeting fraud and waste" isn't necessarily a foolproof way to cut costs, as you'd have to increase administrative spending. (not to mention the danger of overcompensating for fraud control, and ending up denying real patients care... what do you think was the initial reason for managed care?)

 

[RGMSU]

Really? And on what higher authority do you have this information? Until Congress votes to that effect that is quite a mouthful.



Someone is a wee bit optimistic (at best). Even the advocates of reform are forced to admit that "fraud and abuse", while not an insignificant number, is insufficient to really make a long term difference. High estimates place the number at $100b. Given that our current public sector expenditures top $1T, this little less that 10% would buy us a year or two at best.... and that's assuming that these assclowns can actually manage to "stomp out fraud and abuse -- and all of it -- something that, if it were so easy, they should have been doing all along).

"Bend the cost curve down"? Really? I'm eagerly -- eagerly -- awaiting your explanation on how this will work. Seriously, I want to hear it.

Never did I say politicians could be always trusted. I am not naive. However, I am asking people to make a simple comparison. (A) We can have for certain Medicare cuts across the board in the future because the government is going to run out of money, or (B) we can make an attempt to bring more payers into the system, reduce fraud and waste, increase focus on primary care and prevention, and see what the result will be. One option is certain failure (A). The other is a good faith attempt (B). Now, no one can predict the future. My understanding is that CBO estimates project a bending of the cost curve down. I am not an accountant. We have Harvard economists arguing about this. I'm pretty sure we're not going to figure it out on here. Nothing has been fully passed, of course, but current recommendations on the table (undercover patients) sound like they would be pretty darn effective to me. I have discussed the politics of Medicare cuts. While politicians are not to be trusted, I can assure you that making across the board cuts to Medicare that are going to tick old Granny off would be just about their last option. Politicians like to get reelected, except apparently, Pres. Obama. I am not saying the legislation is perfect, I'm just saying it's the best thing out there. Republicans had control of the White House for 8 years and did nothing to address health care access. They had an opportunity to give suggestions at the recent healthcare summit. Any reasonable suggestions they gave were adopted by the president. Now, they still are against the proposals, even with their own suggestions in them.

Will eliminating waste and fraud alone bend the Medicare healthcare cost curve downward? No. The only thing that will bend that downward is when the baby boomers start passing away. What I am referring to is an overall cost curve stabilization let's say by spreading the costs around more adequately. Insurance company reforms to keep premiums at reasonable levels so that more payers can be brought into the system enables providers to have more sources of revenue and more stable revenue that will make physicians less dependent on any one source. How much money is lost to pro-bono work? How much is the cost of others' healthcare (ie, those with a third party payer) increasing because of those who don't have adequate coverage?

Healthcare costs are increasing because the cost of our technology is exceeding our ability to pay for it. The reasonable options are (A) to attempt to spread the costs out by as much as possible, which is the whole point of everyone being covered by mandate and no free rides; (B) to emphasize cheaper alternatives that will lessen the likelihood of needing more expensive technology for the majority of patients, that is controlling hyperlipidemia and hypertension instead of paying for a coronary bypass; (C) eliminating waste and fraud. Current proposals address these things.

I am a realist. Ideally, there would be more in this bill to disincentivize profligate healthcare spending. Those options were not really considered too effectively. However, expansion of insurance will work to this effect in some respects. They won't just pay for anything, anytime. I fully expect tax rates to increase in the future to pay for entitlement spending of multiple types.

I'm still waiting to hear better ideas from those who oppose the proposed legislation. It is only natural in the face of change to say "no," but sometimes change is needed.

 

[MOHS_01]

Never did I say politicians could be always trusted. I am not naive.

However, I am asking people to make a simple comparison. (A) We can have for certain Medicare cuts across the board in the future because the government is going to run out of money, or (B) we can make an attempt to bring more payers into the system, reduce fraud and waste, increase focus on primary care and prevention, and see what the result will be. One option is certain failure (A). The other is a good faith attempt (B). Now, no one can predict the future. My understanding is that CBO estimates project a bending of the cost curve down. I am not an accountant. We have Harvard economists arguing about this. I'm pretty sure we're not going to figure it out on here.

Medicare is going broke because the dishonest pandering pansy politicians write checks that their asses can't cash. It has been woefully underfunded from its inception and, like SS, is a Ponzi scheme in its base form. Ignorance of the actual funding and structure of MC abounds across the spectrum -- politicos, physicians, the general public, and everyone in between. It is broke because it promises something for less than cost, without limit. The financial ruin of such a system should not catch anyone by surprise and was easily predicted. As for the elite economists who argue on the matter -- I hope that you're not referring to Krugman...... brilliant man, great mind, suffers from a philosophical bias that tends towards faulty premises, which subsequently are backed up by excellent math and beautiful charts... only to come away "proving" a faulty premise and a subsequent failure for the observed to match the predicted. It is these very "elite Harvard economists" who so miserably missed the mark on the severity of the job losses and overstated the impact of stimulus.

At least both the above quoted paragraph as well as the one below demonstrates a (possibly subconscious) understanding of your political biases. Above you state "bring more payers in" -- tax more, basically. Force the citizen, under threat of imprisonment at the barrel of a gun, to pay for a private consumption good that will be paid out to another citizen. Nice.

Nothing has been fully passed, of course, but current recommendations on the table (undercover patients) sound like they would be pretty darn effective to me. I have discussed the politics of Medicare cuts. While politicians are not to be trusted, I can assure you that making across the board cuts to Medicare that are going to tick old Granny off would be just about their last option. Politicians like to get reelected, except apparently, Pres. Obama. I am not saying the legislation is perfect, I'm just saying it's the best thing out there. Republicans had control of the White House for 8 years and did nothing to address health care access. They had an opportunity to give suggestions at the recent healthcare summit. Any reasonable suggestions they gave were adopted by the president. Now, they still are against the proposals, even with their own suggestions in them.

Repubs didn't do ****.....Wah... Actually, they did do **** -- they made matters worse by passing a prescription drug benefit which they chose not to fund. I hope they lose their shirts too this fall. They all suck. As for the proposals on the table currently: they do precious little to rein in costs. The only way to rein in costs in as sustainable manner would be to somehow limit consumption. That involves what most would call rationing; it is the mechanism of the rationing where people differ. The proposals will compound our problems and suck more money into the system.

Will eliminating waste and fraud alone bend the Medicare healthcare cost curve downward? No. The only thing that will bend that downward is when the baby boomers start passing away. What I am referring to is an overall cost curve stabilization let's say by spreading the costs around more adequately. Insurance company reforms to keep premiums at reasonable levels so that more payers can be brought into the system enables providers to have more sources of revenue and more stable revenue that will make physicians less dependent on any one source. How much money is lost to pro-bono work? How much is the cost of others' healthcare (ie, those with a third party payer) increasing because of those who don't have adequate coverage?

There's that "spreading the wealth" mantra again. You do realize that "the cost curve" is a function of the disconnect between payer and consumer, correct? It is both predictable and reproducible -- yet somehow the "solution" to this fire to expand upon the very structure that got us here in the first place? Realist you say?

Healthcare costs are increasing because the cost of our technology is exceeding our ability to pay for it. The reasonable options are (A) to attempt to spread the costs out by as much as possible, which is the whole point of everyone being covered by mandate and no free rides; (B) to emphasize cheaper alternatives that will lessen the likelihood of needing more expensive technology for the majority of patients, that is controlling hyperlipidemia and hypertension instead of paying for a coronary bypass; (C) eliminating waste and fraud. Current proposals address these things.

I am a realist. Ideally, there would be more in this bill to disincentivize profligate healthcare spending. Those options were not really considered too effectively. However, expansion of insurance will work to this effect in some respects. They won't just pay for anything, anytime. I fully expect tax rates to increase in the future to pay for entitlement spending of multiple types.

I'm still waiting to hear better ideas from those who oppose the proposed legislation. It is only natural in the face of change to say "no," but sometimes change is needed.

Want a better idea? The best would be to tell government to GTFO of direct healthcare financing altogether. Even Emanuel's voucher system would be preferable to this central economic planning approach utilized today. If they won't do that, go ahead and create a two tier system so that the public can realize what a travesty this entire social justice experiment and government expansion has been. How about we allow the market at least an opportunity to open up the secretive system we have today and find an answer. This top down central economic planning initiative has never worked and will not work this time.

 

[RabbMD]

Healthcare costs are increasing because the cost of our technology is exceeding our ability to pay for it. The reasonable options are (A) to attempt to spread the costs out by as much as possible, which is the whole point of everyone being covered by mandate and no free rides; (B) to emphasize cheaper alternatives that will lessen the likelihood of needing more expensive technology for the majority of patients, that is controlling hyperlipidemia and hypertension instead of paying for a coronary bypass; (C) eliminating waste and fraud. Current proposals address these things.

Or D). Make people understand that health care is not free. Too many Grandmas that have been demented for 3 years are getting 3 month ICU stays. Too many people who have a knee pain get MRIs because they do not have to pay for it. Doctors may even want to try and convince their patients (and the patients families) not to do these things, but often they do not because they can get sued at any time for delaying treatment, and it does not cost the doctors anything. So why would you risk a lawsuit for "failing to treat" at great cost to yourself to stop a procedure that you thing is 9/10 of the time unnecessary, when going ahead and doing the test/procedure costs you nothing.

How does one reconnect the buyer to the cost of something? GREATLY expand HSAs. Now the problem with that of course is 47% of Americans already pay ZERO income tax, so they would not care about the tax benefits, so you would have to likely make high deductible plans the norm, and subsidize low income people with government provided HSA account funding. Maybe families would think twice about giving demented Grandma the full ICU three PEG course if they had to spend money out of Grandma's HSA account they would inherit otherwise. Look at some of the ideas on physicians for reform or Louis Gohmert HSA based plans.

 

[Grrr]

NOw these same doctors are crying about the Medicare cuts...done because of out of control deficits..that are because of tax cuts...

Really, get a grip. Do you honestly believe the out of control deficits have anything to do with the tax cuts? Look at the federal budget, and the federal revenues, year by year. The causes are a war, an economic recession from easy fed credit, and a HUGE MEDICAL BILL. HUGE.

I really hate to see Medicare Cuts happen but they are inevitible. Nothing is going to bring down the costs of medicine, in my opinion, because we can always spend the money on something useful. Reduce the fraud, implement IT, encourage more preventitive care...I really don't see any evidence that these will impact Medicare expenditures in any meaningful way. Hell, throw in some Tort reform once the dem's are out. It wont be enough.

 

[orangele]

The administration is doing a lovely job saving medical jobs. Is this all part of the new focus on jobs they were talking about recently? I predict this is all much ado about nothing. With the rough election year Dems face already, the last thing they are going to do is let Medicare cuts stick, at least not this type of Medicare cut. Don't everybody start quitting med school or firing people just yet.

How about using all the money we will be saving from the new healthcare plan to pays docs? Yea right........

 

[DoctwoB]

There is only one way to truly bring down medicare costs. Its not by cutting reimbursements (those can only go down so far, and docs will just do more procedures/bill more to compensate), and its not by eliminating bureaucratic waste (while significant, this isn't what's driving cost growth).

Ultimately, to make medicare solvent, we must cut what medicare covers. By reducing coverage for high tech but unproven procedures, and non-palliative end of life care (I've heard many a horror story about patients coded many many times with no hope for meaningful recovery), not only will costs be reduced but the rate of growth will be reduced as well.

Of course, first person to suggest that gets voted out of office. Thats why these things should not be decided by congress but instead by panels of physicians/hospital administrators.

 

[MOHS_01]

There is only one way to truly bring down medicare costs. Its not by cutting reimbursements (those can only go down so far, and docs will just do more procedures/bill more to compensate), and its not by eliminating bureaucratic waste (while significant, this isn't what's driving cost growth).

Ultimately, to make medicare solvent, we must cut what medicare covers. By reducing coverage for high tech but unproven procedures, and non-palliative end of life care (I've heard many a horror story about patients coded many many times with no hope for meaningful recovery), not only will costs be reduced but the rate of growth will be reduced as well.

Of course, first person to suggest that gets voted out of office. Thats why these things should not be decided by congress but instead by panels of physicians/hospital administrators.

I understand what you are saying, but in essence you are really only trading one political bureaucracy for another. Rationing must take place, and this cannot be accomplished via price controls.

The most appealing (read least offensive) way, to me, would be to reduce MC to cover certain services as a coinsurance -- and to allow the private market to fill in the gaps. This may mean supplemental, MC replacement plans, direct contracting, etc. Eliminate all price fixing and allow people to make decisions with regards to what services they want to pay for and at what price.

 

[DoctwoB]

I understand what you are saying, but in essence you are really only trading one political bureaucracy for another. Rationing must take place, and this cannot be accomplished via price controls.

The most appealing (read least offensive) way, to me, would be to reduce MC to cover certain services as a coinsurance -- and to allow the private market to fill in the gaps. This may mean supplemental, MC replacement plans, direct contracting, etc. Eliminate all price fixing and allow people to make decisions with regards to what services they want to pay for and at what price.

There already is the medicare advantage plans, where medicare pays for you to choose a private plan (at a subsidized rate, though the subsidy will soon disappear due to the health care bill). While many feel that medicare advantage offers better service/care than medicare, it still doesn't control costs.

I guess what I'm saying is i don't mind government involvement as a payer, but keep congress out of it. Unintended consequences from congressional interventions gave us our employer based health insurance system, a hodgepodge medicare which covers seniors and ESRD, and an underfunded medicaid. What I feel we need is a congressionally independent organization, a la NHS in england, that has the power to alter medicare/medicaid coverage. We're eventually going to face rationing one way or another, I'd rather it be along a rational $$$/QUAL basis than the irrational politically motivated crap that comes from Congress.

 

[RabbMD]

There already is the medicare advantage plans, where medicare pays for you to choose a private plan (at a subsidized rate, though the subsidy will soon disappear due to the health care bill). While many feel that medicare advantage offers better service/care than medicare, it still doesn't control costs.

I guess what I'm saying is i don't mind government involvement as a payer, but keep congress out of it. Unintended consequences from congressional interventions gave us our employer based health insurance system, a hodgepodge medicare which covers seniors and ESRD, and an underfunded medicaid. What I feel we need is a congressionally independent organization, a la NHS in england, that has the power to alter medicare/medicaid coverage. We're eventually going to face rationing one way or another, I'd rather it be along a rational $$$/QUAL basis than the irrational politically motivated crap that comes from Congress.

Or you could ration by actually making people understand what things cost (which yes requires better price transparency) and allowing them to pay for grandmas PEG and hip replacement out of grandmas HSA if they desire it. If Grandma is competent she decides. If grandma is not, then the family does. We over treat things now, drastically. The main reason we over treat is doctors get paid for the procedure and risk getting sued if they refuse to do a procedure. Patients do not have to pay for it if the patient is elderly on medicare. Who is there to worry about "is it worth it." No one. Central planning is not the answer for that question either. Ask the 50s-80s Soviet farmers how that worked out for something as simple as growing food.

 

[Miykael]

Any updates in regards to the legislation?

 

[JaggerPlate]

http://blogs.do-online.org/dailyreport.php?itemid=42691

This says it's cut and wasn't fixed ... I think. I still can't tell what's up. If someone who isn't so jaded and pissed with every god damn thing related to medicine lately wants to read and explain for me - I'd really appreciate it.

 

[DOCTORSAIB]

I've been posting updates in the ophtho forum. Go there:

http://forums.studentdoctor.net/showthread.php?t=705396

 

[wheatbar]

i'm sorry but i think some posters may be biased because they are coming from areas that are not the most desirable/popular places to live. there is (already) a big saturation in several specialties in areas like la, miami, boston, sf, manhattan, dc, etc. (basically all the areas with the highest metro area gdp). a large percentage of people that want to be doctors want to live in these desirable/popular places (i.e. not some old, decaying former midwestern industrial town). it is difficult in many specialties to find jobs at all in those places because the market is already saturated or they have to accept salaries well below the median to practice there. they are opening or planning to open TONS of new medical schools (particularly on the DO side, who can do MD residencies, but also on the MD side). this will mean new residents will be forced into positions they don't want and medical school graduates will be forced into residencies they don't want (i.e. forced into primary care). the people that are not worried about these medicare (which equals salary) cuts and changes to the profession imposed by government (regarding new cost controls or regulation for procedures/consultations) are going to be in for a rude awakening very soon. i feel particularly bad for premeds...don't get me started with the caribbean grads. absolute job security that is noteworthy in the medical profession for physicians is never guaranteed, and these changes are eating away at it (look what has happened to the legal profession -- there are TONS of unemployed lawyers and unless you are top 5-10% of your class or top 1/2 at a t-14 or go to harvard/stanford/yale good lucking find any job in the legal profession let alone one that will pay back your loans). this is because they opened tons of new law schools! these increases in medical school slots and openings of new medical schools are being pushed by mainstream media stories about doctor shortages not actual doctors! the problem is not that there are not enough physicians - the problem is that there are not enough physicians that want to live in sh*tty or rural/middle of nowhere areas; that will continue even if there are more doctors.

 

[wheatbar]

RGMSU, i think the fact that you are coming from texas, where there is still lots of opportunities for new physicians, may influence the way you see things.

 

[bronx43]

i'm sorry but i think some posters may be biased because they are coming from areas that are not the most desirable/popular places to live. there is (already) a big saturation in several specialties in areas like la, miami, boston, sf, manhattan, dc, etc. (basically all the areas with the highest metro area gdp). a large percentage of people that want to be doctors want to live in these desirable/popular places (i.e. not some old, decaying former midwestern industrial town). it is difficult in many specialties to find jobs at all in those places because the market is already saturated or they have to accept salaries well below the median to practice there. they are opening or planning to open TONS of new medical schools (particularly on the DO side, who can do MD residencies, but also on the MD side). this will mean new residents will be forced into positions they don't want and medical school graduates will be forced into residencies they don't want (i.e. forced into primary care). the people that are not worried about these medicare (which equals salary) cuts and changes to the profession imposed by government (regarding new cost controls or regulation for procedures/consultations) are going to be in for a rude awakening very soon. i feel particularly bad for premeds...don't get me started with the caribbean grads. absolute job security that is noteworthy in the medical profession for physicians is never guaranteed, and these changes are eating away at it (look what has happened to the legal profession -- there are TONS of unemployed lawyers and unless you are top 5-10% of your class or top 1/2 at a t-14 or go to harvard/stanford/yale good lucking find any job in the legal profession let alone one that will pay back your loans). this is because they opened tons of new law schools! these increases in medical school slots and openings of new medical schools are being pushed by mainstream media stories about doctor shortages not actual doctors! the problem is not that there are not enough physicians - the problem is that there are not enough physicians that want to live in sh*tty or rural/middle of nowhere areas; that will continue even if there are more doctors.

Actually, the mere fact that there is a shortage of doctors in sh*tty areas means that there is an actual overall shortage of doctors. New grads certainly won't like it, but when you're 200k in debt and have a family to support, and the only job you can find is in the middle of nowhere, you don't think twice.

 

[MOHS_01]

Actually, the mere fact that there is a shortage of doctors in sh*tty areas means that there is an actual overall shortage of doctors. New grads certainly won't like it, but when you're 200k in debt and have a family to support, and the only job you can find is in the middle of nowhere, you don't think twice.

How unbelievably and incredibly wrong. Econ 001 FAIL. That is tantamount to saying "the mere fact that some people remain poor means that there is an actual shortage of dollars in the system". Incredibly wrong...

 

[bronx43]

How unbelievably and incredibly wrong. Econ 001 FAIL. That is tantamount to saying "the mere fact that some people remain poor means that there is an actual shortage of dollars in the system". Incredibly wrong...

Uh... no. That analogy fails hard. There's an absolute limitation to market saturation, after which supply will trickle down to less desirable locations. Are you seriously going to argue that increasing the number of physicians won't lead to increased physician coverage in less desirable locales?

 

[MOHS_01]

Uh... no. That analogy fails hard. There's an absolute limitation to market saturation, after which supply will trickle down to less desirable locations. Are you seriously going to argue that increasing the number of physicians won't lead to increased physician coverage in less desirable locales?

Ummm.. yes. I will argue that. I welcome you to find any example of a correction of distribution problems in response to an increase in the number of providers. Please let us all know when you do -- for I have been a student of this very phenomenon since the mid 90's and I can promise you that, despite state medical societies and medical schools' best efforts, it does not work in practice.

 

[bronx43]

Ummm.. yes. I will argue that. I welcome you to find any example of a correction of distribution problems in response to an increase in the number of providers. Please let us all know when you do -- for I have been a student of this very phenomenon since the mid 90's and I can promise you that, despite state medical societies and medical schools' best efforts, it does not work in practice.

I can't provide an example, simply because saturation hasn't occurred. But, logically speaking, with an absolute and unchanging financial burden for providers, there must be a point of saturation within desirable locations (we'll simplify it to desirable/non-desirable as the dichotomy), where they won't be able to sustain said financial burden. In that scenario, the supply of providers will inevitably spill over to non-desirably locations.

Explain what happens if medical schools were to expand enrollment by 50%. What will those future graduates do when the only job available is in the boonies?

 

[MOHS_01]

I understand where you are coming from -- I'm just pointing out that, for whatever reason, this is not observed in reality. Say's law? Perhaps it does play some role in the matter given the disconnect between the consumer and the point of sale payer.... The reasons for the "less than perfect" distribution are many -- payer mix is often worse in non-metropolitan areas, population densities are insufficient to support specialty and subspecialty care, PCP's do not have a desirable support network, fewer opportunities for the children of the provider, etc. Why are there not Montessori schools in rural communities? Dance studios? MMA training facilities? BMW or Mercedes dealerships? There are real and fundamental reasons behind these observations -- they are not the result of chance.

I would also suggest that, when studying on this distribution:volume of providers dilemma, one should pay particular attention to the change in the number of providers over time and the per capita distribution; if anything, the problem has worsened with the rather significant expansion in the absolute number of physicians that has taken place over the last three decades or so.

Another fundamental question is "should we flood the market with providers?" There are many, many reasons why the answer to this should be a resounding "NO"....

 

[bronx43]

I understand where you are coming from -- I'm just pointing out that, for whatever reason, this is not observed in reality. Say's law? Perhaps it does play some role in the matter given the disconnect between the consumer and the point of sale payer.... The reasons for the "less than perfect" distribution are many -- payer mix is often worse in non-metropolitan areas, population densities are insufficient to support specialty and subspecialty care, PCP's do not have a desirable support network, fewer opportunities for the children of the provider, etc. Why are there not Montessori schools in rural communities? Dance studios? MMA training facilities? BMW or Mercedes dealerships? There are real and fundamental reasons behind these observations -- they are not the result of chance.

I would also suggest that, when studying on this distribution:volume of providers dilemma, one should pay particular attention to the change in the number of providers over time and the per capita distribution; if anything, the problem has worsened with the rather significant expansion in the absolute number of physicians that has taken place over the last three decades or so.

Another fundamental question is "should we flood the market with providers?" There are many, many reasons why the answer to this should be a resounding "NO"....

Flooding the market with providers would certainly be the heavy handed approach to correcting distribution problems, and one that, like you said, would likely cause more problems than solutions.

But, just by looking around at job opportunities, it seems that many of the first tier markets are already showing signs of saturation. There simply aren't many jobs in NYC, LA, Boston, DC - let alone well paying ones. This is, of course, also variable amongst specialties, though the overall trend is similar. Out of all the residents I know who are close to finishing up, there aren't more than a small handful going to a major metropolitan area, and those who did took a pretty hefty pay cut. This is merely anecdotal, but coupled with the actual job locations I found, it only leads me to believe that the trickling effect is already taking place.

 

[MOHS_01]

.

 

[bronx43]

I believe that you are looking at the data and drawing a less than perfect conclusion. The physician pool for many specialties is already beyond the point of saturation -- spend a few moments in the (largely) hospital dependent specialty forums to get a glimpse of what I mean. Start with pathology. Then look at derm -- the supposed golden egg -- and look at the number of questions about jobs, the job market, etc. These questions were not even asked just five years ago. I wish that I still had the data on raw numbers of physicians over time, docs per capita over time, etc, but I lost all of that one fateful night of thunderstorms........ so we'll go with the anecdotal: at least in KY -- somewhere that I would not consider a MD Mecca -- we have greatly increased the number of providers over the short period of time that I have been cognizant of the process. At the same time, per physician productivity has escalated such that more volumes are being provided by more providers.... so why again is there any question as to why we have increased expenditures again? Anyway, the point is that we have seen an increase in the number of providers, even in this forsaken rural state, yet we continue to hear the same complaints of maldistribution. It is for cause, people -- and flooding the market will not change these reasons.


You want a better "distribution" -- send oil to $1000 dollars/barrel and consolidate the population into denser centers. That's about the only way that I have been able to arrive at that does not result in "true" healthcare cost inflation for those in rural areas (you have to create an increased cost burden elsewhere to incentivize the changes desired).

I don't think I completely understand what you're saying. If rural KY is seeing an increase in provider density, then why is there still a perception of maldistribution? Is it because demand for services out-paces the growth rate of providers?

 

[MOHS_01]

.

 

[bronx43]

It's because the metric being employed - the per capita physician density - continues to demonstrate a similar distribution irrespective of absolute numbers. A better metric would be physician wait times, overall access to care, etc. Worse yet, these statistics fail to tell the whole story; part-time satellite clinics (the most viable way to address any specialty / subspecialty service shortage) are not included in the measure. It is also important to recognize that we should not be addressing statistical models of what represents some arbitrary "idealized ratio"; that is a wholly inappropriate end point. We should focus on the desires and demands of the community -- which often will not correlate with any centrally determined scenario. The mere placement of a physician in a community based upon any statistically derived perceived need does not absolutely eventuate in a busy provider; in fact, the converse is often found to be true -- hence one of the major causes of the high physician turnover rate in rural -- or even small metropolitan areas. It is not always a question of community need so much as it is a question of population density and the community's willingness to seek care locally -- thus the drivers of volume. There exists this belief -- that is stubbornly persistent -- that quality care cannot be obtained locally, one must travel to receive it. Expanding the physician provider pool to frankly stupid levels will do precious little -- if anything -- to address this matter.... and any attempt to do so comes at great cost.

Interesting. This is the first time I've heard that rural physician shortages are maintained, at least in part, by local market demands and perceptions, and not entirely by preferential distribution of providers.

But, back to job availability. From what I've seen (can't find any real data on this topic), there seems to be a lacking in major metropolitan physician positions. Do you agree with this, or have you seen different?

 

[MOHS_01]

Cannot say with any authority as I would rather be kicked in the 'nads than work in a major metro..... but I will say this: most of our policy makers have only an academic interest and understanding of the dynamics of rural health care delivery. They study it as scientists studying a rat. This, in large part, is why the proposed changes result in little demonstrable improvement.

 

[wheatbar]

if physicians and younger physicians want to protect the job security, salaries, and specialty/location choice that is eroding very quickly even today as a result of media stories regarding physician shortages (and cost controls/OBAMACARE), they need to take a stand now against AOA/AMA unless they want to end up like Germany or the legal profession. These stories are by people that do not understand the realities of the job market for current and future residents. people need to act now to make sure this HUGE EXPANSION in the number of medical school spots (DO especially; and slowly but surely residency spots as well) does not destroy the profession. all of these lax and academic responses to what anyone who looks at the data can see are MAJOR CHANGES in the works to the profession for people that are currently in it or want to be in it is a huge problem. obviously there are other reasons for the expansion/oversupply in the number of law students but a major part of it if you look back was media articles about there being a shortage of attorneys (particularly in public interest) believe it or not -- look how that turned out. it's so great that we have a poster who understands these issues (MOHS_01) so that he/she can explain it to bronx43, whose reaction suggests a lack of an understanding of market conditions in undesireable/sh**ty areas.

 

[bronx43]

if physicians and younger physicians want to protect the job security, salaries, and specialty/location choice that is eroding very quickly even today as a result of media stories regarding physician shortages (and cost controls/OBAMACARE), they need to take a stand now against AOA/AMA unless they want to end up like Germany or the legal profession. These stories are by people that do not understand the realities of the job market for current and future residents. people need to act now to make sure this HUGE EXPANSION in the number of medical school spots (DO especially; and slowly but surely residency spots as well) does not destroy the profession. all of these lax and academic responses to what anyone who looks at the data can see are MAJOR CHANGES in the works to the profession for people that are currently in it or want to be in it is a huge problem. obviously there are other reasons for the expansion/oversupply in the number of law students but a major part of it if you look back was media articles about there being a shortage of attorneys (particularly in public interest) believe it or not -- look how that turned out. it's so great that we have a poster who understands these issues (MOHS_01) so that he/she can explain it to bronx43, whose reaction suggests a lack of an understanding of market conditions in undesireable/sh**ty areas.

I still need to see statistics to be completely convinced that increased numbers don't result in any level of redistribution. But, either way, expanding supply of primary care providers, regardless of redistribution, will lead to an increase in the absolute number of providers in any area. Therefore, in a vacuum, it would work to alleviate shortages. In the real world, however, it might lead to more problems than solutions.