27% medicare cut

[dyk343]

* The Democrats would also extend unemployment benefits for a year, extend farm subsidies for a year, and avoid a 27% cut in Medicare payments to doctors

I was under the impression that this was already a done deal as a part of Obama care? I admit I am not as up on the issues as I should be but if I am reading this right... and it goes through the medicare cuts will not happen (for now)?

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[dyk343]

Well I guess that's a big "nevermind"

 

[diabeticfootdr]

Well I guess that's a big "nevermind"

The 26.5% cut to providers was avoided in last night's fiscal cliff bill. This is being paid for, in part, by cutting reimbursements to hospitals, pharmacies, and dialysis clinics.

However, there is still a 2% cut for providers as part of sequestration that was put off for another 2 months, to the next self-inflicted (congressionally-inflicted) fiscal cliff.

Interestingly, doctors in the House of Representatives overwhelmingly voted against the bill 12-3.

 

[dyk343]

Thanks for the reply.

27% is a lot of income. Especially with the amount of loans and increasing interest rates students/new grads are and facing. I was starting to get pretty nervous, although if the hospitals take a hit..... so will doctors.

 

[pacpod]

Interestingly, doctors in the House of Representatives overwhelmingly voted against the bill 12-3.

Interesting point, thanks for your input!

 

[Feli]

Those crafty democrats once again "fixed" the nation's health care pilon fracture with scotch tape, sutured it with paper clips, and then casted it all up with rags. Let's see how that works out.

Health care costs too much because patients expect too much, and also because docs over-utilize (overpriced) implants and technology... especially "new and advanced" imaging, new Rx, and surgical implants when basic ones will do just fine. But hey, gotta keep up with the "standard of care" and feed the almighty doctor egos with 3D scanning, amniotic fluid for plantar plate repair (wtf?), and all kinds of other hocus pocus that costs trillions... if you are not doing the latest and greatest high tech medicine, your colleagues might be more up-to-date than you... and then the lawyers might get ya, right? Right?

Wrong. The fact of the matter is that anatomy does NOT change. The proper physician H&P, use of common sense, and swallowing your ego that wants to use bullspit toys like virtual 5G neon MRI or space age 6 component total ankle implants is just too much for most guys to ever comprehend. Even worse, the fearful "well, I just gotta do X like everybody else or I could get sued" makes the highly necessary art of "plain Jane" surgery get lost nowadays. Well, it's necessary assuming we as doctors want to do our part to avoid crushing an economy already crippled by entitlement and the 47%'s bad "what can the government do for me" posture. Self reliance and self motivation that fueled winning the world wars and the industrial revolution is an increasingly lost American quality. All great empires crumble from within, and that is sad but true. Sad but true.

Consider me a Renaissance man, but that old world craft of cost effective 20-30 clinic patients per day diagnostic medicine and then doing surgery with some k-wires and a non-cannulated, non-locking, non-titanium fragment repair set for 95% of cases is EXACTLY what you will probably find me performing for an acceptable cash for service fee in a decade or two... no ObamaCare accepted. If patients prefer to gamble on using their ObamaCare providers, then I will gladly refer them to dozens of overworked colleagues who are trying to see 80+ patients per day, booked out months for surgery and unable to plan or follow up on those surgeries very well due to overbooking, and basically doing quasi-haphazard work to avoid having the whip cracked on them. Everyone has choices, and one of the mods should make a choice to stick this post, please.

*ducks and covers for the wrath of liberial DPMs saying I'm a greedy SOB who should see 100 MedicAid pts per day and enjoy it*

 

[air bud]

Those crafty democrats once again "fixed" the nation's health care pilon fracture with scotch tape, sutured it with paper clips, and then casted it all up with rags. Let's see how that works out.

Health care costs too much because patients expect too much, and also because docs over-utilize (overpriced) implants and technology... especially "new and advanced" imaging, new Rx, and surgical implants when basic ones will do just fine. But hey, gotta keep up with the "standard of care" and feed the almighty doctor egos with 3D scanning, amniotic fluid for plantar plate repair (wtf?), and all kinds of other hocus pocus that costs trillions... if you are not doing the latest and greatest high tech medicine, your colleagues might be more up-to-date than you... and then the lawyers might get ya, right? Right?

Wrong. The fact of the matter is that anatomy does NOT change. The proper physician H&P, use of common sense, and swallowing your ego that wants to use bullspit toys like virtual 5G neon MRI or space age 6 component total ankle implants is just too much for most guys to ever comprehend. Even worse, the fearful "well, I just gotta do X like everybody else or I could get sued" makes the highly necessary art of "plain Jane" surgery get lost nowadays. Well, it's necessary assuming we as doctors want to do our part to avoid crushing an economy already crippled by entitlement and the 47%'s bad "what can the government do for me" posture. Self reliance and self motivation that fueled winning the world wars and the industrial revolution is an increasingly lost American quality. All great empires crumble from within, and that is sad but true. Sad but true.

Consider me a Renaissance man, but that old world craft of cost effective 20-30 clinic patients per day diagnostic medicine and then doing surgery with some k-wires and a non-cannulated, non-locking, non-titanium fragment repair set for 95% of cases is EXACTLY what you will probably find me performing for an acceptable cash for service fee in a decade or two... no ObamaCare accepted. If patients prefer to gamble on using their ObamaCare providers, then I will gladly refer them to dozens of overworked colleagues who are trying to see 80+ patients per day, booked out months for surgery and unable to plan or follow up on those surgeries very well due to overbooking, and basically doing quasi-haphazard work to avoid having the whip cracked on them. Everyone has choices, and one of the mods should make a choice to stick this post, please.

*ducks and covers for the wrath of liberial DPMs saying I'm a greedy SOB who should see 100 MedicAid pts per day and enjoy it*

I saw those at a program. They literally implant themselves. You just open the skin, open the package ---- boom, ankle replaced. It even closes the skin. Why would you not use it?

On a more serious note, I agree with a lot of what you said. At one program I remember seeing a guy take out a silastic implant that he put in 2 years before ---- and then put in another silastic implant. It was my first experience with the guy and has shaped my perception since then. This guy would use they newest and fanciest thing every time. Another guy I saw stuffed a void with bone chips and tons of stem cell filler - then proceeded to wash it out numerous times and do other stuff, then wash again. There are lots of things you see as a student that you question (to yourself of course), it is good to remember and learn from.
Looking back on the programs that I liked and the attendings I liked, they generally tended to be screw and plate guys. Basic screws, basic plates. Of course I am still a student, so I havent used nor seen followups of patients. I am still trying to figure out how I feel about things like smart toes/hammerlocks, bone pins, specific plates (a kouts plate for example), types of bone grafts/supplements etc.

 

[Feli]

...Looking back on the programs that I liked and the attendings I liked, they generally tended to be screw and plate guys. Basic screws, basic plates. Of course I am still a student, so I havent used nor seen followups of patients. I am still trying to figure out how I feel about things like smart toes/hammerlocks, bone pins, specific plates (a kouts plate for example), types of bone grafts/supplements etc.

0.62 k-wire = $5 or $10
SmartToe or similar competitor products = $500+

Do the math, bro. "Fancy surgery" with expensive implants is for egos... it's the fantasy that the surgeon is somehow more cutting edge and better than the rest who don't use that brand new implant just released last month or the most expensive metal alloy implant. Also, it's the fantasy that he's somehow a better surgeon since he's using "what the pros use" (aka what surgeons who are paid consultants for the implant industry). Newsflash: good technology in implants will never compensate for poor surgical technique. Take that to the bank (or the malpractice lawyer?).

...Here'a a flatfoot + forefoot from a couple weeks ago (gastroc, MCDO, Lapidus, Akin, Weil, AD2, AP5, Tailors). You will notice the buried k-wire in the 2nd toe desis site. That hammertoe was 100% done skin to skin in about as fast as it may have taken a rep to go get a SmartToe out of the cooler and the circulator nurse to write down the implant number. I don't even have to mention how much easier it is for the hospital biller to get the insurance to pay for the $5 wire versus hundreds for the SmartToe. Can anyone reasonably tell me I'd get the patient dramatically better results if I'd used a SmartToe, Akin lock plate, Lapidus lock plate, Kouts step plate, put some Graftjacket in where I took out the Tailor bunion bursa, etc etc... maybe used a fancy pants plantar plate repair kit or done my gastroc endoscopic and used all those disposable instruments (maybe I could even damage the $100k endoscope set)? You can't.

...I will say that there are a few niche implants where I think the cost is justified due to time savings in the OR (ie some cannulated screws) or time savings in that the patient truly can recover and go back to work faster (ie stronger Haglund surgery anchor system or lock plates for unstable or complex fracture patterns). Not too many, however.

And for goodness sake, please please realize that stainless steel is only about 1/3 the cost of titanium and non-lock plates are only about 1/4 the cost of nonlock (therefore a stainless nonlock plate is probably <1/10 the cost of titanium locking). The reps will never get you a straight answer on costs, and the hospitals have a tough time themselves. If your surgical principles and your training is good, the frag sets, k-wires, and decent assistant team is really all you need for the vast vast majority of cases. The anatomy doesn't change.

 

[air bud]

0.62 k-wire = $5 or $10
SmartToe or similar competitor products = $500+

Do the math, bro. "Fancy surgery" with expensive implants is for egos... it's the fantasy that the surgeon is somehow more cutting edge and better than the rest who don't use that brand new implant just released last month or the most expensive metal alloy implant. Also, it's the fantasy that he's somehow a better surgeon since he's using "what the pros use" (aka what surgeons who are paid consultants for the implant industry). Newsflash: good technology in implants will never compensate for poor surgical technique. Take that to the bank (or the malpractice lawyer?).

...Here'a a flatfoot + forefoot from a couple weeks ago (gastroc, MCDO, Lapidus, Akin, Weil, AD2, AP5, Tailors). You will notice the buried k-wire in the 2nd toe desis site. That hammertoe was 100% done skin to skin in about as fast as it may have taken a rep to go get a SmartToe out of the cooler and the circulator nurse to write down the implant number. I don't even have to mention how much easier it is for the hospital biller to get the insurance to pay for the $5 wire versus hundreds for the SmartToe. Can anyone reasonably tell me I'd get the patient dramatically better results if I'd used a SmartToe, Akin lock plate, Lapidus lock plate, Kouts step plate, put some Graftjacket in where I took out the Tailor bunion bursa, etc etc... maybe used a fancy pants plantar plate repair kit or done my gastroc endoscopic and used all those disposable instruments (maybe I could even damage the $100k endoscope set)? You can't.

...I will say that there are a few niche implants where I think the cost is justified due to time savings in the OR (ie some cannulated screws) or time savings in that the patient truly can recover and go back to work faster (ie stronger Haglund surgery anchor system or lock plates for unstable or complex fracture patterns). Not too many, however.

And for goodness sake, please please realize that stainless steel is only about 1/3 the cost of titanium and non-lock plates are only about 1/4 the cost of nonlock (therefore a stainless nonlock plate is probably <1/10 the cost of titanium locking). The reps will never get you a straight answer on costs, and the hospitals have a tough time themselves. If your surgical principles and your training is good, the frag sets, k-wires, and decent assistant team is really all you need for the vast vast majority of cases. The anatomy doesn't change.

 

[dyk343]

Don't worry. The government will just mint a couple trillion dollar coins and we will be out of this mess.

 

[NatCh]

I like your application of the Kirschner wire, Feli. I do something similar but a little bit different. I cross the DIPJ, bend the tip and bury it subcutaneous. I can remove the K wire in the future as a quick office procedure under local anesthesia if I want to or leave it in place to stabilize both joints.

 

[ManUnderFire]

The 26.5% cut to providers was avoided in last night's fiscal cliff bill. This is being paid for, in part, by cutting reimbursements to hospitals, pharmacies, and dialysis clinics.

However, there is still a 2% cut for providers as part of sequestration that was put off for another 2 months, to the next self-inflicted (congressionally-inflicted) fiscal cliff.

Interestingly, doctors in the House of Representatives overwhelmingly voted against the bill 12-3.

So this subsequently affects hospital staff and providers? Will hospital providers be doubly affected by hospital cuts and provider cuts? Do any of these cuts have a direct effect on residency positions?

 

[diabeticfootdr]

So this subsequently affects hospital staff and providers? Will hospital providers be doubly affected by hospital cuts and provider cuts? Do any of these cuts have a direct effect on residency positions?

The fiscal cliff deal keeps the Medicare reimbursement rate for providers steady. They won't be affected until possibly March, when the sequestration takes effect, calling for across the board cuts to many government programs, including a 2% Medicare cut to hospitals and providers.

Right now, GME funding is not affected. There is talk that GME funding will be on the table during negotiations to avoid sequestration and to raise the debt ceiling. If GME is cut, it could have a drastic impact on residencies (and hospitals).

 

[ManUnderFire]

right on the money...(no pun intended)

http://www.ama-assn.org/amednews/2013/01/07/gvl10107.htm

 

[PikminOC]

Those crafty democrats once again "fixed" the nation's health care pilon fracture with scotch tape, sutured it with paper clips, and then casted it all up with rags. Let's see how that works out.

Health care costs too much because patients expect too much, and also because docs over-utilize (overpriced) implants and technology... especially "new and advanced" imaging, new Rx, and surgical implants when basic ones will do just fine. But hey, gotta keep up with the "standard of care" and feed the almighty doctor egos with 3D scanning, amniotic fluid for plantar plate repair (wtf?), and all kinds of other hocus pocus that costs trillions... if you are not doing the latest and greatest high tech medicine, your colleagues might be more up-to-date than you... and then the lawyers might get ya, right? Right?

Wrong. The fact of the matter is that anatomy does NOT change. The proper physician H&P, use of common sense, and swallowing your ego that wants to use bullspit toys like virtual 5G neon MRI or space age 6 component total ankle implants is just too much for most guys to ever comprehend. Even worse, the fearful "well, I just gotta do X like everybody else or I could get sued" makes the highly necessary art of "plain Jane" surgery get lost nowadays. Well, it's necessary assuming we as doctors want to do our part to avoid crushing an economy already crippled by entitlement and the 47%'s bad "what can the government do for me" posture. Self reliance and self motivation that fueled winning the world wars and the industrial revolution is an increasingly lost American quality. All great empires crumble from within, and that is sad but true. Sad but true.

Consider me a Renaissance man, but that old world craft of cost effective 20-30 clinic patients per day diagnostic medicine and then doing surgery with some k-wires and a non-cannulated, non-locking, non-titanium fragment repair set for 95% of cases is EXACTLY what you will probably find me performing for an acceptable cash for service fee in a decade or two... no ObamaCare accepted. If patients prefer to gamble on using their ObamaCare providers, then I will gladly refer them to dozens of overworked colleagues who are trying to see 80+ patients per day, booked out months for surgery and unable to plan or follow up on those surgeries very well due to overbooking, and basically doing quasi-haphazard work to avoid having the whip cracked on them. Everyone has choices, and one of the mods should make a choice to stick this post, please.

*ducks and covers for the wrath of liberial DPMs saying I'm a greedy SOB who should see 100 MedicAid pts per day and enjoy it*

It's not about 'swallowing our egos'. It's all about CYA, and it has to be as long as there is no tort reform.

Our malpractice rates are ridiculous as is. People are leaving states like IL because they can't afford malpractice and the lawyers actually petitioned and obtained MORE money on contingency cases.

IL is just one example, but they are also not paying their medicaid bills. Docs have to wait 6 months or more for reimbursement.

 

[Feli]

It's not about 'swallowing our egos'. It's all about CYA, and it has to be as long as there is no tort reform.

Our malpractice rates are ridiculous as is. People are leaving states like IL because they can't afford malpractice and the lawyers actually petitioned and obtained MORE money on contingency cases.

IL is just one example, but they are also not paying their medicaid bills. Docs have to wait 6 months or more for reimbursement.

It sounds like you and some of those IL guys need better investment and legal advice then. If that doesn't work for you, move to a republican state, go cash pay practice, and help people who actually want to contribute to society. You can always do as much or as little pro bono cases as you choose

Let's face it, world war 3 has already started. 2008 election was never a black and a white thing. It was a rich and a poor thing. It always has been, and it always will be. It's physicians versus lawyers. They can take away our freedom or our money, but we could make sure they die a painful death (both physically and conscientiously). Who wins? Well, I'm not so sure it has to be an "I win, you must lose" affair. I'd like to think that our race's greatest tool is the human mind.

...As a Catholic who modifies his religion's historic customs to fit his own needs (see the shows Nip/Tuck or Sopranos or the movie 300), I know what Catholicism is (a proven model to positively model human social behavior... and the most successful business in the world) and what it isn't (a panacea).

I don't know how I would've felt about a Mormon president (newer religion and some questionable philosophies, and way too much pressure for their followers to leech govt services IMO, but that's JMO). I get what they were trying to do by writing to mix Christianity and Muslim, but it's overly restrictive and therefore against American ideals IMO. But that's a better discussion for happy hour or a golf outing than online. At any rate, I have great respect for Mitt Romney as a man for seriously considering American presidency for all the right reasons... not just doing it as a puppet for ego and financial gains (ie Obama family). I also loved 'The 7 Habits of Highly Effective People.' All of the models work, but you have to use what suits you. Personally, as I noted above, I'm a Renaissance man. That's what you get when you have heritage from a romance country... and a bride who's the same.

In all seriousness, there are no easy answers. However, when health care is America's biggest expenditure, something has to give. I'm not giving up my money, and doctors going 'on strike' would be bargaining with human lives (aka terrorism). Therefore, cooler heads will prevail. I know it, and I will do my part to help by doing cost effective surgery. If I get sued, I get sued. If the corrupt attorneys (aka democrats) can live with themselves for taking away from me, then at least I will have my integrity. Think Mel Gibson in Braveheart, man: they can take my house, but they can never take my freedom. Personally, I've always kinda liked camping.

 

[MaxillofacialMN]

Ya'll should have voted for the only MD running for president: Ron Paul.

 

[Feli]

Ya'll should have voted for the only MD running for president: Ron Paul.

Probably would've, and I will absolutely vote 3rd party in the future. I think a Pitt/Jolie ticket or a Jenna Jameson/Peter North would potentially do well. Not even joking. Us Americans love our sex and celebs. They are the only ones who can win 3rd party without more money than I think any one person could ever feasibly make in a lifetime.

For 2012, I thought Mitt Romney had a shot, so I supported him. I guess I was bamboozled by "the game" just like millions of ppl. Marketing is the ultimate mind control, isn't it?

 

[MaxillofacialMN]

Probably would've, and I will absolutely vote 3rd party in the future. I think a Pitt/Jolie ticket or a Jenna Jameson/Peter North would potentially do well. Not even joking. Us Americans love our sex and celebs. They are the only ones who can win 3rd party without more money than I think any one person could ever feasibly make in a lifetime.

For 2012, I thought Mitt Romney had a shot, so I supported him. I guess I was bamboozled by "the game" just like millions of ppl. Marketing is the ultimate mind control, isn't it?

You might be into something there. When Jesse Ventura won governor of Minnesota, he only raised like 5% of the money of either party. I want to say he raised only 200k while republicans and democrats spent about 6 million each...