Big Beautiful Bill

[DocEspana]

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Just if you need numbers on what the increase in uninsured will look like (and a bit of context at how few of them are because they are just layabouts not even trying to work enough hours)

 

[EctopicFetus]

Just if you need numbers on what the increase in uninsured will look like (and a bit of context at how few of them are because they are just layabouts not even trying to work enough hours)

View attachment 406081View attachment 406082

I don’t feel great about it all but how many of them will roll onto an ACA plan?

 

[Pinner Doc]

I don’t feel great about it all but how many of them will roll onto an ACA plan?

There are also new changes to the ACA that are projected to reduce enrollment. Policyholders will no longer be able to automatically reenroll, but they must update their information annually. The window to do that has also been shortened (the open enrollment period will now end about a month earlier).

Additionally, anyone applying for ACA coverage outside of that period (eg, they changed jobs or need to add family members to their policy) will need to wait for all of their documentation to be processed before they can receive government subsidies to help pay for their monthly premiums.

 

[RustedFox]

Maybe that might force these professional schools to be 3-yr programs and to no longer require a bachelor degree as a defacto requirement to get in. It's actually one of the provisions of that law that I agree with.

I have been saying that since I finished med school. Medical school should be a 2-yr prerequisite and 3-yr med school.

Honestly, a lot of med school needs to be pared down. SO much first year rehash of topics covered at least twice prior to matriculation.

Yes, you should take undergrad biochem and some variety of undergrad A&P. No, you don't get to be an econ major with a minor in Russian Folktales and get in.

 

[AlmostAnMD]

Honestly, a lot of med school needs to be pared down. SO much first year rehash of topics covered at least twice prior to matriculation.

Yes, you should take undergrad biochem and some variety of undergrad A&P. No, you don't get to be an econ major with a minor in Russian Folktales and get in.

Rude! My undergrad degree is in Japanese :O

Biochem hit me haaaaard

My highest math class in college was algebra. I was arts all the way

I had to learn what a logarithm was just to take the MCAT (still got an 11 on science, which on the new scale is like 1000 or something?)

 

[thegenius]

So speaking as someone that now works on the hospital money side, and I say this with respect, this view is somewhat myopic.

The overwhelming concern coming up at the system level for these cuts is on the inpatient side.

We're talking about people with medicaid having protracted sepsis stays, lucrative joint replacement surgeries, liver transplants, etc....some of these things even with medicaid will run bills nearly half a million dollars across the entire episode of care.

The absolute smallest potatoes to worry about is ED revenue for two reasons:

1) Most (not all!) ED's are contracted. Once you contract something out, outside of patient satisfaction/overt safety/throughput issues hospitals don't care what's going on in the ED. The RN's in the department are funded by the hospital not the EM group. The revenue for the docs is simply not their concern, and expecting it to be is like waiting for that ex you really want back to call you ASAP. She gone, she got other **** to worry about.

And I'm not saying I don't disagree. I fully agree with you. But it's definitely not the view I'm hearing. I haven't heard ED revenue come up even once in these discussions.

2) ED revenue is truly, truly small potatoes by comparison to inpatient revenue. Sure, you could do a procedure and bill 99291 and 99292 but if you're putting that much time into the patient, imagine the IP resources utilized over the next 5-6 days.

This wasn't popular in another topic I mentioned this (soapboxing again, apologies) but it's just a fact most critical care time billed in the ED probably is unwarranted. But it's such a small, small amount by comparison to the charges from the rest of the stay that insurance spends their time fighting LOC and DRG issues. Those administrative challenges to us cost them time and money, but if they win they can eek out 5-20k a pop, which is multiples of the ENTIRE ED BILL. So going after CC billing isn't even worth their administrative time, which is why no one from UHC, Humana, Centene, etc even LOOK at CC billing. The future and AI might get involved, but that's a separate discussion way down the road to auto-deny those.

That ramble ties into my main point, which is ED revenue is so small the "plight" of the ED docs isn't even being discussed at the executive level in our large system. Although that's not entirely heartless--what are we to do? We'll quite possibly lose so much money that subsidizing our ED just isn't a realistic choice.


Also ties into my final point, why I left EM. I grew increasingly concerned that the island of revenue is shrinking, and one of the first groups voted off of it is EM.

My best guess for the future when this passes:

Some smaller places close
larger places just take the hit. Everyone complains, nothing changes.
From an ED specific standpoint, revenue has been shrinking and this will just be another hit to revenue. "it's your problem." EM docs in general don't have much of an alternative, so if your pay goes down another 30-50k/year, what will you do? Everywhere you go, it'll be the same unless you move to a rich area with no medicaid patients.


FWIW, I find revenue work highly rewarding. My specific focus is actually FIGHTING medicaid payors. Our problem is they are ALREADY breaking the law and denying payments/downgrading DRG's for no goddam reason. So even though they currently HAVE the funding, they are STILL refusing to pay in many situations. This was already a five-alarm fire BEFORE this bill, which is almost certainly going to be used as an excuse to deny even more care to people who RETAIN medicaid. It's a goddam mess.

I'm trying to lay out facts as best I can from my situation and discussions with my own leadership. If it comes off as callous I apologize, but we've entered a strictly financial discussion and there just aren't a lot of warm feels in the financial aspect of medicine, just accounts.

TLDR: Healthcare is a burning house. Inpatient activity/finances are the children the parents (C-suite) are rushing in to save. EM is the furniture hoping the parents have time to come back in and get saved, but will probably burn with the house.

/ramble

Very nice reply. What I mean by our "plight" is our overall situation and not anything related to post-OBBB reductions in pay. But yes I understand that since we are reimbursed 2 - 5 RVUs / patient, our concerned really won't ever be heard by admin.

 

[VA Hopeful Dr]

Rude! My undergrad degree is in Japanese :O

Biochem hit me haaaaard

My highest math class in college was algebra. I was arts all the way

I had to learn what a logarithm was just to take the MCAT (still got an 11 on science, which on the new scale is like 1000 or something?)

I was a chemistry major and after at best 6-8 weeks in med school we had moved beyond all the biochem I learned in college.

 

[RustedFox]

Rude! My undergrad degree is in Japanese :O

Biochem hit me haaaaard

My highest math class in college was algebra. I was arts all the way

I had to learn what a logarithm was just to take the MCAT (still got an 11 on science, which on the new scale is like 1000 or something?)

Well konnichiwa, bro - but I said what I said.

You don't need calc I, but you need biochem, and A&P

 

[AlmostAnMD]

Rofl

I had none of that

I just thought med school would be fun

Clearly well planned

 

[dozitgetchahi]

The more I look into this, the more I see that's a feature, not a bug. The goal is to make it so difficult to keep medicaid people just give up and lose coverage. Lawmakers, of course, won't GAF because when they show up at your door for treatment, they don't pay for it---hospital/you eat the cost. Saving money! lol

The thing the politicians on Capitol Hill don’t realize is that this move isn’t actually “saving” money overall. Yes, they think it will lead to “current savings” in the federal government budget, but ultimately the costs will be absorbed across the healthcare system (as well as by local and state governments) in the least efficient ways possible. And a lot of these costs will indeed feed back to the federal government’s bottom line, whether they admit it or not.

My “hot take”: these Medicaid cuts take 5-8 years to be phased in, and meanwhile I’m anticipating a political backlash that will lead to new legislation that will undo a lot of these cuts. Bear in mind that the Republicans just barely control the House and Senate right now - and this “big beautiful bill” just barely got through both houses with lots of wrangling and pushing by the Repub leadership. There is already anger building towards Republicans among voters in a number of states, and the next midterm elections may flip a lot of seats currently held by Republicans. So I’m not too concerned yet. Because the folks who have been hurt by things like DOGE, this new spending bill, etc etc sure as hell aren’t going to be voting Republican for the foreseeable future. (And there are so many people who fall into that category that I don’t see how the Repubs can possibly hold many of the seats they currently have.)

 

[CliveStaples]

The thing the politicians on Capitol Hill don’t realize is that this move isn’t actually “saving” money overall. Yes, they think it will lead to “current savings” in the federal government budget, but ultimately the costs will be absorbed across the healthcare system (as well as by local and state governments) in the least efficient ways possible. And a lot of these costs will indeed feed back to the federal government’s bottom line, whether they admit it or not.

My “hot take”: these Medicaid cuts take 5-8 years to be phased in, and meanwhile I’m anticipating a political backlash that will lead to new legislation that will undo a lot of these cuts. Bear in mind that the Republicans just barely control the House and Senate right now - and this “big beautiful bill” just barely got through both houses with lots of wrangling and pushing by the Repub leadership. There is already anger building towards Republicans among voters in a number of states, and the next midterm elections may flip a lot of seats currently held by Republicans. So I’m not too concerned yet. Because the folks who have been hurt by things like DOGE, this new spending bill, etc etc sure as hell aren’t going to be voting Republican for the foreseeable future. (And there are so many people who fall into that category that I don’t see how the Repubs can possibly hold many of the seats they currently have.)

Agreed. I expect further legislation that protects hospitals from the future downstream consequences.

 

[Janders]

And remember BBB doesn’t only impact Medicaid. While it was pitched as not touching Medicare, that is a very limited truth—

The BBB adds roughly $3.3 trillion to the deficit, so the Statutory Pay-As-You-Go (PAYGO) Act triggers significant cuts… roughly $500 billion in Medicare cuts over the next ten years, beginning October 1, 2025… and there are tons of downstream effects

A good read:

Don’t touch my Medicare!

The politics of self-interest explode on Independence Day

absurdlyrational.substack.com

 

[allantois]

Maybe that might force these professional schools to be 3-yr programs and to no longer require a bachelor degree as a defacto requirement to get in. It's actually one of the provisions of that law that I agree with.

I have been saying that since I finished med school. Medical school should be a 2-yr prerequisite and 3-yr med school.

2 year prereqs would be adequate, however, because admissions is so competitive and the supply for loans has been unlimited; this is how we got to people pursuing master’s degree to beef up their applications

 

[AlmostAnMD]

The thing the politicians on Capitol Hill don’t realize is that this move isn’t actually “saving” money overall. Yes, they think it will lead to “current savings” in the federal government budget, but ultimately the costs will be absorbed across the healthcare system (as well as by local and state governments) in the least efficient ways possible. And a lot of these costs will indeed feed back to the federal government’s bottom line, whether they admit it or not.

My “hot take”: these Medicaid cuts take 5-8 years to be phased in, and meanwhile I’m anticipating a political backlash that will lead to new legislation that will undo a lot of these cuts. Bear in mind that the Republicans just barely control the House and Senate right now - and this “big beautiful bill” just barely got through both houses with lots of wrangling and pushing by the Repub leadership. There is already anger building towards Republicans among voters in a number of states, and the next midterm elections may flip a lot of seats currently held by Republicans. So I’m not too concerned yet. Because the folks who have been hurt by things like DOGE, this new spending bill, etc etc sure as hell aren’t going to be voting Republican for the foreseeable future. (And there are so many people who fall into that category that I don’t see how the Repubs can possibly hold many of the seats they currently have.)

Oh, that's my internet sarcasm not coming through well.

I fully and 100% agree this will not save, long term, any money. If anything cost more, probably, for reasons that are both long and rambling.

Politicians keep half-comitting to killing poor people. Either help them, or change EMTALA , etc so we can just let them die without legal repercussion (KIDDING, but it does seem like thats what they actually want without coming out to say it, or make it legal, but their actions definitely encourage it)

 

[EctopicFetus]

Hard to know what future legistlation will entail. Hospitals run lean. This could be a boon to HCA who unlike most hospitals and systems knows how to make money. Failing hospitals = cheap purchases for them.

I am not sure that the political climate will change as much as some think. I do think the next election will have a whiplash effect but the BBB will be forgotten especially if people dont really feel the impact. A lot of the provisions are pushed off. On the other hand when the new census comes out the blue states will be picking up votes in the electoral college as well as seats in the house. The purple states will matter much less and my feeling is that younger people are leaning more to the right than my generation did.

And while I think it is total nonsense the Rs tend to be associated with fiscal responsibility. As the debt becomes a bigger story (and I think it will in the next decade) people will look to them for solutions. As federal spending gets gobbled up by interest payments frustration will grow. Maybe AI has a solution for us and our economy can boom to fix our deficit and debt. I have no idea how that plays out.

Reality is that we will have to have significant cuts to Medicare/Medicaid, defense or social security and tax increases to fix things. None of those are palatable. Would be great if we had adults as politicians who could lead us. I would propose a true $1 in spending cuts matched with $1 in tax increases. I would even consider a 1:2 ratio to be fair. The math suggests we can not tax our way out of this problem. It would be a fun exercise to have the D’s in charge of bth and the Rs in charge of both sides and see where they end up. Goal would be balance the budget and then a prescribed cut in our debt. I would love to see what they come up with. If I have time I may task AI with this project. Would be fun to see the outcome.

 

[EctopicFetus]

Oh, that's my internet sarcasm not coming through well.

I fully and 100% agree this will not save, long term, any money. If anything cost more, probably, for reasons that are both long and rambling.

Politicians keep half-comitting to killing poor people. Either help them, or change EMTALA , etc so we can just let them die without legal repercussion (KIDDING, but it does seem like thats what they actually want without coming out to say it, or make it legal, but their actions definitely encourage it)

I will say I am not a big fan of”healthcare saves lives”. So much of healthcare is wasted and not data driven. Is there are data to suggest annual visits to a pediatrician are beneficial? I think as a parent you can figure out there is a problem. My healthy kids need a physical every year for their school to play. This is but one example. We all know tons of these examples. Simply, the same can be said for a lot of things in healthcare including many critical access hospitals. We expend a crazy amount of money to care for a few patients many of which are basically urgent care. Again, some CAH are different but simply if you arent seeing 24 patients in 24 hours I think you need to be shut down or the city/county/state should pony up the money. (Note my 1 pph) is a purely made up number.

 

[AlmostAnMD]

Hard to know what future legistlation will entail. Hospitals run lean. This could be a boon to HCA who unlike most hospitals and systems knows how to make money. Failing hospitals = cheap purchases for them.

I am not sure that the political climate will change as much as some think. I do think the next election will have a whiplash effect but the BBB will be forgotten especially if people dont really feel the impact. A lot of the provisions are pushed off. On the other hand when the new census comes out the blue states will be picking up votes in the electoral college as well as seats in the house. The purple states will matter much less and my feeling is that younger people are leaning more to the right than my generation did.

And while I think it is total nonsense the Rs tend to be associated with fiscal responsibility. As the debt becomes a bigger story (and I think it will in the next decade) people will look to them for solutions. As federal spending gets gobbled up by interest payments frustration will grow. Maybe AI has a solution for us and our economy can boom to fix our deficit and debt. I have no idea how that plays out.

Reality is that we will have to have significant cuts to Medicare/Medicaid, defense or social security and tax increases to fix things. None of those are palatable. Would be great if we had adults as politicians who could lead us. I would propose a true $1 in spending cuts matched with $1 in tax increases. I would even consider a 1:2 ratio to be fair. The math suggests we can not tax our way out of this problem. It would be a fun exercise to have the D’s in charge of bth and the Rs in charge of both sides and see where they end up. Goal would be balance the budget and then a prescribed cut in our debt. I would love to see what they come up with. If I have time I may task AI with this project. Would be fun to see the outcome.

Great post.

The only thing I have to add to this, from a fiscal responsibility standpoint, is something few people talk about: Healthcare is, in fact, getting more expensive.

20 years ago, the average 65 year old was much, much healthier than the average 65 year old of today. And I shudder to think what current 45 year olds will look like in 20 years. Will half of them be on dialysis and stroke #2? The origin of this is a complex topic but I don't think people will generally refute me much when I say people are, on average, just getting more unhealthy.

The cost difference of treatment between all three of these groups is astronomical. This is an issue that, irrespective of BBB, will need to be addressed at some point. Fiscal responsibility and efficient taxing, however you get there, still will fall apart when half this country needs a dialysis clinic/heart transplant (exaggerating....mildly...)

 

[Tiger26]

FWIW, I'm coming at this from the perspective of just seeing a patient who came in for chronic hyperglycemia who "can't" pay $40 every two weeks for her insulin yet could afford getting Door Dash brought to the hospital, but it's neither my job nor my responsibility for pay for the healthcare of millions of people who don't value it enough to allocate their own funding for it.

As someone who's stayed in the Army National Guard for 22 years largely because of the health care benefits, I'd encourage them all to join up if if healthcare coverage truly matters to them.

Same concept as the fact that people are unhealthier than they have been in the past. Not my problem. Exercise is free, as is smoking cessation, abstinence from alcohol, not having kids at 19, etc.

As has been mentioned, there's also still so much waste in healthcare that I wouldn't be surprised if this is only the beginning. We now have 4 layers of both MBA and nursing admins who's job revolves around logging onto meetings and listening in the background. It can't be any different than the charts showing the rise in college administration compared to teaching staff.

And lastly, with regard to limiting borrowing power for student loans--hallelujah!! The federal government greenlighting blank check educational borrowing is what has enabled colleges to exponentially outpace inflation with tuition prices. As a society, we need to be doing more to discourage completely meanlingless paths of study. Want a gender studies degree? Great--pay for it up front or have your parents put their house up as collateral.

 

[dozitgetchahi]

FWIW, I'm coming at this from the perspective of just seeing a patient who came in for chronic hyperglycemia who "can't" pay $40 every two weeks for her insulin yet could afford getting Door Dash brought to the hospital, but it's neither my job nor my responsibility for pay for the healthcare of millions of people who don't value it enough to allocate their own funding for it.

As someone who's stayed in the Army National Guard for 22 years largely because of the health care benefits, I'd encourage them all to join up if if healthcare coverage truly matters to them.

Same concept as the fact that people are unhealthier than they have been in the past. Not my problem. Exercise is free, as is smoking cessation, abstinence from alcohol, not having kids at 19, etc.

As has been mentioned, there's also still so much waste in healthcare that I wouldn't be surprised if this is only the beginning. We now have 4 layers of both MBA and nursing admins who's job revolves around logging onto meetings and listening in the background. It can't be any different than the charts showing the rise in college administration compared to teaching staff.

And lastly, with regard to limiting borrowing power for student loans--hallelujah!! The federal government greenlighting blank check educational borrowing is what has enabled colleges to exponentially outpace inflation with tuition prices. As a society, we need to be doing more to discourage completely meanlingless paths of study. Want a gender studies degree? Great--pay for it up front or have your parents put their house up as collateral.

There is significant “waste, fraud and abuse” in healthcare, but this bill does practically nothing to address it. If that was the major concern, we would be hacking away at bloated management in hospitals, blocking direct to patient drug advertising, encouraging competition among hospitals (rather than having them merge into huge medical conglomerates), preventing insurance companies from owning their own medical clinics and pharmacies, and on and on. In other words, cutting the fat where it exists.

Dumping a bunch of people off Medicaid isn’t going to save any money whatsoever. I completely agree that a big portion of the US population makes very stupid decisions about taking care of themselves and prioritizing their finances, but removing the (already ****ty) healthcare coverage these people have isn’t going to change that, and is going to make society much worse overall.

 

[Tiger26]

There is significant “waste, fraud and abuse” in healthcare, but this bill does practically nothing to address it. If that was the major concern, we would be hacking away at bloated management in hospitals, blocking direct to patient drug advertising, encouraging competition among hospitals (rather than having them merge into huge medical conglomerates), preventing insurance companies from owning their own medical clinics and pharmacies, and on and on. In other words, cutting the fat where it exists.

Dumping a bunch of people off Medicaid isn’t going to save any money whatsoever.

Totally agree--that why I said that I think this is likely just the start.

Still, not my job to pay for healthcare for so many people who don't value paying for it themselves. My parents were self-employed and had to pay for their own healthcare while we were growing up and they prioritized that payment before anything else except for their mortgage.

Lots of healthcare charities though--feel free to contribute some of your money to make up for the cuts.

 

[Kryptocoin]

Totally agree--that why I said that I think this is likely just the start.

Still, not my job to pay for healthcare for so many people who don't value paying for it themselves. My parents were self-employed and had to pay for their own healthcare while we were growing up and they prioritized that payment before anything else except for their mortgage.

Lots of healthcare charities though--feel free to contribute some of your money to make up for the cuts.

A nice libertarian sentiment but has zero application in the real world.

 

[Tiger26]

A nice libertarian sentiment but has zero application in the real world.

Nothing preventing you from donating your income to pay for the healthcare of others. You just got a tax cut, so you might as well do some good with it

 

[Splenda88]

Totally agree--that why I said that I think this is likely just the start.

Still, not my job to pay for healthcare for so many people who don't value paying for it themselves. My parents were self-employed and had to pay for their own healthcare while we were growing up and they prioritized that payment before anything else except for their mortgage.

Lots of healthcare charities though--feel free to contribute some of your money to make up for the cuts.

I actually thought you were serious on your first post. No one would take you seriously anymore after saying that... This is right wing nonsense. "If you want to pay more taxes, why don't you send a check to the IRS." Seriously!

 

[Tiger26]

I actually thought you were serious on your first post. No one would take you seriously anymore after saying that... This is right wing nonsense. "If you want to pay more taxes, why don't you send a check to the IRS." Seriously!

You don't have to send a check to the IRS but you can absolutely contribute to a charity that provides healthcare. My guess is that's something you don't want to do, though ...

 

[Kryptocoin]

Nothing preventing you from donating your income to pay for the healthcare of others. You just got a tax cut, so you might as well do some good with it

Buddy that's not how it works. You live in a shared society. You're free to move to an island and live out your libertarian fantasies.

 

[Splenda88]

You don't have to send a check to the IRS but you can absolutely contribute to a charity that provides healthcare. My guess is that's something you don't want to do, though ...

Stop repeating what you hear on Fox News.

 

[Tiger26]

Buddy that's not how it works. You live in a shared society. You're free to move to an island and live out your libertarian fantasies.

Well you live in a shared society where democrats lost an election, so ....

But from a societal standpoint, why am I paying for healthcare for someone who won't allocate $40 every other week to pay for her insulin but will spend that much on Door Dash to the ED?

 

[Splenda88]

Well you live in a shared society where democrats lost an election, so ....

But from a societal standpoint, why am I paying for healthcare for someone who won't allocate $40 every other week to pay for her insulin but will spend that much on Door Dash to the ED?

I actually agree with that people should have some skin in the game. However, telling someone to send 2-5k to some charity organization to improve healthcare coverage is nonsense.

I think we are approaching universal healthcare. The public will demand law makers to fix the system once healthcare expenditure is > 25% of the country GDP.

It's hard to fix a system when there are so many players who are making millions from it. The default "fix" will be medicare for all.

 

[Tiger26]

I actually agree with that people should have some skin in the game. However, telling someone to send 2-5k to some charity organization to improve healthcare coverage is nonsense.

I think we are approaching universal healthcare. The public will demand law makers to fix the system once healthcare expenditure is > 25% of the country GDP.

It's hard to fix a system when there are so many players who are making millions from it. The default "fix" will be medicare for all.

I'm not entirely sure if we'll end up with universal healthcare or not. The system is clearly broken but it still works better than many other systems around the world. The other important aspect is that we have so many other societal problems that contribute to poor health outcomes.

Nevertheless, I genuinely don't understand why you don't think it's reasonable to send $2-5k to a healthcare charity yet it should be required of all of us to send it to the government to provide healthcare ...

 

[Splenda88]

I'm not entirely sure if we'll end up with universal healthcare or not. The system is clearly broken but it still works better than many other systems around the world. The other important aspect is that we have so many other societal problems that contribute to poor health outcomes.

Nevertheless, I genuinely don't understand why you don't think it's reasonable to send $2-5k to a healthcare charity yet it should be required of all of us to send it to the government to provide healthcare ...

I don't think it is unreasonable. I actually send money to a children's hospital. I am sure that poster you said that to might contribute to some charities as well. The reason we have the government is to attempt to fix some of these societal issues. The money I send might help (who the f... knows), but it won't make a meaningful difference if the root cause of the issue is not addressed at a larger scale.

 

[Tiger26]

I don't think it is unreasonable. I actually send money to a children's hospital. I am sure that poster you said that to might contribute to some charities as well. The reason we have the government is to attempt to fix some of these societal issues. The money I send might help (who the f... knows), but it won't make a meaningful difference if the root of the issue is not addressed.

I'm all for government and society helping out those who lost the genetic lottery, had a catastropic event, have become totally destitute, etc but we're just keeping people dependent on the government indefinitely while they spend money on whatever else they want.

We should require some coverage at the very least for catastrophic care and risk adjust premiums to account for decisions people make (smoking, drugs, drunk driving, medication non-compliance, and all sorts of other risky behaviors).

At some point, the money is going to run out and someone is going to be left holding the bag. I'm definitely not happy with the deficit spending in this bill, but I'm not going to get upset that people are going to need more skin in the game when it comes to their own healthcare coverage. Again, I literally continue to stay in the Army (at risk to myself and therefore my family) because I get great healthcare coverage with it.

 

[VA Hopeful Dr]

. There is already anger building towards Republicans among voters in a number of states, and the next midterm elections may flip a lot of seats currently held by Republicans. So I’m not too concerned yet. Because the folks who have been hurt by things like DOGE, this new spending bill, etc etc sure as hell aren’t going to be voting Republican for the foreseeable future. (And there are so many people who fall into that category that I don’t see how the Repubs can possibly hold many of the seats they currently have.)

I hope I'm wrong, but I'm going to get ahead and say this ain't happening. People talk big, but we'll see what the next Boogeyman the GOP comes up with to scare people into not voting for Democrats is.

 

[VA Hopeful Dr]

I'm all for government and society helping out those who lost the genetic lottery, had a catastropic event, have become totally destitute, etc but we're just keeping people dependent on the government indefinitely while they spend money on whatever else they want.

We should require some coverage at the very least for catastrophic care and risk adjust premiums to account for decisions people make (smoking, drugs, drunk driving, medication non-compliance, and all sorts of other risky behaviors).

At some point, the money is going to run out and someone is going to be left holding the bag. I'm definitely not happy with the deficit spending in this bill, but I'm not going to get upset that people are going to need more skin in the game when it comes to their own healthcare coverage. Again, I literally continue to stay in the Army (at risk to myself and therefore my family) because I get great healthcare coverage with it.

As a PCP, I get this. Around 1/3rd of my income now is quality based. But while I get punished if patients refuse to get a mammogram, they suffer no consequences (other than maybe cancer).

Put a $10/month fee onto their Medicare premiums until they get up to date on screenings and medication compliance and we'll see some changes pretty damned fast.

 

[Splenda88]

I'm all for government and society helping out those who lost the genetic lottery, had a catastropic event, have become totally destitute, etc but we're just keeping people dependent on the government indefinitely while they spend money on whatever else they want.

We should require some coverage at the very least for catastrophic care and risk adjust premiums to account for decisions people make (smoking, drugs, drunk driving, medication non-compliance, and all sorts of other risky behaviors).

At some point, the money is going to run out and someone is going to be left holding the bag. I'm definitely not happy with the deficit spending in this bill, but I'm not going to get upset that people are going to need more skin in the game when it comes to their own healthcare coverage. Again, I literally continue to stay in the Army (at risk to myself and therefore my family) because I get great healthcare coverage with it.

If it was up to me, we would have 5-6 tax brackets, and ZERO deduction whatsoever. EVERYONE would have to contribute. Our politicians are corrupt and we are brainwashed to the point that people don't vote on policies anymore.

 

[Tiger26]

If it was up to me, we would have 5-6 tax brackets, and ZERO deduction whatsoever. EVERYONE would have to contribute. Our politicians are corrupt and we are brainwashed to the point that people don't vote on policies anymore.

I'd rather we all just pay the same percentage based rate with no deductions.

Make $0, pay $0.
Make $100k, pay 20k.
Make a billion, pay 200 million.

 

[AlmostAnMD]

I actually agree with that people should have some skin in the game. However, telling someone to send 2-5k to some charity organization to improve healthcare coverage is nonsense.

I think we are approaching universal healthcare. The public will demand law makers to fix the system once healthcare expenditure is > 25% of the country GDP.

It's hard to fix a system when there are so many players who are making millions from it. The default "fix" will be medicare for all.

I used to think this was nonsense but the more I learn about how payors operate the more that makes sense.

Someone mentioned the blight of hosptial admin growth. From a money side, this is reactionary from hosptials. Without that, our system would lose around $50,000,000 a year from insurance denials.

Here is a rundown of the process currently used with commercial insurance/managed medicaid/managed Medicare (ALL NON-GOVT ENTITIES):

Around 70% of our claims are not challenged (which makes sense, UHC makes money denying claims but they cant realistically deny someone as inpatient status who is intubated for his entire stay)

Actually as an aside they did do that to me once and I had to point this out. But anyway...


30% or so are denied

Here is the process

1) a UM nurse in our department (making 80k/ yr) flags a case as inpatient

2) if it meets strict guidelines as IP status they just tell attending to upgrade. If they aren't sure they ask me. Next step is same regardless

3) the claim is sent to a payor as a request for inpatient authorization.

4) another nurse making 80k/yr but this time working for a payor is incentivized to find a way to look at the same guidelines but see that they don't "meet" for inpatient. For the record, both nurses are looking at the same data and the same pretty clear guidelines but making different interpretations and its usually the payor nurse just making **** up

5) payor nurse flags case for denial

6) payor nurse refers case to a payor medical director (MD). MD, from my experience, just does whatever the Ai or denying nurse says and half the time never actually reviews the case, which is obvious when I talk to them

7) MD denies case

8) payor RN faxes our RN a denial letter

9) our RN contacts me to see if denial is worth fighting

10) I review case and conclude inpatient status is appropriate and the denial is not

11) I tell RN to challenge denial

12) RN contacts our scheduling assistant, someone making 50k/yr, to reach out to MD scheduling assistant who makes probably the same or more

13) a peer-to-peer is scheduled where I spent 2 minutes clearly pointing out to MD this denial is nonsense

14) MD agrees to overturn denial

15) I inform our staff of p2p result and to anticipate a fax

16) MD informs his RN case is overturned

17) payor RN faxes my RN an approval code and inpatient is approved.

This is all assuming MD agrees. If this goes to appeal you can add another 30 steps. Some MDs just deny because they can, regardless of medicine or logic. This is a topic unto itself, but there are some cases I know I will win or lose just because of the name on the calendar.


Look at this nonsense I just wrote. Then multiple it by 100 every single day. Every. Single. Day. THIS is private insurance. This is "competition." How can you look at this and not conclude it's a waste of time, money, and resources?

Yet, this is necessary. These denials are so complex and so common that regular docs cannot do this--they would be left without any actual time for patient care.

NOW, here is the process for full Medicare...actually real federal government insurance

1) nurse flags case as inpatient. Either meets for inpatient or, as with before, they ask my opinion

2) patient is made inpatient

The end.


Everyone thinks about government and insurance as a horrific bureaucracy but look at what i just outlined. Let me ask you this: which system would YOU rather work with?

Now, a logical conclusion is, well, if you can just make anyone inpatient wouldn't that increase risk of fraud? Answer is not really.

Every state has a QIO designated to watch for fraud (quality office). They will randomly pull out charts made inpatient and if >20% are flagged as inappropriate (or especially a 1MN stay that was unwarranted as IP) they can come down hard on you.

So there is a fraud protection mechanism that works very well and it isn’t an entire line of BS that UHC et al invented to siphon profit from hospitals.

So I do actually agree now a federal medicare for all program would probably cut a lot of red tape.

Problem is, it would cut TOO MUCH. It's not politically viable. It would lay off hundreds of thousands of people dedicated to this process and most importantly companies profiting off of denying care would cease to exist. These are the same companies handing checks to congressmen to make sure it never happens for the obvious reason everyone on the inside knows it would be better but too much profit would be lost....so it will not happen, not with the current political climate, anyway.

 

[Splenda88]

I'd rather we all just pay the same percentage based rate with no deductions.

Make $0, pay $0.
Make $100k, pay 20k.
Make a billion, pay 200 million.

It would hurt the poors

 

[Splenda88]

I used to think this was nonsense but the more I learn about how payors operate the more that makes sense.

Someone mentioned the blight of hosptial admin growth. From a money side, this is reactionary from hosptials. Without that, our system would lose around $50,000,000 a year from insurance denials.

Here is a rundown of the process currently used with commercial insurance/managed medicaid/managed Medicare (ALL NON-GOVT ENTITIES):

Around 70% of our claims are not challenged (which makes sense, UHC makes money denying claims but they cant realistically deny someone as inpatient status who is intubated for his entire stay)

Actually as an aside they did do that to me once and I had to point this out. But anyway...


30% or so are denied

Here is the process

1) a UM nurse in our department (making 80k/ yr) flags a case as inpatient

2) if it meets strict guidelines as IP status they just tell attending to upgrade. If they aren't sure they ask me. Next step is same regardless

3) the claim is sent to a payor as a request for inpatient authorization.

4) another nurse making 80k/yr but this time working for a payor is incentivized to find a way to look at the same guidelines but see that they don't "meet" for inpatient. For the record, both nurses are looking at the same data and the same pretty clear guidelines but making different interpretations and its usually the payor nurse just making **** up

5) payor nurse flags case for denial

6) payor nurse refers case to a payor medical director (MD). MD, from my experience, just does whatever the Ai or denying nurse says and half the time never actually reviews the case, which is obvious when I talk to them

7) MD denies case

8) payor RN faxes our RN a denial letter

9) our RN contacts me to see if denial is worth fighting

10) I review case and conclude inpatient status is appropriate and the denial is not

11) I tell RN to challenge denial

12) RN contacts our scheduling assistant, someone making 50k/yr, to reach out to MD scheduling assistant who makes probably the same or more

13) a peer-to-peer is scheduled where I spent 2 minutes clearly pointing out to MD this denial is nonsense

14) MD agrees to overturn denial

15) I inform our staff of p2p result and to anticipate a fax

16) MD informs his RN case is overturned

17) payor RN faxes my RN an approval code and inpatient is approved.

This is all assuming MD agrees. If this goes to appeal you can add another 30 steps. Some MDs just deny because they can, regardless of medicine or logic. This is a topic unto itself, but there are some cases I know I will win or lose just because of the name on the calendar.


Look at this nonsense I just wrote. Then multiple it by 100 every single day. Every. Single. Day. THIS is private insurance. This is "competition." How can you look at this and not conclude it's a waste of time, money, and resources?

Yet, this is necessary. These denials are so complex and so common that regular docs cannot do this--they would be left without any actual time for patient care.

NOW, here is the process for full Medicare...actually real federal government insurance

1) nurse flags case as inpatient. Either meets for inpatient or, as with before, they ask my opinion

2) patient is made inpatient

The end.


Everyone thinks about government and insurance as a horrific bureaucracy but look at what i just outlined. Let me ask you this: which system would YOU rather work with?

Now, a logical conclusion is, well, if you can just make anyone inpatient wouldn't that increase risk of fraud? Answer is not really.

Every state has a QIO designated to watch for fraud (quality office). They will randomly pull out charts made inpatient and if >20% are flagged as inappropriate (or especially a 1MN stay that was unwarranted as IP) they can come down hard on you.

So there is a fraud protection mechanism that works very well and it isn’t an entire line of BS that UHC et al invented to siphon profit from hospitals.

So I do actually agree now a federal medicare for all program would probably cut a lot of red tape.

Problem is, it would cut TOO MUCH. It's not politically viable. It would lay off hundreds of thousands of people dedicated to this process and most importantly companies profiting off of denying care would cease to exist. These are the same companies handing checks to congressmen to make sure it never happens for the obvious reason everyone on the inside knows it would be better but too much profit would be lost....so it will not happen, not with the current political climate, anyway.

Our system is a mess.

I am trying to be financially independent in another 7-10 years before the system blows up.

Everyone will be looking at us since they think we are the "leaders" and most of us are aloof to their plight.

 

[Tiger26]

I used to think this was nonsense but the more I learn about how payors operate the more that makes sense.

Someone mentioned the blight of hosptial admin growth. From a money side, this is reactionary from hosptials. Without that, our system would lose around $50,000,000 a year from insurance denials.

Here is a rundown of the process currently used with commercial insurance/managed medicaid/managed Medicare (ALL NON-GOVT ENTITIES):

Around 70% of our claims are not challenged (which makes sense, UHC makes money denying claims but they cant realistically deny someone as inpatient status who is intubated for his entire stay)

Actually as an aside they did do that to me once and I had to point this out. But anyway...


30% or so are denied

Here is the process

1) a UM nurse in our department (making 80k/ yr) flags a case as inpatient

2) if it meets strict guidelines as IP status they just tell attending to upgrade. If they aren't sure they ask me. Next step is same regardless

3) the claim is sent to a payor as a request for inpatient authorization.

4) another nurse making 80k/yr but this time working for a payor is incentivized to find a way to look at the same guidelines but see that they don't "meet" for inpatient. For the record, both nurses are looking at the same data and the same pretty clear guidelines but making different interpretations and its usually the payor nurse just making **** up

5) payor nurse flags case for denial

6) payor nurse refers case to a payor medical director (MD). MD, from my experience, just does whatever the Ai or denying nurse says and half the time never actually reviews the case, which is obvious when I talk to them

7) MD denies case

8) payor RN faxes our RN a denial letter

9) our RN contacts me to see if denial is worth fighting

10) I review case and conclude inpatient status is appropriate and the denial is not

11) I tell RN to challenge denial

12) RN contacts our scheduling assistant, someone making 50k/yr, to reach out to MD scheduling assistant who makes probably the same or more

13) a peer-to-peer is scheduled where I spent 2 minutes clearly pointing out to MD this denial is nonsense

14) MD agrees to overturn denial

15) I inform our staff of p2p result and to anticipate a fax

16) MD informs his RN case is overturned

17) payor RN faxes my RN an approval code and inpatient is approved.

This is all assuming MD agrees. If this goes to appeal you can add another 30 steps. Some MDs just deny because they can, regardless of medicine or logic. This is a topic unto itself, but there are some cases I know I will win or lose just because of the name on the calendar.


Look at this nonsense I just wrote. Then multiple it by 100 every single day. Every. Single. Day. THIS is private insurance. This is "competition." How can you look at this and not conclude it's a waste of time, money, and resources?

Yet, this is necessary. These denials are so complex and so common that regular docs cannot do this--they would be left without any actual time for patient care.

NOW, here is the process for full Medicare...actually real federal government insurance

1) nurse flags case as inpatient. Either meets for inpatient or, as with before, they ask my opinion

2) patient is made inpatient

The end.


Everyone thinks about government and insurance as a horrific bureaucracy but look at what i just outlined. Let me ask you this: which system would YOU rather work with?

Now, a logical conclusion is, well, if you can just make anyone inpatient wouldn't that increase risk of fraud? Answer is not really.

Every state has a QIO designated to watch for fraud (quality office). They will randomly pull out charts made inpatient and if >20% are flagged as inappropriate (or especially a 1MN stay that was unwarranted as IP) they can come down hard on you.

So there is a fraud protection mechanism that works very well and it isn’t an entire line of BS that UHC et al invented to siphon profit from hospitals.

So I do actually agree now a federal medicare for all program would probably cut a lot of red tape.

Problem is, it would cut TOO MUCH. It's not politically viable. It would lay off hundreds of thousands of people dedicated to this process and most importantly companies profiting off of denying care would cease to exist. These are the same companies handing checks to congressmen to make sure it never happens for the obvious reason everyone on the inside knows it would be better but too much profit would be lost....so it will not happen, not with the current political climate, anyway.

Being a physician advisor is like getting to see how the sausage is made. I've had so many unbelievable denials lately. I'd add that our Medicaid insurers almost always try to deny anything (even intubated patients) if the stay is less than 3 midnights.

 

[Kryptocoin]

Well you live in a shared society where democrats lost an election, so ....

And they didn't storm the Capitol ..............sounds like democracy works. Although it seems one-way lately.

But from a societal standpoint, why am I paying for healthcare for someone who won't allocate $40 every other week to pay for her insulin but will spend that much on Door Dash to the ED?

Where do you draw the line? Why should my taxes go to farmers that can't turn a profit? Why should I pay more in taxes to live in the city, only to have that money be diverted to support sprawling suburbs and rural towns, since those areas require more funding than they generate?

 

[AlmostAnMD]

Being a physician advisor is like getting to see how the sausage is made. I've had so many unbelievable denials lately. I'd add that our Medicaid insurers almost always try to deny anything (even intubated patients) if the stay is less than 3 midnights.

Rofl

You're like the 5th advisor I've seen use that phrase about this

And it's very accurate, because i also know how sausage is made

The end product is sooooo much prettier than the process

 

[Tiger26]

And they didn't storm the Capitol ..............sounds like democracy works. Although it seems one-way lately.



Where do you draw the line? Why should my taxes go to farmers that can't turn a profit? Why should I pay more in taxes to live in the city, only to have that money be diverted to support sprawling suburbs and rural towns, since those areas require more funding than they generate?

Preach! Why are we paying farmers NOT to farm some land? People do crazy things when it's not their own money

 

[EctopicFetus]

I actually agree with that people should have some skin in the game. However, telling someone to send 2-5k to some charity organization to improve healthcare coverage is nonsense.

I think we are approaching universal healthcare. The public will demand law makers to fix the system once healthcare expenditure is > 25% of the country GDP.

It's hard to fix a system when there are so many players who are making millions from it. The default "fix" will be medicare for all.

0% chance this happens in America in the next 50 years. The best chance was during the ACA. People dont want it. Let’s also face the truth.. a lot of the Medicaid recipients dont vote, a lot are young and dont feel the “need” for insurance. I dont suspect society cares that much and politicians care even less.

 

[Pinner Doc]

Well konnichiwa, bro - but I said what I said.

You don't need calc I, but you need biochem, and A&P

I was a Spanish major, religion minor, took all the premed requisites - but I don’t believe that ever included a day of biochem.

 

[RustedFox]

I was a Spanish major, religion minor, took all the premed requisites - but I don’t believe that ever included a day of biochem.

Well, amiga - peace be with you (and also with you), lift up our hearts (we lift them up to the Lord), - but in my brain, you need biochem before med school.

 

[Tiger26]

Well, amiga - peace be with you (and also with you), lift up our hearts (we lift them up to the Lord), - but in my brain, you need biochem before med school.

I feel like biochem was a great weed-out at the beginning of med school, though. It was like getting thrown into the pool to figure out if you could swim or not.

FWIW, I majored in government (I originally wanted to be a lawyer) and minored in history. I took the MCAT with 5 total science classes at that point and with no organic chemistry other that reading the "Organic Chemistry as a Second Language" book I found on Amazon.

 

[Apollyon]

It's an old phrase - "anyone who loves the law or sausage should never watch either one being made".

 

[RustedFox]

I feel like biochem was a great weed-out at the beginning of med school, though. It was like getting thrown into the pool to figure out if you could swim or not.

FWIW, I majored in government (I originally wanted to be a lawyer) and minored in history. I took the MCAT with 5 total science classes at that point and with no organic chemistry other that reading the "Organic Chemistry as a Second Language" book I found on Amazon.

1. How is "government" a major? Like, how? That shouldn't be a thing.
2. Yeah, it was good to make people sweat as a MS1, but if you can't biochem, you shouldn't have even been let in to begin with.

 

[Tiger26]

1. How is "government" a major? Like, how? That shouldn't be a thing.
2. Yeah, it was good to make people sweat as a MS1, but if you can't biochem, you shouldn't have even been let in to begin with.

Political science for a liberal arts school that wanted to feel fancier than it was

 

[DocEspana]

Hard to know what future legistlation will entail. Hospitals run lean. This could be a boon to HCA who unlike most hospitals and systems knows how to make money. Failing hospitals = cheap purchases for them.

I am not sure that the political climate will change as much as some think. I do think the next election will have a whiplash effect but the BBB will be forgotten especially if people dont really feel the impact. A lot of the provisions are pushed off. On the other hand when the new census comes out the blue states will be picking up votes in the electoral college as well as seats in the house. The purple states will matter much less and my feeling is that younger people are leaning more to the right than my generation did.

And while I think it is total nonsense the Rs tend to be associated with fiscal responsibility. As the debt becomes a bigger story (and I think it will in the next decade) people will look to them for solutions. As federal spending gets gobbled up by interest payments frustration will grow. Maybe AI has a solution for us and our economy can boom to fix our deficit and debt. I have no idea how that plays out.

Reality is that we will have to have significant cuts to Medicare/Medicaid, defense or social security and tax increases to fix things.

Also just revert to the 44% top tax rate of Reagan
or the 50% top tax rate of Reagan
or the 70% top tax rate of Reagan.

He cut the top tax rate *a lot* of times.

And its not a panacea for everything and its not a perfect solution, but it is undoing a bad (or three bad) decisions of Reagan which lead to him starting with a 1 trillion debt and making it a 2 trillion debt in his first term and a 4 trillion debt by his second term and we have been off to the debt races ever since. He proved cutting taxes recklessly gets you elected and Bush (the greater) proved that increasing them gets you voted out. so now we are just left growing programs AND not finding any way to pay for them forever and ever, amen.