Bush cuts medicare reimbursment for internship/residency

[Dr. Dukes]

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An article in today's New York Times (http://www.nytimes.com/2007/02/06/ny...2f65&ei =5070) reported that in the budget Bush submitted to Congress he cut the medicare budget for reimbursing hospitals for taking on interns/residents.
I'm quoting here:

Medicare, the federal health plan for the elderly and the disabled, is a major supporter of training programs for interns and residents at teaching hospitals. In New York and some other states, Medicaid, the program for the poor, also pitches in for that training — known as Graduate Medical Education, or G.M.E. — while other states have opted not to take that step.

Mr. Bush proposed gradually eliminating that use of Medicaid money — about $600 million a year in federal funds for New York, more than any other state.

“Current law does not explicitly authorize such payments,” the administration’s budget summary said. “Paying for G.M.E. is outside of Medicaid’s primary purpose, which is to provide medical care to low-income individuals.”

What do people think? Will this pass? How will it effect us?

 

[sirus_virus]

An article in today's New York Times (http://www.nytimes.com/2007/02/06/ny...2f65&ei =5070) reported that in the budget Bush submitted to Congress he cut the medicare budget for reimbursing hospitals for taking on interns/residents.
I'm quoting here:

Medicare, the federal health plan for the elderly and the disabled, is a major supporter of training programs for interns and residents at teaching hospitals. In New York and some other states, Medicaid, the program for the poor, also pitches in for that training — known as Graduate Medical Education, or G.M.E. — while other states have opted not to take that step.

Mr. Bush proposed gradually eliminating that use of Medicaid money — about $600 million a year in federal funds for New York, more than any other state.

“Current law does not explicitly authorize such payments,” the administration’s budget summary said. “Paying for G.M.E. is outside of Medicaid’s primary purpose, which is to provide medical care to low-income individuals.”

What do people think? Will this pass? How will it effect us?

It will pass because there is no opposition to it. Did someone in one of these threads say doctors need to start leaning how to fight for themselves?

 

[veo1]

"Paying for G.M.E. is outside of Medicaid's primary purpose, which is to provide medical care to low-income individuals."

This is the line that gets me. Who else but interns/residents are gonna take care of low-income patients? Its tough work that most practicing physicians shy away from. They have no incentive to take care of this patient population (these people are often the sickest and cannot afford their own health insurance, hence you often lose money taking care of them!). And its not like residents are making a killing doing it. Geez. In my opinion residents aren't paid enough for the kind of work they do. I think most of us accept these meagerly wages in light of the fact that its a part of the training process that's been in place for years. I'd be appalled if this did have an impact on compensation during residency. Physicians are losing power, fast. Any pre-meds lurking these boards ought to make note of this.

 

[Winged Scapula]

"Paying for G.M.E. is outside of Medicaid's primary purpose, which is to provide medical care to low-income individuals"

Curious how they haven't made the connection between paying for residency at inner city and other hospitals to providing enough doctors to take care of the indigent.

Oh well, we'll just close down those residencies which can't come up with the money and the low income patients will have to wait even longer to see someone.😡

 

[sirus_virus]

Is it just me, or are both political parties hell bent on screwing doctors?

 

[Winged Scapula]

Is it just me, or are both political parties hell bent on screwing doctors?

its not you. They are.

 

[dutchman]

This is why I keep saying that doctors are threading dangerous waters these days. Politicians have discovered that doctors are the weakest link in the healthcare sector and they are ready to start pounding away. The era of defenseless doctors needs to be buried, it is time to unionize and start fighting.

 

[Adam_K]

NY State is one of the least efficient when it comes to funding GME, especially on a per head basis. Before this proposal hit the table, Gov. Spitzer proposed some radical changes regarding funding for GME in the state.

It seems that the perception is that NY hospitals have grown fat and inefficient on GME payments.

http://www.nytimes.com/2007/02/06/nyregion/06health.html

Just 15 hospitals would absorb more than half the losses for all of the state's more than 200 hospitals, and 14 of the 15 are in New York City. Most of the big losses would be suffered by hospitals that are relatively successful financially and in relatively affluent neighborhoods, but there are notable exceptions, like Interfaith and Brooklyn.

From Spitzer's earlier speech:

http://www.medicalnewstoday.com/healthnews.php?newsid=61754

Another example of institutions driving the system is the way the State pays for graduate medical education. New York's Medicaid program has spent more than $8 billion over the last five years on graduate medical education - $77,000 per graduate resident in 2005 compared to similar states like California that spent just $21,000 per resident.

This education is critically important, but we're currently funding it in an excessive and irrational way that isn't directly correlated to the actual students being taught - thus costing the State exorbitant amounts of money in what amounts to general subsidies to teaching hospitals. In fact, when we looked closer at this broken formula, we discovered that many of those dollars are going to pay for phantom residents and doctors who don't even exist.

 

[Dr. Dukes]

The problem is this: unionization only works when the union can strike and get sympathy. Police/Fire unions reproducibly and predictably get screwed because it is illegal for them to strike (public saftey unions can't). If a doctor's union struck and all the doctors stopped treating people (read: treating people who use insurance) the world would be up in arms. Yes, doctors are underpaid compared to our educational peers (MBAs and JDs), but still make 3-4x the national average of ~$50,000/year. Imagine how it would play out in the press if a Harvard MD making $200,000/year refused to treat a single mom who works four jobs to make $20,000. That particular MD (and the entire commmunity) would get lambasted by the press.
Medicine is a noble profession, but it is a noble profession that can't controll its own fate because our paycheck is controlled by non-MDs (insurance companies, lawyers, lawmakers) who don't get destroyed in the press for screwing over medicine and making much more than physicians do in the process.

 

[Dr. Dukes]

Another example of institutions driving the system is the way the State pays for graduate medical education. New York's Medicaid program has spent more than $8 billion over the last five years on graduate medical education - $77,000 per graduate resident in 2005 compared to similar states like California that spent just $21,000 per resident.

This education is critically important, but we're currently funding it in an excessive and irrational way that isn't directly correlated to the actual students being taught - thus costing the State exorbitant amounts of money in what amounts to general subsidies to teaching hospitals. In fact, when we looked closer at this broken formula, we discovered that many of those dollars are going to pay for phantom residents and doctors who don't even exist.

1/7 of all residency trained physicians nationwide are trained in NY, and many (most) leave NYC after their training to go elsewhere and practice. On the one hand, it doesn't make sense for NYC/NYS to pay a lot of money to train the future doctors of North Dakota, but on the other hand, those residents, who tend to be very smart and competent, spend their training treating NYC/NYS citizens.
Clearly, as a country we can't cut federal funding for internship/residency programs, otherwise we'll be screwed in 15 years when all the babyboomer docs retire and our current physician shortage gets worse because we didn't train anyone to replace them. However, as a taxpayer in both NY and MA, I don't feel right that some of my tax dollars are spend educating docs who will leave and not provide a future service to either state.

 

[mig26x]

what else can we expect from Bush???

 

[Dr. Dukes]

what else can we expect from Bush???

Not sure I want to think about it...

 

[Adam_K]

1/7 of all residency trained physicians nationwide are trained in NY, and many (most) leave NYC after their training to go elsewhere and practice. On the one hand, it doesn't make sense for NYC/NYS to pay a lot of money to train the future doctors of North Dakota, but on the other hand, those residents, who tend to be very smart and competent, spend their training treating NYC/NYS citizens.

I'm not sure that you are completely clear on this, but just so you know, Medicare (for those 65 and older) is federally funded. Medicaid (for the indigent) is jointly funded by the federal and state governments. Most of the funding for residents comes from Medicare, not Medicaid.

The problem isn't necessarily the number of residents, it is how that funding is used. Why is the Medicaid per resident funding 3.5 times greater in New York than California? This clearly points to waste, or that the money that should be spent on educating physicians is in fact a general subsidy to those hospitals. Why should the federal taxpayer and the New York taxpayer subsidize a bunch of NY hospitals above and beyond others?

Clearly, as a country we can't cut federal funding for internship/residency programs, otherwise we'll be screwed in 15 years when all the babyboomer docs retire and our current physician shortage gets worse because we didn't train anyone to replace them. However, as a taxpayer in both NY and MA, I don't feel right that some of my tax dollars are spend educating docs who will leave and not provide a future service to either state.

It seems that you are not aware that there is already a cap on the number of residents that get funded. You may in part thank the AMA for this, as they predicted a doctor shortage not too long ago.

 

[Miami_med]

If they stop paying for GME, can I skip it and apprentice in place of some PA for twice the money as residency? The whole system of government paying for years of low wage work only exists to feed the ridiculous medical licensing process anyway. There are other ways to learn. Also, does this mean that residents will be allowed to start billing for procedures on Medicare patients? Isn't there some rule against that?

 

[Adam_K]

If they stop paying for GME, can I skip it and apprentice in place of some PA for twice the money as residency?

They are proposing eliminating the Medicaid funding for GME (which apparently was not legal anyway), not the Medicare funding which pays for the lion's share.

The whole system of government paying for years of low wage work only exists to feed the ridiculous medical licensing process anyway. There are other ways to learn.

Don't think that too many people on this board will agree with you on this point, though I will.

Also, does this mean that residents will be allowed to start billing for procedures on Medicare patients? Isn't there some rule against that?

No and Yes.

 

[sirus_virus]

The problem is this: unionization only works when the union can strike and get sympathy. Police/Fire unions reproducibly and predictably get screwed because it is illegal for them to strike (public saftey unions can't). If a doctor's union struck and all the doctors stopped treating people (read: treating people who use insurance) the world would be up in arms. Yes, doctors are underpaid compared to our educational peers (MBAs and JDs), but still make 3-4x the national average of ~$50,000/year. Imagine how it would play out in the press if a Harvard MD making $200,000/year refused to treat a single mom who works four jobs to make $20,000. That particular MD (and the entire commmunity) would get lambasted by the press.
Medicine is a noble profession, but it is a noble profession that can't controll its own fate because our paycheck is controlled by non-MDs (insurance companies, lawyers, lawmakers) who don't get destroyed in the press for screwing over medicine and making much more than physicians do in the process.

Doctors strike all the time in other countries. The solution is simple: Rich doctors like the one you described can stay on the job while the poor pediatricians, primary care folks and residents stage a walkout.

 

[Adam_K]

The AAMC has a bunch of pages devoted to Medicare GME payments.

The overview of direct GME is at http://webdb.aamc.org/advocacy/library/gme/gme0001.htm

The overview of indirect GME is at http://webdb.aamc.org/advocacy/library/gme/gme0002.htm

 

[NinerNiner999]

To Clarify - the funding of GME by Medicare was legal, just not required. It resulted from lobbying efforts of the ACGME and other medical organizations to obtain funding that was not available to support specialty expansion.

I do not think the proposal by Bush will be accepted in its entirety, simply because there are too many resident positions nationwide at risk (and the AMA and other large lobbying organizations will fight against the bill).

I do think it is likely that federal funding for specialty training (all fields except for primary care) will be phased out in some way, and will shape the number of available specialty training positions available (read: will make specialty training MORE competitive and increase the number of primary care physicians who enter training).

Of note, the medicare funding amount per resident is about $100k per year, and is "guaranteed" when each resident matches. This means that a surgeon (6 year training) costs twice as much as an internist, pediatrician, or other graduate of a three year program. The people who make the budget on capital hill don't care too much about what kind of doctors we produce, as long as the bottom line looks good.

Until congress gets a clear grasp of the reality, sees that we are in a health care shortage in our country, and starts impacting the real areas of medical cost/deficit (pharmaceuticals, managed care, etc) this will only get worse for physicians.

Moreover, the offices of Medicare and Medicaid are two fully funded government organizations each with similar duties and separate budgets. If the government looked internally, they might realize that there is not a fiscally responsible reason to have this division. Combining Medicare and Medicaid into one government entity would save hundreds of millions of government dollars annually. Of course, a democratic congress will never even consider eliminating goverment jobs, no matter how inefficient, out-dated, or useless they may be.

We as physicians are only responsible for an estimated 4-5% of the total healthcare cost in this country. The CEO's and top executives from major healthcare corporations reap annual compensation equal to 20 times the total physician income (if not more) of our country combined. There are individual PAC's and congressman who see a portion of this income to target us, and all the while complain that our salaries are too high.

Maybe I should have gone to Law school, so I could run for congress, sell out my ideals, and steal from the American people under the illusion that physicians are the bad guys. Heck - if I did that and became a Democrat, maybe I could even run for president some day.

To all the pre-meds, college hopefuls, and children of this country - please look wide open at the future of medicine, and think before you decide to be a doctor.

 

[sirus_virus]

That is because doctors have reduced themselves to a powerless pulp. It disgusts me sometimes to see how powerless doctors are. I am not all for rioting, but whoever said doctors need to start establishing some authority is right.

 

[Stimulate]

That is because doctors have reduced themselves to a powerless pulp. It disgusts me sometimes to see how powerless doctors are. I am not all for rioting, but whoever said doctors need to start establishing some authority is right.

Whether you agree with ALL their politics or not, being a member of the AMA is probably the best thing you can do to advocate for physicians. The AMA does have power in D.C. and if everyone were members and contributed to their PAC (political action committee) our voices would be even louder. Unfortunately money and lobbyists shape policy not reason and logic.

 

[Adam_K]

To Clarify - the funding of GME by Medicare was legal, just not required. It resulted from lobbying efforts of the ACGME and other medical organizations to obtain funding that was not available to support specialty expansion.

I'm guesssing that you meant MedicAID, above.

I do not think the proposal by Bush will be accepted in its entirety, simply because there are too many resident positions nationwide at risk (and the AMA and other large lobbying organizations will fight against the bill).

How many positions exactly are at risk? I think that you are being alarmist. How is it that New York state is spending 3.5 times as much in MedicAID funding for GME than California?

Moreover, it appears that the beneficiaries of this subsidy are by and large affluent hospitals.

I do think it is likely that federal funding for specialty training (all fields except for primary care) will be phased out in some way, and will shape the number of available specialty training positions available (read: will make specialty training MORE competitive and increase the number of primary care physicians who enter training).

I doubt it, unless we suddenly adopt socialized healthcare wholesale. Then again, medicare/medicaid is socialized medicine by another moniker.

Of note, the medicare funding amount per resident is about $100k per year, and is "guaranteed" when each resident matches. This means that a surgeon (6 year training) costs twice as much as an internist, pediatrician, or other graduate of a three year program. The people who make the budget on capital hill don't care too much about what kind of doctors we produce, as long as the bottom line looks good.

No one knows what kind of doctors need to be trained down the line. Market mechanisms are much more efficient than government dictats when it comes to predicting this.

Until congress gets a clear grasp of the reality, sees that we are in a health care shortage in our country, and starts impacting the real areas of medical cost/deficit (pharmaceuticals, managed care, etc) this will only get worse for physicians.

What shortage? Have you ever been to a country with socialized medicine?

Moreover, the offices of Medicare and Medicaid are two fully funded government organizations each with similar duties and separate budgets. If the government looked internally, they might realize that there is not a fiscally responsible reason to have this division. Combining Medicare and Medicaid into one government entity would save hundreds of millions of government dollars annually. Of course, a democratic congress will never even consider eliminating goverment jobs, no matter how inefficient, out-dated, or useless they may be.

Gotta agree with you there.

We as physicians are only responsible for an estimated 4-5% of the total healthcare cost in this country. The CEO's and top executives from major healthcare corporations reap annual compensation equal to 20 times the total physician income (if not more) of our country combined.

No way. Show me the numbers.

There are individual PAC's and congressman who see a portion of this income to target us, and all the while complain that our salaries are too high.

Maybe I should have gone to Law school, so I could run for congress, sell out my ideals, and steal from the American people under the illusion that physicians are the bad guys. Heck - if I did that and became a Democrat, maybe I could even run for president some day.

To all the pre-meds, college hopefuls, and children of this country - please look wide open at the future of medicine, and think before you decide to be a doctor.

Up until the point that the whole system becomes socialized, there will always be opportunities for excellent physicians and surgeons.

 

[HCE]

Fortunately, Mr. Bush can only propose budget items....Congress has the power of the purse. Any medical student who doesn't make a phone call to their representative about such a ludicrous proposal has no one else to blame but themself...

 

[NinerNiner999]

I'm guesssing that you meant MedicAID, above.

Oops - I did.

How many positions exactly are at risk? I think that you are being alarmist. How is it that New York state is spending 3.5 times as much in MedicAID funding for GME than California?

A move that impacts a state as large as New York will likely evolve to effect the entire country.

Moreover, it appears that the beneficiaries of this subsidy are by and large affluent hospitals.

Correct, and these affluent hospitals will take the biggest hit in funding.

I doubt it, unless we suddenly adopt socialized healthcare wholesale. Then again, medicare/medicaid is socialized medicine by another moniker.

A move such as cutting funding to restrict individualized training subsidy is the first step towards socialized medicine.

No one knows what kind of doctors need to be trained down the line. Market mechanisms are much more efficient than government dictats when it comes to predicting this.

Unless the government sees restricting funding as a way to increase their front line of socialized providers (see above). And no, I don't subscribe to conspiracy theories

What shortage? Have you ever been to a country with socialized medicine?

Emergency medicine, for example, has a projected shortage of providers and overcrowding that, even with current recruitment numbers, is projected to last until 2030. This is even worse for primary care physicians (which is why most ED's are overcrowded).

Gotta agree with you there.

Thanks😉

No way. Show me the numbers.

Bill Frist (Republican, TN and former CEO of HCA, the largest hospital corporation in country) put his stock in a blind fund and turned leadership of his corporation over to his brother, who is now the CEO of HCA. Last year alone, his base salary was 7 million dollars, and his stocks, dividends, and other "benefits" amounted to close to 60 million dollars. He is worth over 1 billion dollars. This is Just HCA. The average physician makes close to $200k. Mr. Frist earned enough salary to pay for 300 average doctors.

After being investigated and found guilty of fraud, HCA recently settled with medicare and medicaid and has paid over 1.3 billion dollars in penalties, and still owes another 675 million. These fines alone total the average salaries of 9875 physicians, or close to 7% of the practicing physicians in our country (estimated 150,000). Again, this is just HCA.

Ironically, the investigation ended and the penalties were limited once Bill First became majority leader of the senate.

Up until the point that the whole system becomes socialized, there will always be opportunities for excellent physicians and surgeons.

I guess my point (and fear) is that limiting funding of residency programs by the government opens this funding up to negotiation, and could potentially, for the reasons listed above, lay the foundation of socialized medicine in the future.

 

[Adam_K]

A move such as cutting funding to restrict individualized training subsidy is the first step towards socialized medicine.

Unless the government sees restricting funding as a way to increase their front line of socialized providers (see above). And no, I don't subscribe to conspiracy theories

You may be right, it could be.

Emergency medicine, for example, has a projected shortage of providers and overcrowding that, even with current recruitment numbers, is projected to last until 2030. This is even worse for primary care physicians (which is why most ED's are overcrowded).

I'm going to disagree with you there. I think that many of the problems facing emergency medicine can be traced to EMTALA and the guild of emergency physicians who insist that everyone working in the ER be EM board certified. Regarding primary care, my feeling is that it is undergoing a structural shift from physicians to midlevels.

Bill Frist (Republican, TN and former CEO of HCA, the largest hospital corporation in country) put his stock in a blind fund and turned leadership of his corporation over to his brother, who is now the CEO of HCA. Last year alone, his base salary was 7 million dollars, and his stocks, dividends, and other "benefits" amounted to close to 60 million dollars. He is worth over 1 billion dollars. This is Just HCA. The average physician makes close to $200k. Mr. Frist earned enough salary to pay for 300 average doctors.

After being investigated and found guilty of fraud, HCA recently settled with medicare and medicaid and has paid over 1.3 billion dollars in penalties, and still owes another 675 million. These fines alone total the average salaries of 9875 physicians, or close to 7% of the practicing physicians in our country (estimated 150,000). Again, this is just HCA.

Ironically, the investigation ended and the penalties were limited once Bill First became majority leader of the senate.

I just want to point out that his paper net worth is wealth, not income. Given the size of HCA, his compensation is not out of line with other comparably large corporations.

I guess my point (and fear) is that limiting funding of residency programs by the government opens this funding up to negotiation, and could potentially, for the reasons listed above, lay the foundation of socialized medicine in the future.

You may be right, but I think that you would need to make much larger changes for socialized medicine to be adopted.

 

[EctopicFetus]

what else can we expect from Bush???

I am an independent (registered etc.) and voted vs Edwards and kerry..

Amazingly though, Bush never ceases to amaze me with his lack of common sense and sheer stupidity. I dont know who is pulling these strings but the moves make NO sense.

 

[EctopicFetus]

Bill Frist (Republican, TN and former CEO of HCA, the largest hospital corporation in country) put his stock in a blind fund and turned leadership of his corporation over to his brother, who is now the CEO of HCA. Last year alone, his base salary was 7 million dollars, and his stocks, dividends, and other "benefits" amounted to close to 60 million dollars. He is worth over 1 billion dollars. This is Just HCA. The average physician makes close to $200k. Mr. Frist earned enough salary to pay for 300 average doctors.

After being investigated and found guilty of fraud, HCA recently settled with medicare and medicaid and has paid over 1.3 billion dollars in penalties, and still owes another 675 million. These fines alone total the average salaries of 9875 physicians, or close to 7% of the practicing physicians in our country (estimated 150,000). Again, this is just HCA.

Ironically, the investigation ended and the penalties were limited once Bill First became majority leader of the senate.

For the record for those not in the know.. Frist's dad founded the company. So these numbers could be skewed heavily if they paid a dividend etc. CEOs of huge corps make tons of money. We could argue if they are worth it but thats not our place. The less the govt messes with us the better. Thats true for medicine and other businesses.

 

[p9142]

what else can we expect from Bush???

Bush budget gives to military, takes from poor

 

[student07]

Oops - I did.

Bill Frist (Republican, TN and former CEO of HCA, the largest hospital corporation in country) put his stock in a blind fund and turned leadership of his corporation over to his brother, who is now the CEO of HCA. Last year alone, his base salary was 7 million dollars, and his stocks, dividends, and other "benefits" amounted to close to 60 million dollars. He is worth over 1 billion dollars. This is Just HCA. The average physician makes close to $200k. Mr. Frist earned enough salary to pay for 300 average doctors.

Bill Frist was never the CEO of HCA. His father and brother founded it. He was an investor, never an employee. Before entering politics, Frist was a heart lung transplant surgeon at Vanderbilt. He never turned over leadership to his brother, because he was never a leader of HCA. His brother served as CEO of HCA from 1988 to February 1994, retired, and came out of retirement to serve as CEO again from July 1997 to January 2001. Frist was elected in 1994 -- after his brother had retired and nearly three years before his return as CEO.

 

[Noeljan]

hey guys
I am starting med school in the fall and keep hearing how physicians need to start standing up for themselves, and being involved. What advice can you give to give incoming med students about this? How do we stand up for our rights? I also think it is ridiculous how much doctors spend in school, and pay for, then the same people who are excited that CEO's or paris hilton purchased a new 10,000 hand bag are the same people who say physicians make too much money.
give us newcomers some advice🙂

 

[Faebinder]

hey guys
I am starting med school in the fall and keep hearing how physicians need to start standing up for themselves, and being involved. What advice can you give to give incoming med students about this? How do we stand up for our rights? I also think it is ridiculous how much doctors spend in school, and pay for, then the same people who are excited that CEO's or paris hilton purchased a new 10,000 hand bag are the same people who say physicians make too much money.
give us newcomers some advice🙂

Learn to unionize... Either that or drift towards not accepting insurance or hospital payment but instead direct from the patient.

 

[Dr. Dukes]

Learn to unionize... Either that or drift towards not accepting insurance or hospital payment but instead direct from the patient.

I am surprised more doctors do not do this. When you go to get your car fixed, you pay for it and your car insurance pays you back (at least thats how mine does it). This way, the autobody shop isn't getting screwed if the insurance company decides that I really didn't need my brakes replaced. Doctors are the only people who perform a service and don't immediatly get compensation. Unless I go into EM/Trauma/Critical Care, I don't think i'm going to take insurance. I'll fill out all the paperwork and submit everything, but if a patient's insurance company says no, it is the patient's battle, not mine. this road is too long and too hard and too expensive for me to get blanked out of money I earned because an insurance company decided to be stupid.

 

[Faebinder]

I am surprised more doctors do not do this. When you go to get your car fixed, you pay for it and your car insurance pays you back (at least thats how mine does it). This way, the autobody shop isn't getting screwed if the insurance company decides that I really didn't need my brakes replaced. Doctors are the only people who perform a service and don't immediatly get compensation. Unless I go into EM/Trauma/Critical Care, I don't think i'm going to take insurance. I'll fill out all the paperwork and submit everything, but if a patient's insurance company says no, it is the patient's battle, not mine. this road is too long and too hard and too expensive for me to get blanked out of money I earned because an insurance company decided to be stupid.

The problem is that if you are the only one not taking insurance... then patients will go to other people.

 

[sirus_virus]

The problem is that if you are the only one not taking insurance... then patients will go to other people.

Which other people? Is it the other doctors that are already knee deep in volume of patients? Dentists reject the hell out of insurances that dont pay them, doctors need to do the same. At least that way, you are not wasting time on patients that will cost you more time and money chasing down payment. If there is a doctor across town that does not mind doubling his/her overhead and busy schedule so they can take care of nonpaying customers, then more power to them. That will even make me feel better to know that the patients are at least taken care of. That is probably where our idealist doctors come into play. We can dump off the nonpaying customers at their doorsteps. Everyone goes home happy.

 

[Noeljan]

Which other people? Is it the other doctors that are already knee deep in volume of patients? Dentists reject the hell out of insurances that dont pay them, doctors need to do the same. At least that way, you are not wasting time on patients that will cost you more time and money chasing down payment. If there is a doctor across town that does not mind doubling his/her overhead and busy schedule so they can take care of nonpaying customers, then more power to them. That will even make me feel better to know that the patients are at least taken care of. That is probably where our idealist doctors come into play. We can dump off the nonpaying customers at their doorsteps. Everyone goes home happy.

I agree with the dentist thing. It is sooo hard to get dental care, and even with insurance you have to pay sooo much out of pocket for things. If medical care is a right for all, why not dental care? I know when I have had a toothache (I had to get a root canal which was sooo expensive) it is the worst pain in the world!! Also, unless you have a good chunk of money upfront my dentist wont even treat you😱

 

[lateness]

Emergency medicine, for example, has a projected shortage of providers and overcrowding that, even with current recruitment numbers, is projected to last until 2030. This is even worse for primary care physicians (which is why most ED's are overcrowded).

i agree with 99er there..

 

[dr kevin40]

i just read this thread, and i think someone wrote the total annual reimbursement for programs is 100k/resident??? how is that possible if we are only getting 42k/ yr???

Where does the rest of the money go?

 

[deleted109597]

i just read this thread, and i think someone wrote the total annual reimbursement for programs is 100k/resident??? how is that possible if we are only getting 42k/ yr???

Where does the rest of the money go?

To pay for all the extra ******* studies we order.

 

[NinerNiner999]

Plus it goes to fund your residency program, things such as benefits, membership dues, lab coats, textbooks, educational costs, meals, etc. This varies widely by program...

 

[blocks]

The problem is this: unionization only works when the union can strike and get sympathy. Police/Fire unions reproducibly and predictably get screwed because it is illegal for them to strike (public saftey unions can't). If a doctor's union struck and all the doctors stopped treating people (read: treating people who use insurance) the world would be up in arms. Yes, doctors are underpaid compared to our educational peers (MBAs and JDs), but still make 3-4x the national average of ~$50,000/year. Imagine how it would play out in the press if a Harvard MD making $200,000/year refused to treat a single mom who works four jobs to make $20,000. That particular MD (and the entire commmunity) would get lambasted by the press.
Medicine is a noble profession, but it is a noble profession that can't controll its own fate because our paycheck is controlled by non-MDs (insurance companies, lawyers, lawmakers) who don't get destroyed in the press for screwing over medicine and making much more than physicians do in the process.

Wrong. Unions work because when they strike, they have people by the balls. The only question is: do doctors have the spine to stand up for temselves and fight?

 

[sirus_virus]

Wrong. Unions work because when they strike, they have people by the balls. The only question is: do doctors have the spine to stand up for temselves and fight?

As simple as that. Doctors actually strike in other countries. If you even in the least say the word "pay", before you can add "cut", doctors in the U.K or netherlands will start calling for mass action, ie, strikes.

 

[m3unsure]

As simple as that. Doctors actually strike in other countries. If you even in the least say the word "pay", before you can add "cut", doctors in the U.K or netherlands will start calling for mass action, ie, strikes.

If doctors strike in America, the laypeople will get mad and then doctors would shed their altruistic image. I think this sort of cultural thing has kept doctors from striking, but if enough people take a shot at our nuts, we'll end up squeezing the bee-gee-zies out of theirs.

I'll take a paycut for all the time and money I put into this AS LONG AS all of the people doing desk jobs take a 30% paycut, or I can never be sued and therefore eliminating malpractice insurance.

Aren't we here to help people who criticize us and will make a quick mil from us if a lawyer tells him/her it's possible? Nobody ever mentioned people's paranoia and mistrust before I started medical school. Or better yet, the nerve to say that you know more than me because you went on WebMD. It's like me walking up to a Toyota engineer and saying "your stupid cuz you can't get me engine that gives 200mpg after reading an instruction manual on making a remote control car." Well something like that.

 

[billydoc]

I was a member of 1199 for RNs when I worked in inpatient setting. Yep! Staff nurses who provide direct patient care (!) with the help from the millitant communist organization such as 1199 are able to tell the big boys and girls...F*** You. If you don't pay us, or don't give pension, or don't pay fpr our family members we're walking out. And sometimes they do. Of course, sometimes there is a judge's order that prohibits striking, the X-mas time of 2005 in NY and the MTA fiasco comes to mind. But at least there is a public awareness. I think doctors must protect their own through some kind of meaningful alliance. Otherwise medicine will be gone, and sold down the river for good, IMHO.

 

[armonia]

I'm not so sure that doctors have an altruistic image in the public's eye. The 5-15min visit lengths aren't helping that cause either. Patient rapport and trust takes time and under the current system, it's near impossible to spend the 30+ min you'd like in order to fully hear your patients out. And, reimbursements continue to fall. It's interesting that insurance companies are still making money, however. So, we are being paid less for a less satisfying/rewarding job and being put through a training process that is dehumanizing.

We do need to take a stand and be politically active. We need to be more active about our training, more active about our practices, more active about reimbursements, and have a united front. We need to stand up not only for ourselves, but for our patients. I have had the (unfortunate) experience of haggling with an insurance company for coverage of care that was outlined as covered under my policy. They deemed the care I needed to be "not medically necessary." Frustrating to say the least. Now imagine if instead of a private company, it was an institution like the IRS that needed to be dealt with. I shudder to think of it. A situation without checks and balances. Government pays for healthcare -->government decides what healthcare services are necessary -->patient who needs care is now supposed to complain to government when care is not covered when justice system is part of the government?

I'm all for having everyone covered. I entered medicine because I wanted to help people, and I really do believe that physicians are in a unique position to do that at a most fundamental level. Current healthcare forces are encroaching upon out abilities to help our patients, from limiting the drugs we prescribe, to limiting the time with our patients, to making decisions on who gets admitted and for how long. It's particularly maddening, when the person calling to kick your patient out of the hospital (who, BTW, has new sudden onset neurological compromise and has just been given both high dose steroids and chemotherapy, and started on a drug that could lead to prompt respiratory depression) has an MD after his name, but has sold out to an insurance company. We need a system that makes insurance companies accountable for their actions, and makes them compete for business. A government run plan is likely to be even less accountable.

I am a little intrigued by the plan put forth by the governor of Massachusetts. Requiring people to buy insurance is an interesting concept. That should get rid of the "plasma tv vs health insurance" dilemna as well as the "I'm too young to need health insurance" mentality. I'm not exactly clear on who is providing the health insurance, however, and how the graded cost is getting paid for. If anyone has any links to concrete information about this plan, please post them on sdn. As for Mr.Schwartzenneger. . .what is the deal with levying a tax on hospitals and doctors in order to fund his plan? Let's see there's not enough money to pay for care, so lets charge the people who provide the care in order pay for the care that they would provide. Sounds a little circular to me.

Maybe we need to come forward with a coverage plan of our own. Maybe we need to start educating the public. Maybe we need an MD to run for president.

If change means unionizing, so be it.

 

[Taurus]

Wrong. Unions work because when they strike, they have people by the balls. The only question is: do doctors have the spine to stand up for temselves and fight?

Correct me if I'm wrong, but I thought that it was illegal for physicians to unionize for the reasons everyone is throwing around. So this talk about fighting back is a little misdirected. The best we can do to fight back is through the legislative process. I don't see much success there. So we're basically screwed. Cosmetics (cash only) here I come, baby!

 

[dutchman]

I'm not so sure that doctors have an altruistic image in the public's eye. The 5-15min visit lengths aren't helping that cause either. Patient rapport and trust takes time and under the current system, it's near impossible to spend the 30+ min you'd like in order to fully hear your patients out. And, reimbursements continue to fall. It's interesting that insurance companies are still making money, however. So, we are being paid less for a less satisfying/rewarding job and being put through a training process that is dehumanizing.

We do need to take a stand and be politically active. We need to be more active about our training, more active about our practices, more active about reimbursements, and have a united front. We need to stand up not only for ourselves, but for our patients. I have had the (unfortunate) experience of haggling with an insurance company for coverage of care that was outlined as covered under my policy. They deemed the care I needed to be "not medically necessary." Frustrating to say the least. Now imagine if instead of a private company, it was an institution like the IRS that needed to be dealt with. I shudder to think of it. A situation without checks and balances. Government pays for healthcare -->government decides what healthcare services are necessary -->patient who needs care is now supposed to complain to government when care is not covered when justice system is part of the government?

I'm all for having everyone covered. I entered medicine because I wanted to help people, and I really do believe that physicians are in a unique position to do that at a most fundamental level. Current healthcare forces are encroaching upon out abilities to help our patients, from limiting the drugs we prescribe, to limiting the time with our patients, to making decisions on who gets admitted and for how long. It's particularly maddening, when the person calling to kick your patient out of the hospital (who, BTW, has new sudden onset neurological compromise and has just been given both high dose steroids and chemotherapy, and started on a drug that could lead to prompt respiratory depression) has an MD after his name, but has sold out to an insurance company. We need a system that makes insurance companies accountable for their actions, and makes them compete for business. A government run plan is likely to be even less accountable.

I am a little intrigued by the plan put forth by the governor of Massachusetts. Requiring people to buy insurance is an interesting concept. That should get rid of the "plasma tv vs health insurance" dilemna as well as the "I'm too young to need health insurance" mentality. I'm not exactly clear on who is providing the health insurance, however, and how the graded cost is getting paid for. If anyone has any links to concrete information about this plan, please post them on sdn. As for Mr.Schwartzenneger. . .what is the deal with levying a tax on hospitals and doctors in order to fund his plan? Let's see there's not enough money to pay for care, so lets charge the people who provide the care in order pay for the care that they would provide. Sounds a little circular to me.

Maybe we need to come forward with a coverage plan of our own. Maybe we need to start educating the public. Maybe we need an MD to run for president.

If change means unionizing, so be it.

Amen

 

[NinerNiner999]

We have a "union"... of sorts, and it is called the AMA. They are the single largest organization by membership and they span all specialties. Even this group has lost its ability to provide meaninful support for physicians today. They have even sold themselves out on many levels, including funding and reimbursement. I am not a member of the AMA for this very reason.

Further, specialty organizations have their own firm lobbying agendas, which at times are at odds with the AMA's policy statements.

There are essentially two payment sources for healthcare in this country - the government and private insurance companies. This has only evolved over the past 40 years or so (in 1920 only 7% of Americans even had insurance!). Medicare has only been around since the late 60's. Blue Cross/Blue Shield insured the majority of patients up until the late 70's/early 80's.

Patients spend their insurance provider's money like they are buying clothes on daddy's credit card - they don't care how much it costs or how many times they need it. The same holds true for medicare. The funny thing is, private insurance companies know how to hedge their losses by increasing the premiums from their cleints - something the government has not yet figured out how to do. As mentioned previously, health insurance corporations still turn a profit, year after year, after year. This is because of their corporate health plans and abundant copay/premium collections.

Perhaps as physicians, we do not need to collectively bargain for our "rights." We are intelligent people and we are caught in between two battling giants (who often times don't even know they are at odds with each other because its easier to place the finger of blame at us). Maybe we should advocate that 1) patients take ownership of their healthcare by establishing medical savings accounts and 2) that the government place a cap on private insurance profiteering, and collect a portion of the insurance "profits" to alleviate the health care deficit.

Being an American is pretty funny, really. If you are sick, the doctor gets paid, and if you stay healthy, the insurance company gets paid. Either way, someone is getting paid for you, by you. I dont know about you, but I would rather pay myself if I stay healthy, and I would pay as much as I could to any doctor to keep me alive.

 

[dutchman]

Correct me if I'm wrong, but I thought that it was illegal for physicians to unionize for the reasons everyone is throwing around. So this talk about fighting back is a little misdirected. The best we can do to fight back is through the legislative process. I don't see much success there. So we're basically screwed. Cosmetics (cash only) here I come, baby!

It is not illegal to unionize, it is illegal for competing contractors to negotiate price under a union(antitrust). There are challenges in courts aimed at allowing physicians the ability to collectively bargain reimbursements with insurance companies, medicare and medicaid much like the pharmaceutical companies are doing. If you turn a blind eye(or run) without fighting, you could allow them pass laws(like they have in some countries) that make it very difficult to accept cash for medical services(hence your cosmetics). That is why an aggressive union and a fight is due. BTW, if we go to a single payer sytem/universal healthcare then the antitrust limitation is gone. If the Union(which is willing to strike) is already in place, physicians will be able to negotiate better.

 

[medgator]

Plus it goes to fund your residency program, things such as benefits, membership dues, lab coats, textbooks, educational costs, meals, etc. This varies widely by program...

And your medical malpractice! (Which I believe is a lion's share of the costs).

 

[Adam_K]

For an alternative view of Spitzer's plans:

http://www.city-journal.org/html/eon2007-02-08ng.html

 

[Littlemantate]

I think all the talk about taking a stand and standing up for docs rights etc is never gonna happen, atleast in our lifetime. I agree with the other poster that taking cash is the only way to drive this system in our favor. Atleast I also am going to be a cash only operation geared towards upscale/middle-class clients that can fork over the dough. I figure I pay my time treating the completely non-paying or illegal people during residency-so I do not feel I have to treat the poeple that are not going to pay me. I mean we are all altruistic enough but most of us, atleast me did not sign up for medicine to help people that do not pay-yes I wanted to help people but help them and be compensated. What motivation is there to attract any smart people into this field in the future if they know other avenues provide much better compensation?

There are very very few poeple in this business who are truly 100 percent in it for the altruistic factor-we all feel we deserve fair compensation for our time/money/sacrifice of training.

The other thing-and people talk about cosmetics is the place to be because it is cash pay-I am not sure if most of you realize but probably only the top 15-20 percent of plastics guys are raking in the money. The others are either doing reconstructive in hospitals or plastics on their own but are barely scraping by. It is TOUGH to break into that business. For one you are signifigantly older when done with all training. Then investing in your own practice, which is how the guys that make money do it. It is not like other docs that just join a practice, or more rarely does this occur. It is because the top plastics are business savvy-they are not necessarily the best plastic surgeon-sure you have to be good but the majority of the lay people cannot tell the diff between an amazing boob job and a pretty damn good one for exmaple.

Anyway bottom line is you need to have some business savviness regardless of what field you are in. For example I knew to primary care docs that invested and bought a radiological facility. They hired the radiologists and ran the facility and just made bank on the money brought in-more than the radiologists or anyone. Or for anesthesia starting your own pain clinics and going cash only. Even IM/peds/Family are starting to venture into the boutique medicine industry which is all cash pay to upper-end clients and your patient load is fixed at very few per year but all pay quite a big chunk to have you as their "personal phsyician" so to speak.

And psychiatrists for a long time have set up their own private practice that only takes cash-for them insurance has never paid them so this really will not effect them much-cutting from nothing is still nothing!

But the fact is that if you hope to make big bucks by working as an attending at a hospital or something and not venturing into your own project-you can expect to not make a whole lot of money-but it is like anything. A degree or skillset is just a tool to use to create your own business. All the very rich in this country are business owners of some type. (other than CEO's, lawyers) etc.

So yes it sucks but very little way out other than making a stand by saying we do not care what you do with reimbursments because we will not take the insurance, or rely on it. Then yes the poor will be punished but nothing gets the govt into action quicker than a public outcry regarding the poor being abused!