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Moving to Topics in Healthcare.
 

bronx43

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Which specialty serves to benefit most?
Nobody is getting a pay raise, I believe. Specialists will probably see a cap at $250k. Primary care will probably stay at $150k, maybe a bit more since there is now an influx of 50 million previously uninsured Americans.

One specialty that I think won't feel too much from this is ER. This bill will reduce the number of people who crowd the ER in search of basic care, due to a lack of insurance. Alot of ERs will at least have patients who will give them some sort of reimbursement.
 
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Will all this have any impact on independant testing? Will clinics and private practices have to adjust their costs on procedures or diagnostic testing at all?
 

CyberKnife19

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Nobody is getting a pay raise, I believe. Specialists will probably see a cap at $250k. Primary care will probably stay at $150k, maybe a bit more since there is now an influx of 50 million previously uninsured Americans.

One specialty that I think won't feel too much from this is ER. This bill will reduce the number of people who crowd the ER in search of basic care, due to a lack of insurance. Alot of ERs will at least have patients who will give them some sort of reimbursement.
Where do you get the $250K cap number?
 

Blue Dog

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Where do you get the $250K cap number?
Not in the bill, that's for sure.

It's interesting to note that in Massachusetts, the first state to experiment with mandated health insurance, they're now talking about capping payments to providers due to runaway costs. Of course, Washington appears to have learned nothing from this.

http://www.heartland.org/policybot/results/27114/Proposed_Caps_for_Massachusetts_Doctor_Payments_Could_Lead_to_Shortages.html

In a nutshell, here's what's in the bill related to physician compensation.

In 2011, Medicare will provide a 10% bonus payment to primary care and general surgeons.

In 2012, payment reforms will be implemented which will encourage doctors to form "accountable care organizations" to improve quality and efficiency of care.

In 2013, the Medicare payroll tax is raised to 2.35% from 1.45% for individuals earning >$200,000 and married couples with incomes >$250,000. Of course, that includes many doctors.

Also in 2013, Medicare would increase payments for Medicaid services TO PRIMARY CARE ONLY to make them at least equal to Medicare rates.

In 2015, Medicare will create a physician payment program aimed at rewarding quality of care rather than volume. The details of this are unclear at present.

http://www.reuters.com/article/idUSN1914020220100319

http://www.nytimes.com/interactive/2010/03/19/us/politics/20100319-health-care-reconciliation.html#tab=6

http://www.reuters.com/article/idUSTRE62H5AL20100319?loomia_ow=t0:s0:a49:g43:r1:c0.219262:b32034412:z0
 
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thedrjojo

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Not in the bill, that's for sure. It's interesting to note that in Massachusetts, the first state to experiment with mandated health insurance, they're now talking about capping payments to providers due to runaway costs. Of course, Washington appears to have learned nothing from this.

In a nutshell, here's what's in the bill related to physician compensation.

In 2011, Medicare will provide a 10% bonus payment to primary care and general surgeons.

In 2012, payment reforms will be implemented which will encourage doctors to form "accountable care organizations" to improve quality and efficiency of care.

Also in 2012, the Medicare payroll tax is raised to 2.35% from 1.45% for individuals earning >$200,000 and married couples with incomes >$250,000. Of course, that includes many doctors.

In 2013, Medicare would increase payments for Medicaid services TO PRIMARY CARE ONLY to make them at least equal to Medicare rates.

In 2015, Medicare will create a physician payment program aimed at rewarding quality of care rather than volume. The details of this are unclear at present.
So in 2013, the hospital my residency is at which gets 33% of its funding from Medicaid will see a nice increase in revenue... excellent news

Medicare is currently a regressive tax, since it is a flat rate taken from everyone, so while it takes 1.45% from everyone, that is from gross earnings, not net and not considering how much disposable income you have, so the less money you make, the more of your disposable income goes towards the FICA taxes (especially Social Security which has caps at 100K of earnings...). So this change in the rate makes the burden of Medicare (which everyone gets to benefit from when they become of age) have an equal impact on all those paying into it.
 

Blue Dog

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So in 2013, the hospital my residency is at which gets 33% of its funding from Medicaid will see a nice increase in revenue
Only if you're in a primary care residency. Not that you'll see any of it, of course. ;)

And if by "nice," you mean "paying the same crappy rates as Medicare," I suppose everything's relative.
 

Sneezing

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Which specialty serves to benefit most?
Primary care. Any and all government intrusion into healthcare falls under the usual law of unintended consequences. Government intervention will stagnate and anhilate anything good left in healthcare. The only groups that will benefit from this are those that have the ability to leave the system and operate cash only operations. Now they will have that extra impetus to seek their independence.

Primary care is best suited for this. Psychiatry, pediatrics, OB/GYN and possibly general surgery are also able to opt out.

All those dependent on insurance and government reimbursement will be hit hard. Radiology, Neurosurgery, ER, Ortho, etc...

Healthcare costs money and government intrusion is rationing. If you don't want to be controlled and rationed - leave the system.
 
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There's a few ways I see this playing out, and the most likely of which scares me.

Factor/s: More people that need to be covered=More money needed by insurance comps. to cover these people.

Outcomes:

A. The CEOs of insurance companies make massive salary cuts in the entire company in order to afford coverage for the newly insured. DON'T BET ON IT
B. The ins. comps. reimburse hospitals and physicians less for their work to account for the insurance companies costs. Physicians/Hospitals stop accepting insurance from that company. One of two things happen.
B1. The company swallows its pride and raises reimbursement rates again in order to persuade docs to accept their insurance. Everyone is happy. HOPEFULLY
B2. The company refuses to raise the rates to normal and goes out of business because no one accepts their coverage. Thousands are layed off and puts more stress on economy and employment reform. Eventually all companies fall victim to the same fate. Millions uninsured. Emergency legislation either requires doctors to accept insurance no matter what or a single payer system is developed to accommodate the public. THE SKY WILL FALL THEORY
 

Blue Dog

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The Democrats want single-payer.

Fortunately, they probably won't be in power long enough to make it happen.
 

EctopicFetus

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Nobody is getting a pay raise, I believe. Specialists will probably see a cap at $250k. Primary care will probably stay at $150k, maybe a bit more since there is now an influx of 50 million previously uninsured Americans.

One specialty that I think won't feel too much from this is ER. This bill will reduce the number of people who crowd the ER in search of basic care, due to a lack of insurance. Alot of ERs will at least have patients who will give them some sort of reimbursement.
ER visits went up in Mass by 11% per yr and in canada it was even more. not sure it is gonna help with the crowding.

Lastly, the 250k number is just some made up bs.
 

EctopicFetus

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Not in the bill, that's for sure.

It's interesting to note that in Massachusetts, the first state to experiment with mandated health insurance, they're now talking about capping payments to providers due to runaway costs. Of course, Washington appears to have learned nothing from this.

http://www.heartland.org/policybot/results/27114/Proposed_Caps_for_Massachusetts_Doctor_Payments_Could_Lead_to_Shortages.html

In a nutshell, here's what's in the bill related to physician compensation.

In 2011, Medicare will provide a 10% bonus payment to primary care and general surgeons.

In 2012, payment reforms will be implemented which will encourage doctors to form "accountable care organizations" to improve quality and efficiency of care.

Also in 2012, the Medicare payroll tax is raised to 2.35% from 1.45% for individuals earning >$200,000 and married couples with incomes >$250,000. Of course, that includes many doctors.

In 2013, Medicare would increase payments for Medicaid services TO PRIMARY CARE ONLY to make them at least equal to Medicare rates.

In 2015, Medicare will create a physician payment program aimed at rewarding quality of care rather than volume. The details of this are unclear at present.

http://www.reuters.com/article/idUSN1914020220100319

http://www.nytimes.com/interactive/2010/03/19/us/politics/20100319-health-care-reconciliation.html#tab=6

http://www.reuters.com/article/idUSTRE62H5AL20100319?loomia_ow=t0:s0:a49:g43:r1:c0.219262:b32034412:z0
From what I read the medicare tax would go into effect much later like 2014 or perhaps a bit later.
 

Blue Dog

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ER visits went up in Mass by 11% per yr
Right, because more insured patients + no access to primary care = more ED visits. Duh.

Can you say, "unintended consequences?" The health care bill is about politics, not reality.
 

EctopicFetus

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yes all about politics. Its not like in 2014 there are gonna be more primary care providers. Instead people will say Ill just go to the ER for my chronic knee pain since I have "insurance" (though thats not what it is) it wont cost me a dime. Ill just have to brush up on my Primary care / Urgent Care skills. Work is gonna be a whole lot busier!!!
 

EctopicFetus

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I'm just quoting what I'm reading.
I read different. Either way it sucks like all taxes. In the end if you make 350k it will cost you 1k more per yr but the expiration of the tax cuts is the biggest bummer.
 

Blue Dog

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Either way it sucks like all taxes. In the end if you make 350k it will cost you 1k more per yr but the expiration of the tax cuts is the biggest bummer.
Face it, as long as the Democrats are in power, the "rich" (a constantly moving target, depending on how much money the ever-enlarging government requires) will always get the shaft.
 
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Nobody is getting a pay raise, I believe. Specialists will probably see a cap at $250k. Primary care will probably stay at $150k, maybe a bit more since there is now an influx of 50 million previously uninsured Americans.

One specialty that I think won't feel too much from this is ER. This bill will reduce the number of people who crowd the ER in search of basic care, due to a lack of insurance. Alot of ERs will at least have patients who will give them some sort of reimbursement.

I think this is great, it means i will not look at my cousin's paycheck with envy. 250k is about the amount you get if you are a specialist in western europe, i (studying in western europe) and my cousin (studying in america) will earn comparable salaries :)
 
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Oh i forgot to add the quarter million student loan he has to pay lol, this is a field day for me, i gotta call him :)
 

bronx43

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Where do you get the $250K cap number?
I admit it's not a number that I derived scientifically, but it's inevitable that physician salary will decrease. Money is being drained out of the system, and it will undoubtedly lead to decreased reimbursement rates. The one thing that is keeping salaries so high is the fact that private insurers are still paying a good amount. The fact that they are getting a squeeze from the bill only means two things. Either they increase coverage prices, and/or decrease reimbursement rates. It will probably be a combination of the two.
 

Lokhtar

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I took a healthcare class this semester, and unfortunately for us, the assignment was to read and discuss the healthcare bill. That means, believe it or not, I've read all 2000+ pages on it - more than I bet most congresspeople have done (on either side).

Here is my conclusion:


The first thing to understand that this will not be repealed. Ever.

Regardless of what people are saying, no one will run on a platform of reopening the doughut hole for seniors, or enableing the re-denial of coverage by insurance companies. The first realistic chance of a repeal would be in 2012 if Obama loses AND Repubs have control of both houses, and by then many (though not all) will have been in effect.

Democrats are smart, they started closing the donought hole immediately, as well as staying on parents policies until 26, and no more children being denied due to pre-existing conditions, and new pools for high risk patients. Those start in 90 days. That means, by the time the first opportunity the bill has of realisitically being repealed, too many people will already be enjoying the entitlements and no politician will run on the platform of removing them.

Hands up for how many Republicans are currently running on the repeal of medicare? Why do you think they don't? It's a politically impossible position. They'd be booted out of office by double digit margins if they tried.

The only thing they could potentially repeal is the individual mandate to buy insurance. What people don't realize is that plays right into the hands of the democrats. If the individual mandate is repealed, that means insurance companies still have to cover everyone, but they don't get the benefit of having healthy young adults in their plan to subsidize the sick. You know what happens then? They go under, and guess what takes the private insurance's place? Yup - a government program, either an expansion of medicare ("medicare for all"), or another public program. This is why the strongest lobbyists for the mandate was the insurance industry, even if they were opposing the bill in general. But I don't think that is likely either, Obama is obviously going to veto any bill that tries to revoke this one, at least until 2012, and Dems will filibuster if they lose the Presidency and both houses of congress. Republicans won't get a foolproof vote majority until at least 2014 (at the earliest, if everything goes right for them, which in politics, it rarely does), and by then almost all the entitelement programs will be in effect. You're never going to get the 40 votes to filibuster, especially as the new Republican senators would have to come from centrist or left-leaning states who won't necessarily tow the line. I doubt that even if you held the vote in 2010, that people like Olympia Snowe and Susan Collins would necessarily vote for the repeal (remember that Snowe voted for the initial bill in the Senate committee, and the only thing she was opposed to was the mandate - she then opposed the bill in the general senate vote due to some of the changes that were inserted that she didn't like).

The final route, the challenge to the individual mandate in the courts, is going to fail. People don't realize that up until the mid nineties, the Republicans were the ones advocating an insurance mandate in response to Clintoncare. It's on solid footing, and it's just political point scoring by the attorneys general.

I hope that clears it a little bit for people. I am hardly an 'expert' but at least I've read the bill (yes, you can feel sorry for me, I had to read it), and I'd be happy to answer questions on it (believe me, I had to write enough reports on this thing over the last semester). I'll try to provide an honest answer that I'll back with actual page numbers in the bill (both the senate and the reconcilliation bill).
 
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bronx43

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Ah, finally, someone who knows what they're talking about. Thanks for sharing your knowledge, Lokhtar.

Firstly, can you explain exactly where the bill plans to cut spending in order to expand coverage, while reducing total spending by $130 billion in ten years?

I understand that it's a combination of taxes and Medicare cuts, but where exactly are those Medicare cuts coming from? Is it mostly just revoking Bush's pharmaceutical legislation, or further cuts to physician reimbursement?
 

Lokhtar

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Ah, finally, someone who knows what they're talking about. Thanks for sharing your knowledge, Lokhtar.

Firstly, can you explain exactly where the bill plans to cut spending in order to expand coverage, while reducing total spending by $130 billion in ten years?

I understand that it's a combination of taxes and Medicare cuts, but where exactly are those Medicare cuts coming from? Is it mostly just revoking Bush's pharmaceutical legislation, or further cuts to physician reimbursement?
First, remember that it does not reduce spending by $130 billion, it reduces the deficit by $130 billion - that can come from either reducing spending or raising revenue. In fact, this bill has few provisions on actually bending the cost curve down. Doing that is politically impossible for either party (real cost bending downward would have to be rationed care - e.g, actually deciding to pull the plug on grandma when she is 104 and has multiple organ failure - advocating which is political suicide, to put it modestly). You could also do some other things like tort reform, and that would add relief for doctors but it would not really bend the overall cost curve downward all that much (as you can see from states with tort reform, such as Texas). And remember that the CBO numbers are if everything in the bill stays as it is. It might be that some taxes are repealed later on, which would not result in deficit savings. So for example, if Republicans control the Presidency and both houses and re-apply the Bush tax cuts that will expire soon, there'd be deficits again.

Second, the money will come from the following places: increase by about 1% percent the medicare tax on individuals earning $200,000 and couples earning $250,000 or more. Note that it's a 1% overall increase, meaning the tax will go up from 2% of payroll to 3%, which is a 33% increase in the tax itself. These people will also see a tax increase in other areas, like capital gains, etc. Bush tax cuts will also expire, adding additional revenue. People making less will not see an increase. There are further taxes, some on the insurance companies itself, some on the really high end insurance plans that some people enjoy, some on the pharma industry, tax on dividends would increase, and actually a new tax is enacted on indoor tanning (10% more at the tanning salon if you want to look like Snookie from Jersey Shore). I can go into more detail on those if anyone wishes.

As for cuts in medicare, the doughnut hole will start to close immediately, but also, starting in 2011, there will be cuts in subsidies that the government provides to insurance companies who insure medicare patients. Eventually, the subsidies will run out completely, saving the government money there. Meaning, if you're a medicare patient and you want to buy additional coverage, you'll have to do it with your own money and not be subsidized by the federal government.

As for the benefits, the first ones start almost immediately, and the rest will be staggered in over the next five years, with new ones going into effect every year.
 
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bronx43

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First, remember that it does not reduce spending by $130 billion, it reduces the deficit by $130 billion - that can come from either reducing spending or raising revenue. In fact, this bill has few provisions on actually bending the cost curve down. Doing that is politically impossible for either party (real cost bending downward would have to be rationed care - e.g, actually deciding to pull the plug on grandma when she is 104 and has multiple organ failure - advocating which is political suicide, to put it modestly). You could also do some other things like tort reform, and that would add relief for doctors but it would not really bend the overall cost curve downward all that much (as you can see from states with tort reform, such as Texas). And remember that the CBO numbers are if everything in the bill stays as it is. It might be that some taxes are repealed later on, which would not result in deficit savings. So for example, if Republicans control the Presidency and both houses and re-apply the Bush tax cuts that will expire soon, there'd be deficits again.

Second, the money will come from the following places: increase by about 1% percent the medicare tax on individuals earning $200,000 and couples earning $250,000 or more. Note that it's a 1% overall increase, meaning the tax will go up from 2% of payroll to 3%, which is a 33% increase in the tax itself. These people will also see a tax increase in other areas, like capital gains, etc. Bush tax cuts will also expire, adding additional revenue. People making less will not see an increase. There are further taxes, some on the insurance companies itself, some on the really high end insurance plans that some people enjoy, some on the pharma industry, tax on dividends would increase, and actually a new tax is enacted on indoor tanning (10% more at the tanning salon if you want to look like Snookie from Jersey Shore). I can go into more detail on those if anyone wishes.

As for cuts in medicare, the doughnut hole will start to close immediately, but also, starting in 2011, there will be cuts in subsidies that the government provides to insurance companies who insure medicare patients. Eventually, the subsidies will run out completely, saving the government money there. Meaning, if you're a medicare patient and you want to buy additional coverage, you'll have to do it with your own money and not be subsidized by the federal government.

As for the benefits, the first ones start almost immediately, and the rest will be staggered in over the next five years, with new ones going into effect every year.
The figure I've seen for Medicare cuts was $500 billion over ten years. So, how much is going to come from closing the donut hole? And how much will be straight up cutting reimbursement rates?
 

Lokhtar

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The figure I've seen for Medicare cuts was $500 billion over ten years. So, how much is going to come from closing the donut hole? And how much will be straight up cutting reimbursement rates?
There is not much in the bill that directly cuts reimbursement rates directly. It actually fixes them for some states, like Washington, who have a lower cost and more efficient way of delivery. And some, like primary care physicians will see something like a 10% increase in reimbursement.

However, the other reforms may have the side effect of lower reimbursement rates - e.g, the insurance companies may have to cut physician reimbursement to stay in business. The medicare savings come from things like cutting out waste (there are provisions to reduce things like fraud). Now, there is language in there to reduce the growth of payment for many services provided under medicare, but not all of that involves physicians. Remember, the medicare subsidies to insurance that medicare patients buy supplementally will be eliminated - that's where the savings comes from. They will also encourage new models of care, and reward outcomes rather than tests done (though this is a bit vague in the bill, and the details will likely be hashed out later).

Remember that payments to physicians are supposed to decrease quite a bit - like 21% or so under medicare - but every year Congress passes legislation to delay those. That'll likely continue.

I took a healthcare class this semester, and unfortunately for us, the assignment was to read and discuss the healthcare bill. That means, believe it or not, I've read all 2000+ pages on it - more than I bet most congresspeople have done (on either side).

Here is my conclusion:


The first thing to understand that this will not be repealed. Ever.

Regardless of what people are saying, no one will run on a platform of reopening the doughut hole for seniors, or enableing the re-denial of coverage by insurance companies. The first realistic chance of a repeal would be in 2012 if Obama loses AND Repubs have control of both houses, and by then many (though not all) will have been in effect.

Democrats are smart, they started closing the donought hole immediately, as well as staying on parents policies until 26, and no more children being denied due to pre-existing conditions, and new pools for high risk patients. Those start in 90 days. That means, by the time the first opportunity the bill has of realisitically being repealed, too many people will already be enjoying the entitlements and no politician will run on the platform of removing them.

Hands up for how many Republicans are currently running on the repeal of medicare? Why do you think they don't? It's a politically impossible position. They'd be booted out of office by double digit margins if they tried.

The only thing they could potentially repeal is the individual mandate to buy insurance. What people don't realize is that plays right into the hands of the democrats. If the individual mandate is repealed, that means insurance companies still have to cover everyone, but they don't get the benefit of having healthy young adults in their plan to subsidize the sick. You know what happens then? They go under, and guess what takes the private insurance's place? Yup - a government program, either an expansion of medicare ("medicare for all"), or another public program. This is why the strongest lobbyists for the mandate was the insurance industry, even if they were opposing the bill in general. But I don't think that is likely either, Obama is obviously going to veto any bill that tries to revoke this one, at least until 2012, and Dems will filibuster if they lose the Presidency and both houses of congress. Republicans won't get a foolproof vote majority until at least 2014 (at the earliest, if everything goes right for them, which in politics, it rarely does), and by then almost all the entitelement programs will be in effect. You're never going to get the 40 votes to filibuster, especially as the new Republican senators would have to come from centrist or left-leaning states who won't necessarily tow the line. I doubt that even if you held the vote in 2010, that people like Olympia Snowe and Susan Collins would necessarily vote for the repeal (remember that Snowe voted for the initial bill in the Senate committee, and the only thing she was opposed to was the mandate - she then opposed the bill in the general senate vote due to some of the changes that were inserted that she didn't like).

The final route, the challenge to the individual mandate in the courts, is going to fail. People don't realize that up until the mid nineties, the Republicans were the ones advocating an insurance mandate in response to Clintoncare. It's on solid footing, and it's just political point scoring by the attorneys general.

I hope that clears it a little bit for people. I am hardly an 'expert' but at least I've read the bill (yes, you can feel sorry for me, I had to read it), and I'd be happy to answer questions on it (believe me, I had to write enough reports on this thing over the last semester). I'll try to provide an honest answer that I'll back with actual page numbers in the bill (both the senate and the reconcilliation bill).
In case people think I am wrong about the repeal, here's what some Republicans are saying this afternoon.

It hasn't even been twenty four hours. And already people are saying that they don't support the repeal the entitlements, and when they said start over, they don't mean 'start completely over'. Kind of opposite of what they were saying yesterday this time.

Starts 4:35 into it:

[YOUTUBE]http://www.youtube.com/watch?v=mR-Lm623M-g[/YOUTUBE]

See what I mean? :smuggrin:
 

EctopicFetus

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I admit it's not a number that I derived scientifically, but it's inevitable that physician salary will decrease. Money is being drained out of the system, and it will undoubtedly lead to decreased reimbursement rates. The one thing that is keeping salaries so high is the fact that private insurers are still paying a good amount. The fact that they are getting a squeeze from the bill only means two things. Either they increase coverage prices, and/or decrease reimbursement rates. It will probably be a combination of the two.
1st I am against the bill but lets keep things factual and honest.


Keep in mind that the bill is a 1 trillion dollar hc bill so to say that money is being drained out the system is not true. This will be "paid" (I dont think they get even 1/4 of this money) from taking out the fraud and waste in Medicare (50 billion per yr) and the medicare tax (another couple of hundred billion).

I think they will 1) increase premiums (see Mass) and cut reimbursement to some degree.
 

EctopicFetus

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A few points..

1) There is merit to the lawsuit from what con law scholars say. It doesnt mean that it will be overturned but never in the history of the US has the federal government tried to make someone pay for something like this. Car insurance is different since you can choose not to drive and many people do this.

2) If the CBO took into account the removal of the 21% cut in medicare payments the bill wouldnt cut the deficit.

3) I dont think the repubs will repeal it but they will make this an issue as long as possible into the elections since 59% of americans polled by CNN (a liberal company) oppose the current legistlation.
 

Lokhtar

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1) There is merit to the lawsuit from what con law scholars say. It doesnt mean that it will be overturned but never in the history of the US has the federal government tried to make someone pay for something like this. Car insurance is different since you can choose not to drive and many people do this.
Yes, but they will argue it is simply a tax on all, and it's a rebate to those who have something. They'll find a way to keep it legal even if they have to change the wording as a result of the ruling - remember that republicans also proposed this in the 90s. Never underestimate the ability of the government to find a way to get a new source of revenue. :)

In any case, if it is not, repealing this provision will have disastrous consequences for private insurance, and will be a huge boon to the medicare for all and the public option crowd.

2) If the CBO took into account the removal of the 21% cut in medicare payments the bill wouldnt cut the deficit.
True and false. It wouldn't cut the deficit as much, but there'd be a deficit reduction still, especially in the second ten years.

3) I dont think the repubs will repeal it but they will make this an issue as long as possible into the elections since 59% of americans polled by CNN (a liberal company) oppose the current legistlation.
True. And they may win big # of seats. But that is not relevant to the discussion of this healthcare bill - it will not be repealed even if they win big in elections.

And it is very important to note that while a majority opposes the bill, if you poll them on individual entitlements in the bill, the public overwhelmingly supports it. Hence when they actually start receiving the benefits, the message of the Republican repeal of the bill may not go over as well as it does now. It would be hard to say 'repeal the bill', but then say 'well, but you can keep this and that'. That is of course political conjecture, and much will depend on how both sides spin their side over the next seven months. That's an eternity in political time and I am not a political pundit! So you may be right or wrong, but either way, the main sections of the bill are not going away.

The taxes may be reduced (in which case bigger deficits), or the mandate may go away (in which case insurance companies are in trouble), but the entitlements will not go away (which is the point of the bill from the perspective of the healthcare providers).
 

EctopicFetus

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Yes, but they will argue it is simply a tax on all, and it's a rebate to those who have something. They'll find a way to keep it legal even if they have to change the wording as a result of the ruling - remember that republicans also proposed this in the 90s. Never underestimate the ability of the government to find a way to get a new source of revenue.

In any case, if it is not, repealing this provision will have disastrous consequences for private insurance, and will be a huge boon to the medicare for all and the public option crowd.
I dont doubt it but if they find this unconstitutional then the bill gets tossed and it has to be passed again from scratch. They cant just cut one part of it out. I know repubs proposed this before but that doesnt make it any more constitutional. The devil is in the details.

True and false. It wouldn't cut the deficit as much, but there'd be a deficit reduction still, especially in the second ten years.
Negative. Everything I read is that without the doctor fix there are no savings. Additionally we all know that those savings wont be there because as the former CBO chief said they cant take into account people's behavior. What we know is that people will act accordingly to save their money.

http://www.miamiherald.com/2010/03/19/1538190/some-analysts-question-cbo-estimates.html

Another interesting bit from the current CBO director

Today, in a letter responding to questions from Congressman Ryan, CBO described the effects on the federal budget of enacting the reconciliation proposal and the Senate-passed health bill if:

* The excise tax on insurance plans with relatively high premiums—which would take effect in 2018 and for which the thresholds would be indexed at a lower rate beginning in 2020—was never implemented;
* The annual indexing provisions for premium subsidies offered through the insurance exchanges continued in the same way after 2018 as before—in contrast with the reconciliation proposal, which would slow the growth of subsidies after 2018;
* The adjustment to physician payment rates under Medicare that was passed by the House last fall was included; and
* The Independent Payment Advisory Board—which would be required, under certain circumstances, to recommend changes to the Medicare program to limit the rate of growth in that program's spending, and whose recommendations would go into effect automatically unless blocked by subsequent legislative action—was never implemented.

We estimated that if this set of changes was made, the legislation as modified would increase federal budget deficits during the decade beyond 2019 relative to those projected under current law—with a total effect during that decade in a broad range around one-quarter percent of GDP.
http://cboblog.cbo.gov/?p=524

FWIW in todays dollars 0.25% of our is GDP 36 billion so over a decade thats 360 billion if I am reading that right.

Also this assumes our GDP doesnt move.
 

Lokhtar

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I dont doubt it but if they find this unconstitutional then the bill gets tossed and it has to be passed again from scratch. They cant just cut one part of it out. I know repubs proposed this before but that doesnt make it any more constitutional. The devil is in the details.
That is not true - they can rule the provision illegal. Congress can simply amend the provision. I don't think they have to vote on the bill again.

Example: http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2007/09/27/MNJ5SF21D.DTL

If you have any information to the contrary, could you provide a source because I am genuinely interested in this topic.

With that said, lawsuits are not fast. It will take years to get to the supreme court (you know there'll be constant challenges from both sides). By that time, the subsidies will have benefited tens of millions, and they won't be simply allowed to expire and leave the people hanging without insurance. Politically, it's suicide.


Negative. Everything I read is that without the doctor fix there are no savings.
Where do you read that from? My data comes from, "Table 6", Section "Changes in Deficits", under "Title I - Coverage, Medicare, Medicaid, and Revenues". It's on page 34 under the CBO report titled, "H.R. 4872, Reconciliation Act of 2010".

I've read like 4000 pages of the bill, the CBO reports, and a bunch of legal briefs for my class, so some things are running together, so please forgive me if I miss some details and I apologize in advance for anything I get wrong. It's not on purpose, or for a specific agenda (to be honest, I care absolutely nothing about deficits from this bill, so this is a very academic discussion for me, but one I'd like to get accurate). If I am asked, I'll definitely go back and look up and quote my sources, and of course, withdraw any factually inaccurate statements :).
 
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JaggerPlate

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Lok ... this is fantastic. Compared to the thread in pre-allo, this is poetry. A few questions ...

1. This one is actually for you and Blue Dog ...

Aren't some of these catch phrases 'increase efficiency,' 'reducing waste,' 'groups working together,' just code for managed care? Is this the direction the government wants medicine, specifically primary care to take? PC docs working on salaries for big groups, receiving bonus incentives for making sure the group doesn't incur overages by being 'efficient' - not ordering too many tests, seeing patients quickly, short hospital stays, etc ???

2. So Lok ... if I follow your logic:

The Republicans, initially - probably just on an emotionally charged issue, discussed overturning the insurance mandate. You argue that this could cut the revenue out of these insurance companies, they would start failing, and the government would take over ... essentially giving dems what they want?

Do you also think this is true at the state appeal level (ie the 36ish states drafting language to 'sue' the government so that their citizens aren't responsible for the mandate).

Am I following that correctly? Furthermore, you now think Republicans understand the outcome of tearing this down, and don't suggest it? What about at the state level?

3. What is your opinion on the 'doc fix?' Are the dems going to do it before mid-terms???
 

EctopicFetus

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That is not true - they can rule the provision illegal. Congress can simply amend the provision. I don't think they have to vote on the bill again.

Example: http://www.sfgate.com/cgi-bin/articl.../MNJ5SF21D.DTL

If you have any information to the contrary, could you provide a source because I am genuinely interested in this topic.

With that said, lawsuits are not fast. It will take years to get to the supreme court (you know there'll be constant challenges from both sides). By that time, the subsidies will have benefited tens of millions, and they won't be simply allowed to expire and leave the people hanging without insurance. Politically, it's suicide.
They can rule the "provision Illegal" but look at things like roe v wade etc. I spoke to my wife (a law prof) and she said typically the whole law gets tossed. It is based on a few things but in the end since this provision is key to the whole bill it would LIKELY (not for sure since she doesnt know for sure) make the whole law null.

2) this could be fast tracked which is what the florida AG said he wants. Look at Bush v Gore that hit the supreme court, was ruled on and decided between the beginning of Nov (the election) and Jan 20 (inauguration day).

BTW one of the reasons they didnt use the "slaughter" rule was simply because this would add to the questions of constitutionality. Currently they are gonna fight one 2 issues. 1) the 10th amendment which says basically that the govt cant make the states spend money and 2) that it cant mandate people to pay for something just because (auto insurance being different since driving is a choice). In the end I dont know how it will pan out, will just this one part come out or will the whole thing fall apart IF they find it unconstitutional. I do know that the US SC is right leaning (now) and Scalia and others are BIG states rights folks and big on individual rights. I am not a lawyer so I dont know how this will play out but I do think it is interesting. If you find something different about what would happen let me know.

http://www.cnn.com/2010/POLITICS/03/22/health.care.lawsuit/index.html?hpt=T1

McCollum said the lawsuit would challenge the bill's provision requiring people to purchase health insurance, along with provisions that will force state government to spend more on health care services.

"This is a tax or a penalty on just living, and that's unconstitutional," he said of the mandate to purchase health coverage. "There's no provision in the Constitution of the United States giving Congress the power to do that."

McCollum also said that portions of the bill would force states to spend money they don't have, which he called a violation of the 10th Amendment to the Constitution.
McCollum said he expected the lawsuit to eventually reach the U.S. Supreme Court.
In the current system they could fast track it and then appeal directly to the US SC. The SC has the choice to hear it and their decisions as you know are not subject to appeal. Lastly, keep in mind that the US SC (theoretically) only decides if something is constitutional or not, it doesnt matter how many people have benefited from this.

Regarding the deficits and stuff see the post right above yours. If those things are fixed we would run a deficit of over 36 billion per yr or 360 billion per decade during the 2020's.

Keep in mind in reconciliation they dont talk about the doctor fix, but we all know it is gonna happen.
 

EctopicFetus

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3. What is your opinion on the 'doc fix?' Are the dems going to do it before mid-terms???
The doc fix is due to expire on Oct 1 so either they patch it again (like 8 years now) or they put through a real fix. One way or another things will happen on or around Oct 1.
 

JaggerPlate

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The doc fix is due to expire on Oct 1 so either they patch it again (like 8 years now) or they put through a real fix. One way or another things will happen on or around Oct 1.
Thanks.


Just read your above post on taking the issue to the SC. Quite interesting.
 

Blue Dog

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Aren't some of these catch phrases 'increase efficiency,' 'reducing waste,' 'groups working together,' just code for managed care? Is this the direction the government wants medicine, specifically primary care to take? PC docs working on salaries for big groups, receiving bonus incentives for making sure the group doesn't incur overages by being 'efficient' - not ordering too many tests, seeing patients quickly, short hospital stays, etc ???
Indeed, Accountable Care Organizations (ACOs) sound very much like HMOs.
 

Lokhtar

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They can rule the "provision Illegal" but look at things like roe v wade etc. I spoke to my wife (a law prof) and she said typically the whole law gets tossed. It is based on a few things but in the end since this provision is key to the whole bill it would LIKELY (not for sure since she doesnt know for sure) make the whole law null.
Your wife might be right. I'm not a lawyer, nor do I play one on TV, so I have to go by what others tell me.
http://www.nytimes.com/2010/03/23/health/policy/23legal.html

Prof. Randy E. Barnett, who teaches constitutional law at Georgetown University Law Center and has been critical of the bill, said a constitutional challenge to the individual requirement to purchase insurance is a “a serious argument that might have success.”
Still, Professor Barnett was careful not to predict that the opponents of the bill would block the legislation completely. He said that even if a court were to strike down the requirement to buy insurance, such a ruling would still be likely to leave other elements of the law in place.
Professor Balkin of Yale said the mandate did not run afoul of the Constitution because Congress had carefully structured it as a tax — and taxes are fully within its power.
 

Lokhtar

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Lok ... this is fantastic. Compared to the thread in pre-allo, this is poetry. A few questions ...

1. This one is actually for you and Blue Dog ...

Aren't some of these catch phrases 'increase efficiency,' 'reducing waste,' 'groups working together,' just code for managed care? Is this the direction the government wants medicine, specifically primary care to take?
It is, among other things. And yes, that's the direction they want doctors to take.

The Republicans, initially - probably just on an emotionally charged issue, discussed overturning the insurance mandate. You argue that this could cut the revenue out of these insurance companies, they would start failing, and the government would take over ... essentially giving dems what they want?
Not all dems. Remember the public option and complete single payer isn't in the bill because there are enough dems who oppose it. But yes, there is a significant number in the progressive caucus who want single payer, and keeping the restrictions and killing the mandate is going to be really bad for the insurance companies and the premiums will skyrocket as a result, giving the single payer crowd - or at least the strong public option crowd - all the ammunition they need. The mandate is in there because the insurance companies begged for it lest they go bankrupt!


Do you also think this is true at the state appeal level (ie the 36ish states drafting language to 'sue' the government so that their citizens aren't responsible for the mandate).
The idea that states are sovereign has expired a very long time ago, but the answer is true. If you don't have the mandate and young healthy people don't buy insurance...the insurance pool gets older and sicker, hence higher premiums. Everyone in my class discussion who did research on this (and we have a few libertarians, republicans, etc as well) agreed that the best way toward a single payer and/or a strong public option would be to keep the bill and drop the mandate.

Am I following that correctly? Furthermore, you now think Republicans understand the outcome of tearing this down, and don't suggest it? What about at the state level?
Oh, people generally have a visceral reaction to being told what to do. Republicans will likely try to capitalize on that and still rail against the mandate even if they realize what's coming after. In politics, generally, getting elected usually trumps ideological policy considerations :). But I'm not a political analyst, so I can't tell you exactly how either side will take this debate.
 
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Instatewaiter

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Here's a healthcare analogy from a classmate of mine:

10 third graders that want candy are in a room with 5 pieces of candy. The liberals' solution - place 5 more third graders in the room and simultaneously decrease funding to the candy supplier. Most elementary school children would argue that this is not a viable solution
 

Lokhtar

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Here's a healthcare analogy from a classmate of mine:

10 third graders that want candy are in a room with 5 pieces of candy. The liberals' solution - place 5 more third graders in the room and simultaneously decrease funding to the candy supplier. Most elementary school children would argue that this is not a viable solution
Doesn't quite work with this bill :). Medicare reimbursement is not decreasing (though federal subsidies for insurance plans under Medicare Advantage is), and more people will be part of the private insurance than there are now.

A closer analogy to this bill would be that there are five pieces of candy and ten students. The government is adding five more pieces of candy to the room by increasing the taxes on the candy maker and forcing the candy supplier to give equal candy to all the kids.
 

MOHS_01

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Doesn't quite work with this bill :). Medicare reimbursement is not decreasing (though federal subsidies for insurance plans under Medicare Advantage is), and more people will be part of the private insurance than there are now.

A closer analogy to this bill would be that there are five pieces of candy and ten students. The government is adding five more pieces of candy to the room by increasing the taxes on the candy maker thereby forcing those who pay to pay for those who do not and then redistributing the candy to more of the kids.
Fixed it for you.
 

MOHS_01

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Yes, you are right of course, I am not disagreeing with you there :). Most services are diproportionately paid for by those who make more. This is no different, those making more than $250,000 will be paying for the bulk of this.
You're still kidding yourself my friend. Yes, it is true that the direct tax will be levied disproportionately according to income, but the total costs will be much more widely distributed in the form of increased premiums that will result from this colossal cluster**** piece of legislation. If you lessen the capacity to segregate out on risk and remove the expenditure cap as is done with this legislation, how do you propose the actuarial studies will be performed? In addition to this, insurance companies have regulatory capital requirements that will cause an immediate increase in premium revenues to offset future losses that will invariably result from this POS legislation.

Tell me again who wins? Tell me again how this is anything more than a welfare entitlement program? Vote buying?
 

EctopicFetus

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I took a healthcare class this semester, and unfortunately for us, the assignment was to read and discuss the healthcare bill. That means, believe it or not, I've read all 2000+ pages on it - more than I bet most congresspeople have done (on either side).

Here is my conclusion:


The first thing to understand that this will not be repealed. Ever.

Regardless of what people are saying, no one will run on a platform of reopening the doughut hole for seniors, or enableing the re-denial of coverage by insurance companies. The first realistic chance of a repeal would be in 2012 if Obama loses AND Repubs have control of both houses, and by then many (though not all) will have been in effect.

Democrats are smart, they started closing the donought hole immediately, as well as staying on parents policies until 26, and no more children being denied due to pre-existing conditions, and new pools for high risk patients. Those start in 90 days. That means, by the time the first opportunity the bill has of realisitically being repealed, too many people will already be enjoying the entitlements and no politician will run on the platform of removing them.

Hands up for how many Republicans are currently running on the repeal of medicare? Why do you think they don't? It's a politically impossible position. They'd be booted out of office by double digit margins if they tried.

The only thing they could potentially repeal is the individual mandate to buy insurance. What people don't realize is that plays right into the hands of the democrats. If the individual mandate is repealed, that means insurance companies still have to cover everyone, but they don't get the benefit of having healthy young adults in their plan to subsidize the sick. You know what happens then? They go under, and guess what takes the private insurance's place? Yup - a government program, either an expansion of medicare ("medicare for all"), or another public program. This is why the strongest lobbyists for the mandate was the insurance industry, even if they were opposing the bill in general. But I don't think that is likely either, Obama is obviously going to veto any bill that tries to revoke this one, at least until 2012, and Dems will filibuster if they lose the Presidency and both houses of congress. Republicans won't get a foolproof vote majority until at least 2014 (at the earliest, if everything goes right for them, which in politics, it rarely does), and by then almost all the entitelement programs will be in effect. You're never going to get the 40 votes to filibuster, especially as the new Republican senators would have to come from centrist or left-leaning states who won't necessarily tow the line. I doubt that even if you held the vote in 2010, that people like Olympia Snowe and Susan Collins would necessarily vote for the repeal (remember that Snowe voted for the initial bill in the Senate committee, and the only thing she was opposed to was the mandate - she then opposed the bill in the general senate vote due to some of the changes that were inserted that she didn't like).

The final route, the challenge to the individual mandate in the courts, is going to fail. People don't realize that up until the mid nineties, the Republicans were the ones advocating an insurance mandate in response to Clintoncare. It's on solid footing, and it's just political point scoring by the attorneys general.

I hope that clears it a little bit for people. I am hardly an 'expert' but at least I've read the bill (yes, you can feel sorry for me, I had to read it), and I'd be happy to answer questions on it (believe me, I had to write enough reports on this thing over the last semester). I'll try to provide an honest answer that I'll back with actual page numbers in the bill (both the senate and the reconcilliation bill).
Ah, finally, someone who knows what they're talking about. Thanks for sharing your knowledge, Lokhtar.

Firstly, can you explain exactly where the bill plans to cut spending in order to expand coverage, while reducing total spending by $130 billion in ten years?

I understand that it's a combination of taxes and Medicare cuts, but where exactly are those Medicare cuts coming from? Is it mostly just revoking Bush's pharmaceutical legislation, or further cuts to physician reimbursement?
There is not much in the bill that directly cuts reimbursement rates directly. It actually fixes them for some states, like Washington, who have a lower cost and more efficient way of delivery. And some, like primary care physicians will see something like a 10% increase in reimbursement.

However, the other reforms may have the side effect of lower reimbursement rates - e.g, the insurance companies may have to cut physician reimbursement to stay in business. The medicare savings come from things like cutting out waste (there are provisions to reduce things like fraud). Now, there is language in there to reduce the growth of payment for many services provided under medicare, but not all of that involves physicians. Remember, the medicare subsidies to insurance that medicare patients buy supplementally will be eliminated - that's where the savings comes from. They will also encourage new models of care, and reward outcomes rather than tests done (though this is a bit vague in the bill, and the details will likely be hashed out later).

Remember that payments to physicians are supposed to decrease quite a bit - like 21% or so under medicare - but every year Congress passes legislation to delay those. That'll likely continue.


In case people think I am wrong about the repeal, here's what some Republicans are saying this afternoon.

It hasn't even been twenty four hours. And already people are saying that they don't support the repeal the entitlements, and when they said start over, they don't mean 'start completely over'. Kind of opposite of what they were saying yesterday this time.

Starts 4:35 into it:

[YOUTUBE]http://www.youtube.com/watch?v=mR-Lm623M-g[/YOUTUBE]

See what I mean? :smuggrin:
You're still kidding yourself my friend. Yes, it is true that the direct tax will be levied disproportionately according to income, but the total costs will be much more widely distributed in the form of increased premiums that will result from this colossal cluster**** piece of legislation. If you lessen the capacity to segregate out on risk and remove the expenditure cap as is done with this legislation, how do you propose the actuarial studies will be performed? In addition to this, insurance companies have regulatory capital requirements that will cause an immediate increase in premium revenues to offset future losses that will invariably result from this POS legislation.

Tell me again who wins? Tell me again how this is anything more than a welfare entitlement program? Vote buying?
The real losers will be everyone who has insurance. Truth is the costs will skyrocket. There is a reason why Mass HC premiums are 2nd highest in the US and over 50% more than they are here in arizona. In the end I think being an ED doc this will make me more money even if I may have to pay 0.9% more on a portion of my income. Of course accountants are smart and we will just take that money in a way the government will never see to limit our tax liability.

This is gonna hurt employers and our recovery. On the brighter side we will give a few (not 30 million) people insurance. I am 100% for fixing things for the "working poor" but everyone else can take care of themselves in my opinion. How weird is it that of the 40+ million "uninsured" 10 or so would qualify now but havent applied?
 

JaggerPlate

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How weird is it that of the 40+ million "uninsured" 10 or so would qualify now but havent applied?
I can't tell if you're being sarcastic, but as an ED attending ... you must know that people don't give a **** about their health. A huge chunk of the population would spend their whole paycheck on ciggies and fast food before they gave .02 seconds/cents to health insurance. Even if the options are just sitting out there, waiting for them.
 

JaggerPlate

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Indeed, Accountable Care Organizations (ACOs) sound very much like HMOs.
:thumbdown: This has been my thought for a while now. Not good to hear it confirmed. I personally think working in this model sounds awful for essentially all concerned (except the organization itself). It's 0% surprising, but disappointing nonetheless. Do you think there will be more fire breathed into the concierge/cash for service model? Especially when these 'ACOs' are overrun with newly insured, and those previously insured, more used to the norm, will start looking for something different??