Future of EM in Obamaworld

[Speed Racer]

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Just wondering what the Attendings and Health policy/business people and people with more polished crystal balls (hehe) than mine think about the direction EM will take in the Obama years.

More/Less profitable

More/Less mis-utilized

More/Less Legal

More/Less Customer service (this may be independent)

More/Less Specialty back up

And anything else: Overcrowding,

One scary thought I had is that more people will be covered by government health insurance (Read:medicaid) and the government MANDATES that we must see everyone (EMTALA).... If I was a cost conscious Fed Desk Jockey, I would just tell ED's that if some one shows up to your ED to receive primary care type treatment, you will be paid as such. And we have no leverage in that situation. A single payer that also writes the legislation.....scary

Alternatively, if they deem the ED's as the safety net for the new Socialist health care system, perhaps we will get direct Gubment subsidies?

 

[NEATOMD]

I don't think the socialisation of healthcare in the US is going to fix it. It will definitely fix some problems, but will undoubtedly create new ones. I get frustrated when I hear the argument that it ought to be socialized because we spend too much and are ranked so low internationally for outcomes. That's funny, becuase we have a socialized education system, that is equally broken. Our social security system sure looks good too...

Anyway, I better stop.

 

[177983]

Our social security system sure looks good too...

I won't argue with the education system comment, but social security actual does its job amazingly well. It's reduced poverty in the elderly population enormously. It runs at like a 3% overhead which is fantastic. It's just damn expensive and going to get more so as the demographics of the U.S. shift.

When soc. security was first passed, the average life span of an American was 62. So, only a pretty small fraction of Americans ever received social security in their lifetime. If we bumped up the time social security kicked in to say 72 (still 6 years less than our current life expectancy), all our problems would be solved. But as Americans, we want to have our cake and eat it too, hence the constant dilemma of how to finance our bloated government spending.

As for the actual topic, Obama doesn't want to socialize medicine and never has said anything of the sort. Many people fear that's the way it will go, but I doubt that. More likely in my mind is a single-payer system similar to Canada's, which is different from a completely socialized system a la Britian's NHS. Think of single-payer as Medicare that everyone's eligible for. Shudder if you want. However, I think if you have the money you'll be able to opt for supplementary insurance and extra special care at a private facility. American's just won't go for a completely forced system. Hilary tried it and failed. Obama and all Dems have learned their lesson and will be more cautious. As for my thoughts on Obama's plan:

More/Less profitable: I think more because everyone who walks through the door should have insurance.

More/Less mis-utilized: Bout the same. More people will go see a PCP because they have the ins. to pay for it, but so others will use the same insurance to go to the ER.

More/Less Legal: Sadly, Obama and most Dems are anti-tort reform. Can't see this getting any better soon...

More/Less Customer service (this may be independent): Not sure what you mean here...

More/Less Specialty back up: Maybe more, though I doubt it. I can't imagine the Obama heath plan will be so lucrative that specialists will be suddenly clamouring to have them as patients. So, I don't think this will improve.

I think the Obama plan (as he talked about it during the campaign) will be a good thing for patients, but a mixed bag for docs. Sure, fewer will be uninsured, but I don't think the plan will be much better financed than Medicare. So, you'll have fewer non-payers, but potentially more lower-end payers. Not sure how it will all play out. I don't think this is the apocalypse, but docs will probably have to keep fighting for pay as they currently do every year with Medicare. Despite all the schooling and loans it takes and the fact that 99% of Americans couldn't shoulder all the work to do it, $200,000-$300,000 still seems like an exorbitant salary to the average American household. So, doctors don't get huge sympathy from the general public when they ask for more money. The median American household made like $45,000 in 2007, so when a single person pulls in 3-5 times that, most people can't imagine that doctors are hurting in any way.

 

[igottaquestion]

no, his plan is *not* single-payer. it retains the costly third-wheel of profit-seeking insurance companies, whose ceos, actuaries, etc. (as well as medical billers) add no value to the actual medical care received by patients. his plan would extend our current broken system to those who currently don't have insurance. this is *not* the single-payer solution that groups such as PNHP espouse, so any potential failures cannot be blamed on the idea of single-payer. unfortunately, a true single-payer system isn't very politically feasible right now, in some part because of people like the op trying to "red scare" people away from engaging the idea intellectually, by calling it "socialized" in order to evoke a knee-jerk reaction. government provision has its place for some services, and i believe health care funding is one of them.

and to have a non-socialized education system, in which people must pay directly out-of-pocket for multi-tiered private education (read: much of the population who can't afford or don't value education opt out and don't go to school)? yeah, i'm sure that would be really good for future job markets, crime rates, etc. i argue that our education system isn't "socialized" enough, in that disparities are created among schools when school funding is tied to local property taxes instead of on a more non-local basis. poor kids who already have the deck stacked against them for educational achievement go to poor schools.

 

[southerndoc]

I think our reimbursements will increase as all patients will be insured (if the plan from Senator Baucus passes). However, if the part barring insurance companies from discriminating based on pre-existing conditions or age passes, then we will have more paying patients, but less reimbursement per patient.

 

[GeneralVeers]

I don't believe Obama will fundamentally change health care during his 8-year tenure in office. He will implement small changes and add new entitlements that will shape the course of health care for the next 50 years.

1. Although he does not explicitly say he wants a single payer system, he does want to provide Federally-paid-for insurance to more people. This will essentially represent an expansion of Medicare, tying more of our reimbursement to the government.

2. Expansion of SCHIP will further increase government-funded health care

3. Cuts in medicare reimbursement would be likely. There is simply no other way to pay for the massive expansion he is asking for. We likely wouldn't see immediate cuts, rather medicare rates would not increase with inflation or cost-of-living. Salary caps would probably not be out of the question.

The result of his plan will push more and more people onto the government plan. Private insurance will still play a part, however bigger and bigger portions of our salary will be paid for by government. We all hate the CMS core measures, well it's going to get worse. With CMS paying the majority of our salaries they are going to implement more "quality improvement measures" that we must comply with.

Just remember, the public is our enemy. Most of them believe that we are rich, greedy, and charge them too much for care. If something needs to be cut to pay for an expansion of the system, we are first on the chopping block, as there is little immediate political consequence to punishing doctors.

 

[EM2BE]

I don't believe Obama will fundamentally change health care during his 8-year tenure in office. He will implement small changes and add new entitlements that will shape the course of health care for the next 50 years.

1. Although he does not explicitly say he wants a single payer system, he does want to provide Federally-paid-for insurance to more people. This will essentially represent an expansion of Medicare, tying more of our reimbursement to the government.

2. Expansion of SCHIP will further increase government-funded health care

3. Cuts in medicare reimbursement would be likely. There is simply no other way to pay for the massive expansion he is asking for. We likely wouldn't see immediate cuts, rather medicare rates would not increase with inflation or cost-of-living. Salary caps would probably not be out of the question.

The result of his plan will push more and more people onto the government plan. Private insurance will still play a part, however bigger and bigger portions of our salary will be paid for by government. We all hate the CMS core measures, well it's going to get worse. With CMS paying the majority of our salaries they are going to implement more "quality improvement measures" that we must comply with.

Just remember, the public is our enemy. Most of them believe that we are rich, greedy, and charge them too much for care. If something needs to be cut to pay for an expansion of the system, we are first on the chopping block, as there is little immediate political consequence to punishing doctors.

I usually don't like to dispute, but I have a few things to say here. For one, elections for presidency occur every 4 years, so we aren't guaranteed 8 yrs of Obama. In addition, a similar program in Hawaii has failed, which in my mind means SCHIP is about to fail as well unless a lot more money is put in to the plan and there are stricter standards as to who gets to receive the benefits.

Here's the Hawaii form of SCHIP:

Child Universal Health Care in Hawaii

Many articles are available on this if you do a search for universal child health care.

 

[GeneralVeers]

I usually don't like to dispute, but I have a few things to say here. For one, elections for presidency occur every 4 years, so we aren't guaranteed 8 yrs of Obama. In addition, a similar program in Hawaii has failed, which in my mind means SCHIP is about to fail as well unless a lot more money is put in to the plan and there are stricter standards as to who gets to receive the benefits.

1. Obama is pretty much guaranteed 8 years, as long as the Republicans keep nominating horrible candidates like Palin.

2. I never said that SCHIP would work, just that Obama will implement it. He's already stated that he'd support it, and the Democratic Congress tried to expand the program last year.

In that Hawaii article you cited, it's interesting to note that parents who could afford health insurance for their children dropped the private insurance to get the "free" government plan. I predict something similar will happen when Obama offers free government care to everyone.

 

[EM2BE]

I predict something similar will happen when Obama offers free government care to everyone.

Me too. So unfortunate that is the attitude of people (if it's free for some people and I can get it for free, then I'll quit trying to do things on my own).

 

[southerndoc]

1. Obama is pretty much guaranteed 8 years, as long as the Republicans keep nominating horrible candidates like Palin.

Ugh, wasn't McCain the party nominee this year? And didn't the American Republicans choose him over the other people running for the party's nomination?

 

[leviathan]

Interesting read about universal healthcare. Very biased but still worth a read:

http://www.cmaj.ca/cgi/content/full...FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT

 

[GeneralVeers]

Not just a bit biased:

Marcia Angell is a senior lecturer in social medicine, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA

Doesn't get much more socialist than a Canadian doctor who supports global health initiatives working at an Ivy League East Coast school.

 

[EC3]

nothing is going to change in healthcare until the American mentality and culture change. i'm not holding my breath, though.

for now we'll remain a materialistic society more focused on reality tv than on education and with a penchant for avoiding personal responsibility while embracing an ever-expanding sense of entitlement.

 

[EC3]

Interesting read about universal healthcare. Very biased but still worth a read:

http://www.cmaj.ca/cgi/content/full...FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT

good article even if it may be a bit biased. i think it's disingenuous, though, when people continue to quote our life expectancy, preventable mortality, and infant mortality as evidence that our system is inferior. i could write a novella on why these are stupid indicators of the caliber of our healthcare system but i'm sure most doctors are familiar.

i do agree, though, with the opinion that the advertising aspect of american medicine is out of control and bordering of fear-mongering. this is especially true with the larger private hospital networks where they are desiginating specialty hospitals and taking the radiowaves and billboards by storm with fear campaigns.

 

[GeneralVeers]

One simple thing would cut health costs by 20-30%: National Torte Reform

Unfortunately the Dems are in the pockets of the trial lawyers so will never support this.

 

[EC3]

One simple thing would cut health costs by 20-30%: National Torte Reform

Unfortunately the Dems are in the pockets of the trial lawyers so will never support this.

More importantly, though, would be the fact that tort reform would greatly improve the actual quality of care delivered. No more unnecessary tests, improved efficiency, etc. etc. I would bet that outcomes would also improve since we could move through more patients per hour. Quality would be improved, satisfaction would be improved, outcomes would be improved... but the lawyers don't care any of these metrics.

 

[southerndoc]

One simple thing would cut health costs by 20-30%: National Torte Reform

Unfortunately the Dems are in the pockets of the trial lawyers so will never support this.

I don't think it's as much a Democratic issue as it is a Congressional issue. The majority of the members in our legislative branch are former lawyers or at least receive large donations from lawyers.

The reason we don't have great tort reform is because physicians are poor lobbyists. We need to band together, which is why AMA, ACEP, etc. are important organizations to join. We need to make our positions known. Writing members of Congress, letters to the editors of local newspapers, etc. are ways to accomplish this.

The nurses are way better lobbyists than we physicians are. Perhaps we should just get them in on the cause (since we suck at it so much since we don't take initiative).

 

[Hallm_7]

I don't think it's as much a Democratic issue as it is a Congressional issue. The majority of the members in our legislative branch are former lawyers or at least receive large donations from lawyers.

The reason we don't have great tort reform is because physicians are poor lobbyists. We need to band together, which is why AMA, ACEP, etc. are important organizations to join. We need to make our positions known. Writing members of Congress, letters to the editors of local newspapers, etc. are ways to accomplish this.

The nurses are way better lobbyists than we physicians are. Perhaps we should just get them in on the cause (since we suck at it so much since we don't take initiative).

I would disagree with the issue of it being congressional rather than Democratic. Just a few short years ago when Republicans controlled both houses of Congress tort reform had the votes to pass in the House and the Senate, but the Dems filibustered the measure. IIRC we were only a couple votes short of reaching cloture in Senate.

As government increasingly represents a larger portion of the pie, and if they continue to keep reimbursement stagnant, I see more and more physicians dropping Medicare from their accepted third party payers. I can also see hospitals starting to kick back at Medicare. I predict that if this happens then there will be hospitals in large cities open that do not accept Medicare and tailor only to the under 65 crowd (typical med/surg, ob, peds, etc). Not accepting Medicare means the hospital doesn't have to follow EMTALA (I don't yet know how the ethics would work) so there would be tremendous savings and it would also get rid of a lot of the billing rules that Medicare forces upon physicians and hospitals. The hospital would also be in a much stronger position to negotiate with third party payers by getting the CMS elephant out of the negotiation room. Essentially a completely private healthcare system would develop in the US over the course of a couple decades that would be closed to the patients who are covered by government entities. Something similar is happening in Canada with the opening of private hospitals, and it would happen to a much faster degree here than it would in Canada.

 

[leviathan]

Not just a bit biased:

Marcia Angell is a senior lecturer in social medicine, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA

Doesn't get much more socialist than a Canadian doctor who supports global health initiatives working at an Ivy League East Coast school.

Heh. I said it was very biased in my original post. 🙂

It still helps to illustrate some interesting points about why the US spends so much on health care and gets so little in return.

 

[NEATOMD]

I won't argue with the education system comment, but social security actual does its job amazingly well. It's reduced poverty in the elderly population enormously. It runs at like a 3% overhead which is fantastic. It's just damn expensive and going to get more so as the demographics of the U.S. shift.

When soc. security was first passed, the average life span of an American was 62. So, only a pretty small fraction of Americans ever received social security in their lifetime. If we bumped up the time social security kicked in to say 72 (still 6 years less than our current life expectancy), all our problems would be solved. But as Americans, we want to have our cake and eat it too, hence the constant dilemma of how to finance our bloated government spending.

I agree, the social security system does a good job now. The reason I pointed out the social security system is that it has been robbed by our government. For instance, Clinton did the best job since we first got the idea as a country that we ought to to spend more than we make of balancing the budget. As a matter of fact, he boldly proclaimed that he had, and many greatly championed him as if he had...but he hadn't really. He stole money that was supposed to be going into social security to balance the budget. Don't get me wrong, like I said, he's done better than pretty much anyone else in recent history with regards to that.

So, what's the point of this rambling? Well, my prediction (and it's hardly a prediction as it would be sure thing) is that the goverment will tax the population to get medical coverage for them and then turnaround and short change the medical community by spending the money on their own pet projects. Nevermind, this already happens...only it'll get worse. You'll see.

 

[Blahblahologist]

Seems like any plan is too hypothetical at this point to make a meaningful call on-- until you drag it through the House and Senate, who knows how it actually comes out.

Any thoughts on how whether having Tom Daeschle in the cabinet is likely to help or hurt matters?

 

[GeneralVeers]

Seems like any plan is too hypothetical at this point to make a meaningful call on-- until you drag it through the House and Senate, who knows how it actually comes out.

Any thoughts on how whether having Tom Daeschle in the cabinet is likely to help or hurt matters?

Hurt. Daschle is a partisan, and is out to promote increased centralization of health care.

 

[paramed2premed]

One simple thing would cut health costs by 20-30%: National Torte Reform

Unfortunately the Dems are in the pockets of the trial lawyers so will never support this.

"Tort law is the name given to a body of law that addresses, and provides remedies for, civil wrongs that do not arise out of contractual duties."

"A torte is a cake made with many eggs and usually ground nuts or even bread crumbs instead of or in addition to flour."

How would National Torte Reform affect the in-the-trenches ED doc?

 

[GeneralVeers]

"Tort law is the name given to a body of law that addresses, and provides remedies for, civil wrongs that do not arise out of contractual duties."

"A torte is a cake made with many eggs and usually ground nuts or even bread crumbs instead of or in addition to flour."

How would National Torte Reform affect the in-the-trenches ED doc?

I was just hungry when they wrote that. I favour free cakes for all EM physicians.

 

[ccfccp]

I think free cakes in the ED should be a right 🙂

 

[psychforme]

Ugh, wasn't McCain the party nominee this year? And didn't the American Republicans choose him over the other people running for the party's nomination?

I thought it was Joe the Plumber? 😕