pinipig523

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ACEP released their take on the Bill. There are apparently some provisions in the bill that help EM.

I think the most important is no more "balance billing" whereby an out-of-network insurance company can choose to NOT compensate you for their client should they step into your ER. This is a HUGE bargaining chip that I've always been afraid would be done away with.

http://www.acep.org/WorkArea/DownloadAsset.aspx?id=48005

They do make mention that we will have more patients.... but who doesn't want that? I suppose from our end, business is booming?

http://www.acep.org/pressroom.aspx?LinkIdentifier=id&id=48082&libID=48111&fid=1636&Mo=No

Although I still believe that EM remaining revenue neutral or even slightly positive post-reform is still not a good enough reason to drag the country even further into debt.

But I guess it could be worse.
 

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The one problem I see is (and I didn't check my facts), is that if you're medicaid, there is no real "co-pay" for ED visits, especially if you pull the "I have no money" game.

So if your now overloaded medicaid accepting MD can't see your for 3 days, going to the ED is more convenient.

While most would say this already happens, I feel that there is a boatload of people that currenlty aren't coming in because they have no medicaid, but are reasonable enough NOT to come to the ED. When the PCP states "you should go to the ED", it may tip them toward us, and not waiting at home for 72hrs.
 

countthestars

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Yea, with all these 31 million new people thinking "OH! I got insurance, so that minor sneeze, why not get that checked out." They call up their PCP looking for an appointment, but wait time is a week. So what do they do? I would guess they would all come to the ER demand to be seen because they are now insured. Since these 31 million new people feel entitled to heath care, they will demand to be seen RIGHT NOW. When they see that gunshot victim going straight in and seeing the doctors without waiting, they will kick and scream and throw a hissy fit. Then when they demand a CT and MRI and X-Ray for their sneeze, and the ER docs will tell them there is no indication to have any of those tests. But, because they feel entitled to heath care I mean they are insured after all they will complain we are not listening to them and we are being horrible doctors. So these 31 million new people will get pissed off, call up their money hungry lawyer and decide to sue us. :rolleyes: With no tort reform, our malpractice rates will skyrocket. Along with that, we will be paying more taxes to give those 31 million new people the heath care that they claimed they paid for and feel so entitled to...Oh and because of EMTALA, EM docs will have to see these people, no matter what....

I could go on and on, but you get my point.
 
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old_boy

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I think the most important is no more "balance billing" whereby an out-of-network insurance company can choose to NOT compensate you for their client should they step into your ER.
Where do you see this in the sheet you linked to? It says that insurance companies have to pay for ED care, but I don't think it explicitly says no balance billing (unless I'm reading it wrong). I know CA recently did away with balance billing - there was a thread on this a while back where it was mentioned that community EPs took a 10% hit because of it.
 

EctopicFetus

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I was going to start a thread similar to this but will just join in here.

My take Mass has seen a 11% annual increase in ED volume since their plan went into effect.

IIRC, the avg is 15% of ALL visits are people without insurance. There is nothing there that says they will cut physician payments. On the contrary there are provisions to increase reimbursement for primary care, have all states pay medicare rates for medicaid (most medicaid is less) and then some taxes.

I am here to have a civil discussion but from my point of view I see this.

An increase by 10+% in visits. 10% more money for the 15% of people with no insurance since medicare/medicaid pay less than private.

At worst we are looking at 10% increase in pay for the work we already do. plus another 10% in volume and I think much of our billing is based on primary care billing codes (docB or someone who has been an attending longer than me can help me out here).

We could see a nice little bump in our pay, on the downside every dollar over 250K would be subject to a new 0.9% tax but there isnt another provision in there that would hurt us.

if you are a doc making 200k you could see a bump to 240k or more, 40k more for a little more work.

Thoughts? Am I just being over optimistic? FWIW I am against the bill.

I also think we might see the SGR get fixed this yr. We will see.
 

EctopicFetus

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Yea, with all these 31 million new people thinking "OH! I got insurance, so that minor sneeze, why not get that checked out." They call up their PCP looking for an appointment, but wait time is a week. So what do they do? I would guess they would all come to the ER demand to be seen because they are now insured. Since these 31 million new people feel entitled to heath care, they will demand to be seen RIGHT NOW. When they see that gunshot victim going straight in and seeing the doctors without waiting, they will kick and scream and throw a hissy fit. Then when they demand a CT and MRI and X-Ray for their sneeze, and the ER docs will tell them there is no indication to have any of those tests. But, because they feel entitled to heath care I mean they are insured after all they will complain we are not listening to them and we are being horrible doctors. So these 31 million new people will get pissed off, call up their money hungry lawyer and decide to sue us. :rolleyes: With no tort reform, our malpractice rates will skyrocket. Along with that, we will be paying more taxes to give those 31 million new people the heath care that they claimed they paid for and feel so entitled to...Oh and because of EMTALA, EM docs will have to see these people, no matter what....

I could go on and on, but you get my point.
Are you really an MS-2? Dude 1st of all we already see all these people. 2) I am for tort reform but lets put this in perspective the lawyers arent gonna sue us for not ordering an MRI. 3) Malpractice might go up simply because volumes will be up.
 

old_boy

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On the contrary there are provisions to increase reimbursement for primary care, have all states pay medicare rates for medicaid (most medicaid is less) and then some taxes.
Are you sure that all states are going to start paying medicare? That was not my understanding, and in fact Obama made some statement a couple of weeks back to the tune of (I'm paraphrasing) "if this bill passes we'll see about maybe increasing medicaid rates to doctors in the future since I understand a lot of them think they are too low." <italics mine> I had read that medicaid rate increases had been discussed only for primary care.

If you have a link to something that says that medicaid rates will increased to medicare for EPs I would be interested, since that was not my understanding.
 

pinipig523

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Where do you see this in the sheet you linked to? It says that insurance companies have to pay for ED care, but I don't think it explicitly says no balance billing (unless I'm reading it wrong). I know CA recently did away with balance billing - there was a thread on this a while back where it was mentioned that community EPs took a 10% hit because of it.
It doesn't say "no balance billing", but the bill says that there will be no more out-of-network ER stipulated visits. Meaning, we don't have to deal with having to worry if the patient we are seeing is out-of-network. Hence, we don't have to balance bill anymore because all types of insurance works with us.
 

pinipig523

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Yea, with all these 31 million new people thinking "OH! I got insurance, so that minor sneeze, why not get that checked out." They call up their PCP looking for an appointment, but wait time is a week. So what do they do? I would guess they would all come to the ER demand to be seen because they are now insured. Since these 31 million new people feel entitled to heath care, they will demand to be seen RIGHT NOW. When they see that gunshot victim going straight in and seeing the doctors without waiting, they will kick and scream and throw a hissy fit. Then when they demand a CT and MRI and X-Ray for their sneeze, and the ER docs will tell them there is no indication to have any of those tests. But, because they feel entitled to heath care I mean they are insured after all they will complain we are not listening to them and we are being horrible doctors. So these 31 million new people will get pissed off, call up their money hungry lawyer and decide to sue us. :rolleyes: With no tort reform, our malpractice rates will skyrocket. Along with that, we will be paying more taxes to give those 31 million new people the heath care that they claimed they paid for and feel so entitled to...Oh and because of EMTALA, EM docs will have to see these people, no matter what....

I could go on and on, but you get my point.
We already see those people, hate to break it to you.

Atleast now, the reform bill has parts in there which actually help us out in seeing those same patients.
 

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Out of curiosity, how do you guys see the bundling of Medicare payments in 2013 affecting EM?
 

GeneralVeers

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The experience in MA would tend to support the hypothesis that ER use will increase out of convenience. Once they implemented their universal healthcare plan, ED visits jumped 11%.

It's true that we already see a lot of these people, but there is still a large number of people who stay away from the ER because they are afraid of what the bill would do to their credit score.
 

countthestars

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The experience in MA would tend to support the hypothesis that ER use will increase out of convenience. Once they implemented their universal healthcare plan, ED visits jumped 11%.

It's true that we already see a lot of these people, but there is still a large number of people who stay away from the ER because they are afraid of what the bill would do to their credit score.
Exactly! I know the ED sees those types of people all the time. However, with 31 million more with insurance I really do think the number of people who visit the ED with BS complaints will increase substantially which will just cause more headache for the docs.
 

pinipig523

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Exactly! I know the ED sees those types of people all the time. However, with 31 million more with insurance I really do think the number of people who visit the ED with BS complaints will increase substantially which will just cause more headache for the docs.
Why would it give docs more headaches? The worry here is that it'll give more headaches to the patients in the waiting rooms especially the sick ones because of the longer wait times. As a doc, I'll just see these fast track type patients and dispo them home - then bill.

That's it. Quick and easy.
 

pinipig523

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Out of curiosity, how do you guys see the bundling of Medicare payments in 2013 affecting EM?
There will be ways to get around this if it deems to be revenue negative. Besides it is only going to be a pilot program. If it fails, it fails.
 

EctopicFetus

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Are you sure that all states are going to start paying medicare? That was not my understanding, and in fact Obama made some statement a couple of weeks back to the tune of (I'm paraphrasing) "if this bill passes we'll see about maybe increasing medicaid rates to doctors in the future since I understand a lot of them think they are too low." <italics mine> I had read that medicaid rate increases had been discussed only for primary care.

If you have a link to something that says that medicaid rates will increased to medicare for EPs I would be interested, since that was not my understanding.
many of the ED billing codes are the same used by primary care. Otherwise you are right there isnt anything that specific.

Out of curiosity, how do you guys see the bundling of Medicare payments in 2013 affecting EM?
its a voluntary program and I think that would be bad for all doctors. Think of it like this. In the ED we also interact with Rads, OB/Gyn, Peds, IM and on and on. Each group would have to fight with the hospital for every dollar directly against their colleagues. Then the fed can say.. "we were paying you x" now we are gonna pay 95% of x.. good luck.

Why would it give docs more headaches? The worry here is that it'll give more headaches to the patients in the waiting rooms especially the sick ones because of the longer wait times. As a doc, I'll just see these fast track type patients and dispo them home - then bill.

That's it. Quick and easy.
+1.. this could be a nice money maker.
 

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Not to rain on the parade, but the bill provides an annual fee (penalty) of $2500 per person who does not have insurance coverage in some way, shape, or form. If I was uninsured, went to the ER, and racked up a $4,000 bill, I'd say I have no money, and just pay the $2500 bill to Uncle Sam.
 

GeneralVeers

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Not to rain on the parade, but the bill provides an annual fee (penalty) of $2500 per person who does not have insurance coverage in some way, shape, or form. If I was uninsured, went to the ER, and racked up a $4,000 bill, I'd say I have no money, and just pay the $2500 bill to Uncle Sam.
Perversely it may actually encourage some people to drop insurance entirely. I'm young and healthy and my PPO plan through my employer surely has a value of greater than $10,000. By 2018 (unless it's repealed) I will have to pay tax on this benefit, which could conceivably be more than $2500. At that point, why wouldn't I just drop my health coverage entirely, pay the penalty, and put the rest into a health savings account?
 

pinipig523

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Not to rain on the parade, but the bill provides an annual fee (penalty) of $2500 per person who does not have insurance coverage in some way, shape, or form. If I was uninsured, went to the ER, and racked up a $4,000 bill, I'd say I have no money, and just pay the $2500 bill to Uncle Sam.
And what stops them from going uninsured now?
 

pinipig523

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Perversely it may actually encourage some people to drop insurance entirely. I'm young and healthy and my PPO plan through my employer surely has a value of greater than $10,000. By 2018 (unless it's repealed) I will have to pay tax on this benefit, which could conceivably be more than $2500. At that point, why wouldn't I just drop my health coverage entirely, pay the penalty, and put the rest into a health savings account?
Because they know that spending a little more than 2500 to cover the Maserati Tax will keep them covered in case they get into any sort of accident/medical emergency.
 

old_boy

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It doesn't say "no balance billing", but the bill says that there will be no more out-of-network ER stipulated visits. Meaning, we don't have to deal with having to worry if the patient we are seeing is out-of-network. Hence, we don't have to balance bill anymore because all types of insurance works with us.
I see. I actually see this as a bad thing.

It's not that I like balance billing, but I like it compared to the alternative because it keeps the insurance companies honest. The problem with mandating that an insurance company HAS TO cover out of network ED care is that they just say "our fair and customary out of network reimbursement is $1" and there is nothing that the ED doc can do about it. He has to accept the $1. With balance billing, at least he can say, "well, the service cost $200" and bill the patient for the extra $199. Then the patient gets pissed, calls the insurance company, and the insurance company realizes it has to pay more than $1 because it doesn't want pissy customers.

With this bill, insurance companies will a)have no incentive to pay more than the $1 and b)have no incentive to be "in network" and therefore negotiate rates for any emergency care. Instead they'll say just say "sorry, we're only going to pay $1 since that is fair and customary" and there is nothing that EM physicians can do. Sounds like a raw deal to me.
 

USCDiver

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Also, since there will be no denials for pre-existing conditions, once you get sick, you buy your insurance then.

I actually don't mind a 10% increase in low acuity patients. Just hire a couple extra PAs and expand your fast track.
 

GeneralVeers

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Also, since there will be no denials for pre-existing conditions, once you get sick, you buy your insurance then.

I actually don't mind a 10% increase in low acuity patients. Just hire a couple extra PAs and expand your fast track.
Short term this may be good, but the long term outlook is bad.

The purpose of this bill is to control the insurance companies, and gradually transition most people to Medicaid. In 10 years when private insurance is too expensive for most employers and a huge percentage of the population are on Medicaid (which pays pennies) do you really think we will be better off?
 

EctopicFetus

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Not to rain on the parade, but the bill provides an annual fee (penalty) of $2500 per person who does not have insurance coverage in some way, shape, or form. If I was uninsured, went to the ER, and racked up a $4,000 bill, I'd say I have no money, and just pay the $2500 bill to Uncle Sam.
I am against this bill but...

Negative. It says if you dont have insurance you pay either $695 or 2% of your income as a penalty and if you make less than 3x (or 4) the poverty line the govt subsidizes you.

Truth is we will be seeing a whole lot more people with insurance.
 

EctopicFetus

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All those cadillac plans will go the way of the dodo bird.. no one is gonna pay that tax.
 

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Actually, as a practicing community emergency physician, the new health plan as passed will be a huge negative.

--It includes a 3.8% increase in taxes on investment income/rental income, and combined with his already proposed 5% increase in capital gains tax, any investment will lose an additional 8.8% more of its return to the federal government (total of 23.8%). [This also means landlords will probably be raising rent on all the individuals Obama promised not to raise taxes on.]

--It includes an additional 0.9% salary tax on people making greater than $200,000 a year which further increases the tax bracket increases that will already occur this year when Obama lets the Bush cuts expire.

--It mandates large cuts in Medicare funding. The government sets medicare reimbursement rates which all other insurers use as a base for payments. A large cut in medicare will inevitably lead to lower reimbursement rates across the board to all providers.

--It fails to address the single largest component of our self-pay population here in Texas where I work. The majority of my self-pay patients are illegal immigrants who use the ER as their personal clinic, secondary to their inability to receive medical treatment anywhere else. Under Obamacare, I will continue to treat these patients free of charge, without any compensation.
 
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ccfccp

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Perversely it may actually encourage some people to drop insurance entirely. I'm young and healthy and my PPO plan through my employer surely has a value of greater than $10,000. By 2018 (unless it's repealed) I will have to pay tax on this benefit, which could conceivably be more than $2500. At that point, why wouldn't I just drop my health coverage entirely, pay the penalty, and put the rest into a health savings account?
You can't do that because health savings accounts are now capped at $2500 under this bill (and I believe $5000 for families.)

Also... can we please stop calling this "insurance?" Let's call it what it is: welfare. Just another brick in the wall.
 

GeneralVeers

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--It includes a 3.8% increase in taxes on investment income/rental income, and combined with his already proposed 5% increase in capital gains tax, any investment will lose an additional 8.8% more of its return to the federal government (total of 23.8%). [This also means landlords will probably be raising rent on all the individuals Obama promised not to raise taxes on.]
True. I doubt our increase in revenues will offset the new taxes. But we're the evil rich after all and have to pay our "fair share".

--It includes an additional 0.9% salary tax on people making greater than $200,000 a year which further increases the tax bracket increases that will already occur this year when Obama lets the Bush cuts expire.
Yes

--It mandates large cuts in Medicare funding. The government sets medicare reimbursement rates which all other insurers use as a base for payments. A large cut in medicare will inevitably lead to lower reimbursement rates across the board to all providers.
On this you are incorrect. The Medicare cuts are not going to happen as they will be addressed as the "doctor fix" in a separate bill. This issue is why proponents of this health plan are HUGE LIARS when it comes to their claim it reduces the deficit. The decrease in Medicare cuts is the cornerstone of this claim, yet they will never happen.

--It fails to address the single largest component of our self-pay population here in Texas where I work. The majority of my self-pay patients are illegal immigrants who use the ER as their personal clinic, secondary to their inability to receive medical treatment anywhere else. Under Obamacare, I will continue to treat these patients free of charge, without any compensation.
So how do you propose to fix this? Should taxpayer money be used to pay for illegals? How about Mexico? Should their government pay? I would support a law that gives them emergency treatment if they show up at the ER and then they would get prompt deportation as soon as they were stabilized.
 

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So how do you propose to fix this? Should taxpayer money be used to pay for illegals? How about Mexico? Should their government pay? I would support a law that gives them emergency treatment if they show up at the ER and then they would get prompt deportation as soon as they were stabilized.
Our government cannot pay for the people that live here legally and so it's just wrong for them to pay for healthcare of illegal residents. Although, I would support the idea that we'll cover their "emergency care" and once they're stabilized, INS is at the door to deport them. The problem with this kind of idea is that once illegal residents learn that they will be deported once stabilized, they will just NOT come to ED, get care some other way and/or risk death just so that they don't get deported.