Interested to see what others think

[KurtBrie]

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Ok.

So the future of reimbursement is increased medicare population (2nd lowest payer to tricare) entering the system at an estimated 20% move over the next 5 years alone. Over all this impacts reimbursement as your total case volume may increase but the money cases (commercials) will be a lower percentage. end result, you work harder for the same or less money.

More commercials will raise deductibles making it harder for us to collect on the half descent payers. Imagine you make 30K a year with a family and you have a 5-6K deductible you might as well have NO insurance until after you have basically defaulted on that 5-6 K deductible. The people you default on send you to collections thereby damaging your credit. Now your credit is gone and there is literally no negative to NOT paying these bills. So you simply continue to default on everything that isnt eating or living or on things that can be taken from you (car etc). End result the anesthesia bill they get 30 days after surgery wont be a priority and more will elect to simply NOT pay it.

Bundled payments will result in all of us being forced into a hospital CIN (clinically integrated network) or IPO (indep. physician org) in order to negotiate with insurers as a larger unit in hopes of creating some negotiating power by doing so. This may sound good but it also results in other specialities having a better idea of our income. That ISNT ever good. Additionally, now we will be pitted against each other to divide the 'flat fee' for a case (say a lap chole or whatever). Anesthesia will be negotiating with surgery and the hospital to divide up that single fee. Imagine how exactly that will go and then remember there is only one of us 3 who does NOT generate revenue. We will be on the bottom of that payment heap. Assume this means you will make less then than you do now. Goodbye to all those cases where your anesthetic is valued at more than the surgical fee.

So where are we headed?

I think bundled payments will fail but that we will be in a limbo with it for an undetermined period of time (maybe a decade regardless of who the president is).

I think commercial reimbursement will continue to rise minimally every contract but that increase will not come close to matching the higher volume of medicare and medicaid cases which flood the system over the next 5 years.

I think medicare $/RVU will stagnate or minimally increase yearly but it will be nearly insignificant.

So the reality is that while strictly, reimbursement is going up the overall revenue per case will decrease as payer mix shifts from an average of 60/40 (medicare/commercial) closer to 70/30. The metric which matters is the decrease in revenue per case not per unit as it best estimates the impact of increasing low payer volume.

What does this mean for the average physician? Here is my estimation:

- Stagnating and lower reimbursement. Especially with the AMC model expanding as it adds a 3rd party being paid (investors) expecting increasing revenues quarter on quarter.

- A disintegration of the physician only practice and an increase in other models of varying types as economics dictate.

- A continued trend of hiring physicians is in the future. With ownership comes power to the owners. However, a breaking point will come where the pendulum swings back to the private practice side. That will happen when hospitals find that paying surgeons (and other physicians) a salary and bonus structure by RVU eventually isnt less than the downstream revenue that they are estimated to generate. Then they will make bonus impossible and everyone will go private again. How long will this take? Not sure. Maybe 5-7 years.

What does everyone else think?

 

[KurtBrie]

Bueller?

 

[BLADEMDA]

Bueller?

Hospital Employee vs Management Company. Only a few groups will survive these changes going forward buy they are out there. The smaller groups will need to merge or sell. The larger ones may be able to ride this out for at least 10 more years. The bottom line is that it will get harder and harder each year to find a true, independent, private practice gig.

I disagree the pendulum will swing back to the old, private practice model. The future is socialized medicine to control costs. They will call it "bundled payments" but it leads to rationing of care. Many middle class families won't be able to afford the higher and higher deductibles of their policies so the end result is lower reimbursement to the providers/hospitals.

When the masses reach a certain level (Obama knew this from the start) they will demand Universal healthcare for all which in the USA means Medicare for all. Good luck with earning 2/3 what our Canadian colleagues do; instead, look to Germany to see just how low Anesthesiologists' salaries can go.

 

[BLADEMDA]

 

[BLADEMDA]

Like in the U.K. and Germany there will be "fee for service" outside the Medicare for all system. This will be a much smaller piece of the pay but those that get to participate will likely double or triple their "Medicare" based salary.

 

[GravelRider]

Hospital Employee vs Management Company. Only a few groups will survive these changes going forward buy they are out there. The smaller groups will need to merge or sell. The larger ones may be able to ride this out for at least 10 more years. The bottom line is that it will get harder and harder each year to find a true, independent, private practice gig.

I disagree the pendulum will swing back to the old, private practice model. The future is socialized medicine to control costs. They will call it "bundled payments" but it leads to rationing of care. Many middle class families won't be able to afford the higher and higher deductibles of their policies so the end result is lower reimbursement to the providers/hospitals.

When the masses reach a certain level (Obama knew this from the start) they will demand Universal healthcare for all which in the USA means Medicare for all. Good luck with earning 2/3 what our Canadian colleagues do; instead, look to Germany to see just how low Anesthesiologists' salaries can go.

Agreed. Obama is a lot smarter than we give him credit for. He knew exactly what he was doing with Obamacare. He is in it for the long game and the end result will be socialized medicine. It's almost like Obama knew he was creating a system that was designed to fail in order to bring about the final goal of socialized medicine. This will bring us more in line with our European and Canadian neighbors. In 10-15 years we will be wishing we practiced in the Canadian or British system.

There is the possibility that a tiered system is created where the majority of Americans will be in the Medicare pool and those that can afford it will pay for more personalized care. You might see small pockets of private practices in wealthy communities, but overall the private practice physician is very much in danger of extinction.

I think we are seeing this feeding frenzy of hospital and national practice consolidation because these businesses see the future. The opportunity to make a lot of money off the business of healthcare is fading fast.

 

[bashwell]

I don't know about the others, but Australia seems very inaccurate. Unless it includes part-timers (also primary care in Australia is basically GP aka FM, and many of them work part-time) and registrars (aka residents) since registrar training can take a long time and senior registrars are obviously paid much less than consultants aka attendings (maybe $150k or so as a senior reg).

 

[Stank811]

Orthopedic surgeons in Canada do much better than what that graph depicts.

 

[DetectiveAlonzo]

Medicine is NOT WORTH making less than 300 grand. NO WAY JOSE.

You've got to be fricking kidding me.

People want ****ty access to care? So be it. Lives will come as a cost.

You get what you pay for.

 

[PainDrain]

Call me crazy but there is no farking way that a US orthopedist will be making 150K ever. Not a snowballs chance in hell. The entire system would have to be turned on its head for this to happen. First off, no med student in their right mind would do 5-7 years of a surgical residency to make 150k. Second, demand for orthopedic surgeons would have to plummet and there would have to be a surplus, which isn't happening anytime soon.

Are the gravy train days of letting CRNAs man the stool while you sip coffee and cruise the web while making 600K over, yah probably. But good riddance, I actually like being involved in patient care.

Lastly, the day my salary drops below 200K is the day I sell my house, pack my bags, default on my loans and move out of country.

 

[Stank811]

Ok.

I think bundled payments will fail but that we will be in a limbo with it for an undetermined period of time (maybe a decade regardless of who the president is).

I think commercial reimbursement will continue to rise minimally every contract but that increase will not come close to matching the higher volume of medicare and medicaid cases which flood the system over the next 5 years.

I think medicare $/RVU will stagnate or minimally increase yearly but it will be nearly insignificant.

So the reality is that while strictly, reimbursement is going up the overall revenue per case will decrease as payer mix shifts from an average of 60/40 (medicare/commercial) closer to 70/30. The metric which matters is the decrease in revenue per case not per unit as it best estimates the impact of increasing low payer volume.

What does this mean for the average physician? Here is my estimation:

- Stagnating and lower reimbursement. Especially with the AMC model expanding as it adds a 3rd party being paid (investors) expecting increasing revenues quarter on quarter.

- A disintegration of the physician only practice and an increase in other models of varying types as economics dictate.

- A continued trend of hiring physicians is in the future. With ownership comes power to the owners. However, a breaking point will come where the pendulum swings back to the private practice side. That will happen when hospitals find that paying surgeons (and other physicians) a salary and bonus structure by RVU eventually isnt less than the downstream revenue that they are estimated to generate. Then they will make bonus impossible and everyone will go private again. How long will this take? Not sure. Maybe 5-7 years.

What does everyone else think?

For the most part I agree with above. AMC are not necessarily the worst thing in the world as long as you do not sell out to them and maintain a strong relationship with the facilities you have contracts with. AMC will negotiate the contracted rates up over time and so will the large employed hospital systems. And like you stated both models will struggle for the reasons you illustrated. PP group will be just fine as long as you don't over react to all this fear...no one can even predict 2 yrs from now.

 

[bashwell]

Call me crazy but there is no farking way that a US orthopedist will be making 150K ever. Not a snowballs chance in hell. The entire system would have to be turned on its head for this to happen. First off, no med student in their right mind would do 5-7 years of a surgical residency to make 150k. Second, demand for orthopedic surgeons would have to plummet and there would have to be a surplus, which isn't happening anytime soon.

Are the gravy train days of letting CRNAs man the stool while you sip coffee and cruise the web while making 600K over, yah probably. But good riddance, I actually like being involved in patient care.

Lastly, the day my salary drops below 200K is the day I sell my house, pack my bags, default on my loans and move out of country.

I dont know if you're referring to what I said about Australia. But I just wanted to clarify the $150k per year in Australia is for senior registrars aka residents in US parlance, not attending level orthopaedic surgeons who make much much much more than $150k at least from what I've seen.

 

[PainDrain]

I dont know if you're referring to what I said about Australia. But I just wanted to clarify the $150k per year in Australia is for senior registrars aka residents in US parlance, not attending level orthopaedic surgeons who make much much much more than $150k at least from what I've seen.

I was referring to the chart that Blade put up and his saying that one day we will wish we were making 2/3 of what our Canadian counterparts make and that we will be making what German docs do.

 

[BLADEMDA]

 

[BLADEMDA]

 

[BLADEMDA]

I realize that the data is dependent on who fills out the surveys.

 

[urge]

What that chart doesn't tell you is that schooling is free in some of those countries and they sometimes give you a stipend to study. Also med school is straight from high school in just 6 years.

An American grad is so far behind in debt that the higher salary doesn't make a dent until 10 years down the line for the better paying specialties.

 

[urge]

I dont know if you're referring to what I said about Australia. But I just wanted to clarify the $150k per year in Australia is for senior registrars aka residents in US parlance, not attending level orthopaedic surgeons who make much much much more than $150k at least from what I've seen.

No resident in the US makes that much.

 

[urge]

Agreed. Obama is a lot smarter than we give him credit for. He knew exactly what he was doing with Obamacare. He is in it for the long game and the end result will be socialized medicine. It's almost like Obama knew he was creating a system that was designed to fail in order to bring about the final goal of socialized medicine. This will bring us more in line with our European and Canadian neighbors. In 10-15 years we will be wishing we practiced in the Canadian or British system.

There is the possibility that a tiered system is created where the majority of Americans will be in the Medicare pool and those that can afford it will pay for more personalized care. You might see small pockets of private practices in wealthy communities, but overall the private practice physician is very much in danger of extinction.

I think we are seeing this feeding frenzy of hospital and national practice consolidation because these businesses see the future. The opportunity to make a lot of money off the business of healthcare is fading fast.

I think you give him too much credit. Obamacare failed because all socialized medicine fails. The Canadian and English system are broke. It is just a matter of time.

 

[bashwell]

Actually, sorry, this (mostly) seems inaccurate too. For example, emergency physicians definitely do not make that little in Australia. A resident/registrar (PGY2-3) can already make $100,000 (especially with overtime pay, Australia does pay overtime for doctors at all levels).

Also, I'm not too sure about this survey in the first place:
-First, who misspells "aesthesiology" (no "n")? And it's more commonly referred to as "anaesthetics" in Australia, though sometimes I've seen "anaesthesiology".
-Pediatrics is spelled "paediatrics" in Australia. Maybe this survey was done by non-Australians?
-In Australia, GP = Family Medicine. They're not really any different. (Unless we count the old-timers who just did an intern year, then became GPs, but that's from generations ago, today they're essentially identical).
-In Australia (certainly NSW) internists are all but required to subspecialize. There are no (or very few, being phased out) general IM physicians left. Internists are also frequently called BPTs (basic physician trainees = general IM). (Or ATs advanced trainees = fellow).

Anecdotally, I know emergency physicians, anesthesiologists (aka anaesthetists in Australian terminology) who make >$300,000 minimum. GPs/FMs probably make about $150-$200k, but that's in the big cities (e.g., Sydney). If you go rural, the money improves a lot. Lots of part-time GPs too so that has to be factored in.

I'm guessing for several of these it's registrars filling out these surveys, not attending level.

 

[bashwell]

I think you give him too much credit. Obamacare failed because all socialized medicine fails. The Canadian and English system are broke. It is just a matter of time.

Anecdotally, there seem to be tons and I mean tons of UK and Irish physicians who have moved to Australia. Almost all of them tell me horrible stories about the UK's NHS (and its equivalents throughout the UK and Ireland). How much harder they have to work for less pay (in comparison to Australia). It could be sample selection bias since after all theyre the ones who moved to Australia. But we see other things like all the strikes by doctors across the UK in the news. Some of the UK physicians have even told me they think the UK government is intentionally allowing the NHS to crumble and fall because it's a path to privatisation (ironically we want to move the other way). No idea if that's true, but that's what they have told me.

Of course, Australia isn't a bed of roses either. The Australian healthcare system has its own significant problems too.

 

[GravelRider]

I think you give him too much credit. Obamacare failed because all socialized medicine fails. The Canadian and English system are broke. It is just a matter of time.

I'm no supporter of a single payer system, but are we sure that all socialized medicine fails? I'm sure there are many Canadians and Europeans that would disagree with you. I'll tell you what will fail though and that's this super consolidated, corporate model of medicine we have here. Costs are just going way too high. Those costs are eventually passed down to the average citizen and it is unsustainable. Obama knew his plan would eventually fail. He is just trying to get people more comfortable with the idea of more government influence in healthcare. Whether you like him or not, he is a smart guy and good politician. Obamacare was a calculated step towards a more socialized system in the U.S.

I also think some of these surveys showing international Doctor salaries are propaganda by certain special interest groups to scare doctors. The salaries in Europe are certainly not as high as the ceiling potential as the United States, but doctors there certainly aren't toiling away for 65 hours a week for a lower middle class lifestyle either. I've met a few Canadian physicians who do quite well, actually.

 

[urge]

I'm no supporter of a single payer system, but are we sure that all socialized medicine fails? I'm sure there are many Canadians and Europeans that would disagree with you. I'll tell you what will fail though and that's this super consolidated, corporate model of medicine we have here. Costs are just going way too high. Those costs are eventually passed down to the average citizen and it is unsustainable. Obama knew his plan would eventually fail. He is just trying to get people more comfortable with the idea of more government influence in healthcare. Whether you like him or not, he is a smart guy and good politician. Obamacare was a calculated step towards a more socialized system in the U.S.

Only a biased person would view a system that expends more money that is allocated to it as a success. Have you seen the news about the physician strikes in England? How about the denial of elective surgery when they have met their yearly quota?

I am surprised how you cannot see the present but have clear vision into the future. You are showing a bias there too.

The only sustainable system in my mind is all cash pay per visit/procedure/day. You will see how much the offspring loves their grandma when they have to pay for it out of pocket.

With the current system they don't care and will ask you to keep her alive at someother's expense. An all cash fee for service system will foster a lot of competition whithin physicians and hospital to achieve the highest quality at the lowest cost. Right now nobody cares. Rack up the bill that some one else is paying. That's why Medicare is forcing bundled care on us. Obamacare doesn't address any of this.

Obamacare is only a tax on younger healthy people. They want them all to pay insurance premiums that will be used to subsidize the care of older unhealthier people that spend way more money than they pay in. It is failing because even with the penalty involved young people have refused to sign up for it. Why pay a thousand dollars a month when it is very unlikely that you will need any care? Better save the money and pony it up if you need it. The unhealthy people on the other hand know they are better off paying a thousand every month because they will expend 100 times that easily in 1 year.

Any system that takes money from a segment of the population to the subsidize another segment of the population will fail.

 

[GravelRider]

Only a biased person would view a system that expends more money that is allocated to it as a success. Have you seen the news about the physician strikes in England? How about the denial of elective surgery when they have met their yearly quota?

I am surprised how you cannot see the present but have clear vision into the future. You are showing a bias there too.

The only sustainable system in my mind is all cash pay per visit/procedure/day. You will see how much the offspring loves their grandma when they have to pay for it out of pocket.

With the current system they don't care and will ask you to keep her alive at someother's expense. An all cash fee for service system will foster a lot of competition whithin physicians and hospital to achieve the highest quality at the lowest cost. Right now nobody cares. Rack up the bill that some one else is paying. That's why Medicare is forcing bundled care on us. Obamacare doesn't address any of this.

Obamacare is only a tax on younger healthy people. They want them all to pay insurance premiums that will be used to subsidize the care of older unhealthier people that spend way more money than they pay in. It is failing because even with the penalty involved young people have refused to sign up for it. Why pay a thousand dollars a month when it is very unlikely that you will need any care? Better save the money and pony it up if you need it. The unhealthy people on the other hand know they are better off paying a thousand every month because they will expend 100 times that easily in 1 year.

Any system that take money from the asegment of the population to the subsidize another segment of the population will fail.

I believe it was the equivalent of residents in Britain who went on strike over work hours. I applaud them for that.

I agree, a cash only system will bring costs down...a lot. It will also bring down physician income...a lot. How many elective knee replacements will happen if people had to pay cash? You are focusing on end of life care, which I agree is expensive and people prolong it unnecessarily because they aren't paying. However, a cash only system would have other unintended consequences as well. You would have to have upfront pricing. You think someone will elect to have that nerve block when you tell them it's only going to last 12 hours and will cost an extra $500? Sure, bring on a cash only system, but unless you live in a wealthy, your income is going way down.

You make a suggestion of rationing care...especially in the critically ill at the end of life. I'm all for some form of rationing care, but a cash only system would ration it in terms of rich and poor. We already have a huge problem with income inequality in the United States as evidenced by the popularity of Bernie Sanders and Donald Trump. Creating a system in which only the richest among us could afford elective medical care will do nothing to help that.

So young healthy people shouldn't have to have any insurance? I'm a good driver, I shouldn't need car insurance. The biggest cause of morbidity and mortality among young people is trauma. Trauma care is pretty expensive. Hopefully those 20 year olds have enough saved up in their health savings account for when then get into that car accident or get hurt playing football.

 

[urge]

I believe it was the equivalent of residents in Britain who went on strike over work hours. I applaud them for that.

1 You think someone will elect to have that nerve block when you tell them it's only going to last 12 hours and will cost an extra $500?


2 You make a suggestion of rationing care...especially in the critically ill at the end of life. I'm all for some form of rationing care, but a cash only system would ration it in terms of rich and poor.

3 So young healthy people shouldn't have to have any insurance? I'm a good driver, I shouldn't need car insurance. The biggest cause of morbidity and mortality among young people is trauma. Trauma care is pretty expensive. Hopefully those 20 year olds have enough saved up in their health savings account for when then get into that car accident or get hurt playing football.

1 I would expect a nerve block to be $100 or less on an all cash system. How many people here brag that it takes like 2 minutes to put one? Plus their salary will be higher because their employer will no longer retain your money for employer's insurance.

2 The whole human experience is rationed based on money. Best seats in concerts, planes, best food, best cars.... everything. You name it. Why would healthcare be any different? That is just denying facts of life.

3 So you think that young people are better off because they have driver's insurance? The state of New Hampshire disagrees with you and I think the young drivers are doing as well as any other place.

Arguments against compulsory auto insurance[edit]
Opponents of compulsory insurance believe that it is not the best way to allocate risk among drivers. New Hampshire and Virginia do not require motor vehicle insurance. In New Hampshire vehicle owners must satisfy a personal responsibility requirement; instead of paying monthly premiums, and prove that they are capable of paying in case of an accident. In Virginia vehicle owners may pay an uninsured motorist fee. In Mississippi vehicle owners may post bonds or cash. Many insurance companies oppose compulsory auto insurance, for example: the NAII (National Association of Independent Insurers). State Farm opposes compulsory auto insurance because it forces poor to choose between groceries and insurance. A study done by Dr Robert Maril showed that, in a poor area of Arizona, 44% said they had trouble buying food or paying rent due to auto insurance. A survey done by the Montana DPHHS showed 12 of the 96 surveyed said auto insurance was a reason for needing food stamps.[19][20]

https://en.wikipedia.org/wiki/Vehicle_insurance_in_the_United_States

 

[GravelRider]

1 I would expect a nerve block to be $100 or less on an all cash system. How many people here brag that it takes like 2 minutes to put one? Plus their salary will be higher because their employer will no longer retain your money for employer's insurance.

2 The whole human experience is rationed based on money. Best seats in concerts, planes, best food, best cars.... everything. You name it. Why would healthcare be any different? That is just denying facts of life.

3 So you think that young people are better off because they have driver's insurance? The state of New Hampshire disagrees with you and I think the young drivers are doing as well as any other place.

So why haven't you started a cash only practice? It has to start somewhere, right? I am sure you can find some like-minded surgeons and doctors of all specialties. Pool your money together and open up some cash only ORs. There is nothing stopping you or anyone else in this country from opening up cash only practices. You can stop accepting insurance tomorrow. Get some local businesses to drop health insurance so that all the local workers will have higher wages and can pay for their total knees themselves.

The American workers have been paying their dues into the healthcare system for decades in the form of wage stagnation. They certainly deserve care. You think that if we got rid of health insurance that XYZ corporation would immediately reward their workers with higher wages since they no longer have to contribute to health insurance premiums? Or would the CEO and shareholders get a nice bonus instead?

I believe, less than 10% of drivers in New Hampshire do not carry auto insurance (actually one of the lower rates of uninsured drivers by state). Those that do not carry auto insurance are probably pretty careful about crossing the borders into nearby states.

 

[urge]

1 So why haven't you started a cash only practice? It has to start somewhere, right? I am sure you can find some like-minded surgeons and doctors of all specialties. Pool your money together and open up some cash only ORs. There is nothing stopping you or anyone else in this country from opening up cash only practices. You can stop accepting insurance tomorrow. Get some local businesses to drop health insurance so that all the local workers will have higher wages and can pay for their total knees themselves.

2 The American workers have been paying their dues into the healthcare system for decades in the form of wage stagnation. They certainly deserve care. You think that if we got rid of health insurance that XYZ corporation would immediately reward their workers with higher wages since they no longer have to contribute to health insurance premiums? Or would the CEO and shareholders get a nice bonus instead?

3 I believe, less than 10% of drivers in New Hampshire do not carry auto insurance (actually one of the lower rates of uninsured drivers by state). Those that do not carry auto insurance are probably pretty careful about crossing the borders into nearby states.

1 It has to start in primary care and trickle to surgical specialties. Makes no sense that the gate keeper is on the insurance system but the surgical physicians are not.

2 Yes. That money that is paid to the insurance will be paid to the worker. It has no cost difference to the employer.

3 Your point being? You haven't answered how they youth of New Hampshire is suffering from not being obligated to buy insurance.

 

[GravelRider]

1 It has to start in primary care and trickle to surgical specialties. Makes no sense that the gate keeper is on the insurance system but the surgical physicians are not.

2 Yes. That money that is paid to the insurance will be paid to the worker. It has no cost difference to the employer.

3 Your point being? You haven't answered how they youth of New Hampshire is suffering from not being obligated to buy insurance.

There are plenty of primary care doctors running cash only practices.

Nope sorry. That's simply false. Corporations offer health insurance now because they have to. If you suddenly take that away, that will just mean bigger bonuses. I'm a little more cynical about corporations providing a fair wage.

My point being is that I have answered your question. Obviously the youth of New Hampshire thinks having insurance is important despite not being required to do so. They have one of the lowest rates of uninsured drivers, so your point is a non-point.

I'm not disagreeing with you that a cash-only system would control costs, but it's simply not realistic now with the extreme price inflation that has gone on in medicine. Doctors have been great beneficiaries of this system because it has allowed them to achieve income not seen in other countries. However, even more than doctors, the major industry players have benefitted from the healthcare game. At some point this system will collapse under the weight of it's own debt. I don't know when that will be, but when it does I think the government will seize control over the healthcare system. Some small, cash only systems may exist for those that can afford to pay for them, but the majority of healthcare will become government run.