Is an All-Cash practice the way to go?

[MedicineMike]

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With all this upheld mandate/obamacare becoming real, should we expect to see a lot more all-cash practices/concierge medicine coming into play? I feel like those options would be quite lucrative and better options for pts if we start losing quality of care and have increased wait times, etc.

Thoughts?

 

[namethatsmell]

A couple things...

Cash practice is generally only feasible in fields where having a very low overhead is possible like primary care or psych, especially if you're a newly minted doc. Most other fields of medicine aren't easy to do for cash on a regular basis, though a few may be possible if you already have an established reputation. The notable exception to this is in derm and plastics where people are willing to pay for "aesthetic" stuff.

There is a HUGE variation of how a cash practices function...concierge, subscription based, direct pay, hybrids of insured patients and cash-only patients, etc etc. Some are set up for rich patients and others are set up for blue collar patients...there's just a ton of variability. You can find a ton on this by searching around on google...

Lastly, charging patients cash may not be an option in the future. The government may prevent docs from doing this since they'll likely need every doc they can get to treat the millions of newly "insured" patients...not trying to start a political thread here, but it's food for thought...

 

[awval999]

Lastly, charging patients cash may not be an option in the future. The government may prevent docs from doing this since they'll likely need every doc they can get to treat the millions of newly "insured" patients...not trying to start a political thread here, but it's food for thought...

This would be coercion and illegal. Also take a peak on one of those Federal Reserve Notes in your pocket, "this is legal tender for all debts public and private".

 

[namethatsmell]

This would be coercion and illegal. Also take a peak on one of those Federal Reserve Notes in your pocket, "this is legal tender for all debts public and private".

Maybe I wasn't clear...the government may prevent physicians from NOT taking insurance. There are direct and indirect ways of achieving this. I agree that it'd be difficult to make a specific law preventing physicians from refusing to take insurance...but there are functional ways of achieving the same ends...such as not giving a doc his DEA number unless he takes insurance.

I'm not trying to be a doomsayer and I of course hope you're right and that nothing like this ever happens...but it's by no means out of the realm of possibility. Do you really think that the government, which has just affirmed the creation of the largest social program in decades, is going to be cool with physicians "opting out" from a system that's already spread thin for providers? Not a chance. They will be absolutely bent on coercing physicians to stay in the system...and I doubt they're going to be doing it with a carrot. Hello, stick.

 

[Perrotfish]

With all this upheld mandate/obamacare becoming real, should we expect to see a lot more all-cash practices/concierge medicine coming into play? I feel like those options would be quite lucrative and better options for pts if we start losing quality of care and have increased wait times, etc.

Thoughts?

1) the bill as it is written doesn't cost you any thing. Actually the bill increases reimbursement for many specialties and procedures. That may change in the future, but as if right now this bill is only hurting you as a taxpayer, not as a physician.

2). The reason the government so easily became such a large part of the healthcare system is because they're the only organization insane enough to pay for the majority of he things we do. Million dollar transplants for alcholoics? Million dollar intensive care stqys for the demented elderly? The insane biling structure of emergency medicine? This is where all the profits margin is in the hospital, and no sane person woukd use their own bank account to pay for any of it.

Physicians salaries skyrocketed after the advent if Medicare in 1965. Back when the US was on a truely cash market physicians were paid a fraction of what they were today in inflation adjusted dollars. If we go back to a cash market I suspect we will go back to the same reimbursement levels.

 

[calvnandhobbs68]

Physicians salaries skyrocketed after the advent if Medicare in 1965. Back when the US was on a truely cash market physicians were paid a fraction of what they were today in inflation adjusted dollars. If we go back to a cash market I suspect we will go back to the same reimbursement levels.

Exactly. Read Lewis Thomas "The Youngest Science" if you want to get a sense of what medicine was like back in the day. In the cash system, you became a doctor for the respect of the position not for the dolla dolla bills. I doubt anyone wants to go back to that now though considering people barely respect doctors at all anymore and think the radiology tech can do the same thing the radiologist does.

 

[Gut Shot]

1) the bill as it is written doesn't cost you any thing. Actually the bill increases reimbursement for many specialties and procedures. That may change in the future, but as if right now this bill is only hurting you as a taxpayer, not as a physician.

2). The reason the government so easily became such a large part of the healthcare system is because they're the only organization insane enough to pay for the majority of he things we do. Million dollar transplants for alcholoics? Million dollar intensive care stqys for the demented elderly? The insane biling structure of emergency medicine? This is where all the profits margin is in the hospital, and no sane person woukd use their own bank account to pay for any of it.

Physicians salaries skyrocketed after the advent if Medicare in 1965. Back when the US was on a truely cash market physicians were paid a fraction of what they were today in inflation adjusted dollars. If we go back to a cash market I suspect we will go back to the same reimbursement levels.

I knew I liked you for a reason. Other than your sweet, sweet can.

 

[bocanutz]

This would be coercion and illegal. Also take a peak on one of those Federal Reserve Notes in your pocket, "this is legal tender for all debts public and private".

When has that ever stopped the government? lol

 

[awval999]

When has that ever stopped the government? lol

I know it's all like "omg the gov't can do anything" but we have a Federal Government of limited and enumerated powers. The most recent Supreme Court decision confirmed this. There is no enumerated power to compel physicians to take a certain insurance.

 

[Shnurek]

When has that ever stopped the government? lol

lol exactly. Like the time Medicare just stopped paying all doctors for a month and never gave a refund. That must have been fun. The government is great 👍

 

[Gut Shot]

lol exactly. Like the time Medicare just stopped paying all doctors for a month and never gave a refund. That must have been fun. The government is great 👍

It's still the hand that feeds (when no one else will).

 

[Votaku]

I don't understand why this is seen as so invasive or unprecedented. Hasn't the government required car insurance for decades? Has that really been so bad?

 

[Law2Doc]

I know it's all like "omg the gov't can do anything" but we have a Federal Government of limited and enumerated powers. The most recent Supreme Court decision confirmed this. There is no enumerated power to compel physicians to take a certain insurance.

The original Clinton healthcare bill actually was pretty much going to do exactly this -- they can make it not feasible to practice outside of the system, by taxing or commercial regulatory hurdles even without outright prohibiting it, and the constitution doesn't really forbid that. A legislative action doesn't have to be an enumerated power, just not be prohibited by the constitution. You can scream about something being unconstitutional, but as some folks saw with Obamacare, that doesn't make it so.

 

[naus]

Physicians salaries skyrocketed after the advent if Medicare in 1965. Back when the US was on a truely cash market physicians were paid a fraction of what they were today in inflation adjusted dollars. If we go back to a cash market I suspect we will go back to the same reimbursement levels.

That's not true at all when adjusted for the high inflation of the 1970s.

Physicians in the US have been well paid relative to other professions since the quack laws were instituted.

 

[naus]

I don't understand why this is seen as so invasive or unprecedented. Hasn't the government required car insurance for decades? Has that really been so bad?

What the hell man? Are there really still people making this stupid analogy?

Does the federal government require you to buy car insurance?

If I live in Manhattan and don't own a car, do I need to buy car insurance?

 

[Abby_Normal]

I highly, highly doubt that anything about the individual mandate will change the fact that a good percentage of the population either doesn't want to or can't afford to pay for medical care out of pocket.

 

[Gut Shot]

I highly, highly doubt that anything about the individual mandate will change the fact that a good percentage of the population either doesn't want to or can't afford to pay for medical care out of pocket.

The can't afford crowd was supposed to be covered by 1.) Medicaid expansion, and 2.) government subsidies to purchase individual policies in the insurance exchanges.

The don't want to segment, those earning enough to afford coverage but choosing not to, was the target of the mandate. We'll see how enforcement goes.

 

[michaelrack]

👍

What the hell man? Are there really still people making this stupid analogy?
?

👍

I find people who don't understand the difference between state and federal government annoying. States have general police/public safety powers that the feds lack (or at least the feds did lack prior to obama)

It's a lot easier to change one's state than one's country- I could easily move my home residence among the states of MS, TN, and Arkansas and still maintain my medical practice in northwest MS.

 

[JackShephard MD]

That's not true at all when adjusted for the high inflation of the 1970s.

Physicians in the US have been well paid relative to other professions since the quack laws were instituted.

Well, at least you can be happy knowing you're making a difference in people's lives.

 

[Marcus Brody]

An "all-cash practice" very soon (if not already) will be a) not very lucrative and/or b) outright illegal.

If it's somehow profitable at all, it will be equivalent to the black market for prescription drugs.

Goodluck competing with corporate medicine.

 

[path or no path]

With all this upheld mandate/obamacare becoming real, should we expect to see a lot more all-cash practices/concierge medicine coming into play? I feel like those options would be quite lucrative and better options for pts if we start losing quality of care and have increased wait times, etc.

Thoughts?

One concierge internist doc told me that concierge model has thus far been a viable option for primary care fields. The right location also matters a lot

 

[jonmadden]

This law makes this not an option as every person will be required to pay for a "bronze" level of care or a fine equivalent to that cost which they estimate at 5k

Location is everything and you can provide care at a fraction of the cost with the reduced overhead as well as not having to wait to be paid after a visit

 

[music2doc]

It would seem that a practice could still simply blackball certain insurance companies unless that was made illegal through further legislation. Many clinics today do not take Medicaid patients and some only take a small percentage of Medicare patients. If entire health systems held the insurance companies (incl. the gov't options) with whom they contract to certain standards of reimbursement (e.g., payment must be in full within 30 days or all future appointments for all patients of that insurance will be immediately suspended), I would think we could actually achieve a fairly favorable compromise for physicians (and other health professionals). Of course, to work, such a health system would need to be large enough to simultaneously p*ss of (tens of) thousands of clients of a given insurance company enough to threaten to cancel their plans.... And such a de facto strike would be quite questionable in terms of medical ethics. Nonetheless, there are times I wish we could simply fight back dirty and cause some legitimate damage to the sleazy insurance companies.

 

[Gut Shot]

This law makes this not an option as every person will be required to pay for a "bronze" level of care

Only if you don't have other insurance. And the premium is dependent on your income and family size. Single people, for example, will receive subsidies on a sliding scale up to 400% of the Federal poverty line, which translates into an annual income of $44,680.

Personally, I think if you're single and making 44K you can afford to shell out $343/month in health insurance premiums. That's just taking personal f-ing responsibility.

 

[Law2Doc]

...

Personally, I think if you're single and making 44K you can afford to shell out $343/month in health insurance premiums. That's just taking personal f-ing responsibility.

...

the number of people willing to pay for health care out if pocket when they already have healthcare covered by insurance is quite low, and rapidly decreasing in this bad economy, which may persist for some time. And physicians who go the concierge route are likely going to have to forego covered patients. so basically the economy is going to support very very few concierge types in each geographic region. For most, it will be sort of like trying to open up a plastic surgery or derm boutique in Beverly Hills today -- you are too late to the party and the economics of the region simply won't support another player.

Concierge services only work in very wealthy and untapped areas, and only if you offer better services than either folks get from insurance plans or folks can get at the local Minute Clinic. So it's really a tiny customer base, and wont support nearly as many players as might want to play that game. Market research and a cooperative economy are going to make or break you.

Folks earning $44k don't use concierge services. Only folks pulling in about four times that and above will realistically consider paying for healthcare above their insurance premiums.

 

[jonmadden]

A PCP should insure their own patients, with other contacts negotiate a network, rather than making money off drugs RX, RVUs, procedures their compensation would be based on the premium and economical care. Caps on net made.

They could have an internal policy to cover catastrophe care scenarios, transplant, ped cancer

With things written into this law, checks and balances are written in like rate hikes, lifetime caps, and denying or dropping coverage for care. For the scumbag docs that need their morality given in the form of laws

20% plus of an insurance premium does not even go to heathcare-admin, lobbying, other BS. And thats the new max written by the law, and this is self reported and theres plenty of ways to book keep to still keep a sinful amount of a premium out of patient healthcare

Some states require a heavier liquid capital on hand then others but with more of an insurance market theyll probably loosen

Either way itd be easy to undercut any company without all the middle BS

Alot of small businesses get gauged and would be better to cater to on a smaller scale, although some companies dont insure more than an avg IM docs pt load

Would bring back more of old school ways like being more involved when a patient is hospitalized rather than leaving it to a hospitalist whos never seen the patient before as it would control costs

Theyd be in the competitive market place so its not like they couldnt provide any care or charge more than well known companies

Reduce pharmas influence as well on prescribing habits as cost savings would far exceed what BS some take for their dignity

More privacy as well which many would be concerned about with the exchange between employer, IRS, state agencies, the insurance company and god knows who else

Basically conceierge; except integrating a policy for the rest of a persons care. At the very least repackaging a policy from a bigger company, providing the preventative care, and quality outcomes would be paid out with a patient group that has less risk and adverse health outcomes as well as economical use lf health resources

Million ways a doc could screw it up and ruin it for others, but for some people maybe starting out and looking for a long term practice and patient set up it would beat any other insurance company up and down

Dakotacare and PA company are owned by physicians, so it exists but they may just resemble other companies

These insurance companies have zero risk to date with ability to cap and drop people, laws change that up and theyve probably doing risk based planning for this before obama was in office. They still can be undercut and outperformed patient carewise if a person isnt greedy or stupid

 

[Gut Shot]

A PCP should insure their own patients, with other contacts negotiate a network, rather than making money off drugs RX, RVUs, procedures their compensation would be based on the premium and economical care. Caps on net made.

They could have an internal policy to cover catastrophe care scenarios, transplant, ped cancer

With things written into this law, checks and balances are written in like rate hikes, lifetime caps, and denying or dropping coverage for care. For the scumbag docs that need their morality given in the form of laws

20% plus of an insurance premium does not even go to heathcare-admin, lobbying, other BS. And thats the new max written by the law, and this is self reported and theres plenty of ways to book keep to still keep a sinful amount of a premium out of patient healthcare

Some states require a heavier liquid capital on hand then others but with more of an insurance market theyll probably loosen

Either way itd be easy to undercut any company without all the middle BS

Alot of small businesses get gauged and would be better to cater to on a smaller scale, although some companies dont insure more than an avg IM docs pt load

Would bring back more of old school ways like being more involved when a patient is hospitalized rather than leaving it to a hospitalist whos never seen the patient before as it would control costs

Theyd be in the competitive market place so its not like they couldnt provide any care or charge more than well known companies

Reduce pharmas influence as well on prescribing habits as cost savings would far exceed what BS some take for their dignity

More privacy as well which many would be concerned about with the exchange between employer, IRS, state agencies, the insurance company and god knows who else

Basically conceierge; except integrating a policy for the rest of a persons care. At the very least repackaging a policy from a bigger company, providing the preventative care, and quality outcomes would be paid out with a patient group that has less risk and adverse health outcomes as well as economical use lf health resources

Million ways a doc could screw it up and ruin it for others, but for some people maybe starting out and looking for a long term practice and patient set up it would beat any other insurance company up and down

Dakotacare and PA company are owned by physicians, so it exists but they may just resemble other companies

These insurance companies have zero risk to date with ability to cap and drop people, laws change that up and theyve probably doing risk based planning for this before obama was in office. They still can be undercut and outperformed patient carewise if a person isnt greedy or stupid

That's the weirdest haiku I've ever seen.

 

[jonmadden]

Key to any is the more that direct care providers are involved with patients they care for directly and regularly, and the less wall street and its bitch the federal government are, cost savings and patient outcomes are easy. They already have the regulations in this bill to prevent docs from running scams.

 

[MT Headed]

There seems to be some confusion between concierge and insuranceless practices.

In a concierge service, the patient pays a monthly fee to have a physician on retainer so that the patient can see the physician quickly and most or all of the medical costs of a visit are eliminated. It's quite similar to purchasing medical insurance directly from your provider.

With insuranceless practices, the doctor simply doesn't accept insurance as a form of payment. This type of practice turns the whole provider/administrator costs on their head. Whereas the typical clinic will have three administrators per medical provider, insuranceless services get by with a ratio of three medical providers per administrator. Eliminating the employee to do the coding, the employee to file insurance claims, and another employee to resubmit rejected claims, etc slashes overhead to near nothing.

The interesting thing about insuranceless medical practices is that they DO have patients who have insurance already. Why would a patient with insurance patronize a clinic that does not accept insurance as a form of payment?

One, because such clinics have to provide better service (same day appointments, longer time spent with the doctor during the appointment) in order to stay in business. When the insurance overhead is eliminated, the provider keeps much more of every patient dollar spent, so they can now afford to have longer patient interactions and see fewer patients a day while still turning a profit.

The second big reason why the insured will patronize insuranceless providers is because the patient can still fill out the forms and seek reimbursement from the insurance company for services rendered. This is significant, because it shifts the pain-in-the-ass insurance hassles away from the provider, who simply wants to provide health care, and onto the person who actually chose to conduct business with the pain-in-the-ass insurance company. If the insurance company proves to be a complete hassle to deal with, then the patient might want to consider switching insurance companies.

These sorts of clinics aren't pipe dreams, they are a reality. Here's one example: http://www.aafp.org/fpm/2007/0600/p19.html

Imagine the possibilities when three doctors share exactly one medical assistant at $30K / year, instead of nine assistants at $270K / year. You could break even on four patients a day.

 

[awval999]

A legislative action doesn't have to be an enumerated power, just not be prohibited by the constitution.

I'm sorry but that is not true.

The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."

The Chief Justice made explicit mention of this in the Affordable Care Act ruling:
"The Federal Government "is acknowledged by all to be one of enumerated powers." Ibid. That is, rather than granting general authority to perform all the conceivable functions of government, the Constitution lists, or enumerates, the Federal Government's powers."

 

[Perrotfish]

Only if you don't have other insurance. And the premium is dependent on your
income and family size. Single people, for example, will receive subsidies on a
sliding scale up to 400% of the Federal poverty line, which translates into an
annual income of $44,680.

Yea but you always want some kind of sliding scale for government entitlement programs. If you have a hard cap where, say, you get the full benifit if your below the poverty line but nothing if you're above it then people start deliberatly keeping their incomes under that line to maintain the benifit.

 

[jonmadden]

Only if you don't have other insurance. And the premium is dependent on your income and family size. Single people, for example, will receive subsidies on a sliding scale up to 400% of the Federal poverty line, which translates into an annual income of $44,680.

Personally, I think if you're single and making 44K you can afford to shell out $343/month in health insurance premiums. That's just taking personal f-ing responsibility.

You must like cliff notes and reading usa today


First off, Every time an employee files for a tax credit, their employer gets hit with the penalty for the difference for not paying enough of the premium, so he pays enough next year if the business can afford it or the person loses their job

Second its 1% 2014, 2% 2015, 2.5% 2016 and there after the average cost of "bronze" coverage which is estimated to be 5k so no gets a free ride

Especially small businesses wholl get hurt by their small employee pool the most in buying insurance

And i imagine alot of big corporations will be ditching the penalty and itll get washed by lobbying money

People should go through the whole bill as it will only dictate their entire career and salary

My haikus awesome, sleeps overrated

Physicians directly providing insurance, on a state level would be easier, would be the only way to beat them at their own game and salvage a decent wage and some dignity. They have a built in advantage of 20% plus to save patients money and undercut the wall street traded companies. Their payout would be upfront reimbursement rather than 10 months later.

They are looking to kill private practices and have everyone work like a resident in a hospital or state clinic, its written all over the bill

It would provide patients more privacy as well as salvage public opinion if physicians werent such a group of spineless brats and/or greedy

I dont care about money. I just dont want some chucklehead on wall street or in DC sitting on their ass using me as a workhorse so they can continue to get rich of healthcare. Theyll let the entire country get cancer with 2.5 trillion a year at stake. Physicians look like the biggest chumps crying they should get .15 or .16 a year for doing all the work

No other developed country allows drug companies the same BS patent protection or profit margins, especially with basically no post marketing surveillance on drugs. Theyll be long gone with enough money to have the supreme court rule cancer doesnt even exist.

 

[FutrPharm]

Only if you don't have other insurance. And the premium is dependent on your income and family size. Single people, for example, will receive subsidies on a sliding scale up to 400% of the Federal poverty line, which translates into an annual income of $44,680.

Thats the thing though. If Obama gets his way, there will be no "other insurance."

Have you ever skimmed over the entirety of the Affordable Care Act's provisions including years 2014 through 2018? *It essentially micromanages from the Dept of Health and Human Services every aspect of US healthcare insurance making the financial operation of private insurance companies a practical impossibility. I defy any objective person to look at just the 2014 provisions alone and then tell me that private insurers will not invariably be driven out of the industry:

- Insurers are prohibited from charging higher plan rates based on pre-existing conditions

- Insurers are prohibited from imposing annual spending caps

- Mandatory maximums imposed on annual deductibles required by insurers

- Pharmaceuticals charged multi-$B annual excise tax relative to market share of Co.

- Private insurers charged multi-$B annual excise tax relative to market share of Co.

Once all of these^^ regulations take hold Jan 2014, it becomes impossible for private insurers to offer anything but high cost Cadillac plans to the wealthiest private employers and enrollees. That of course will only last until the Jan 2018 effective date introducing the provision of a new 40% excise tax charged to insurers on each and every Cadillac plan they provide.

These are not theories about nationalizing the health insurance industry, these are facts derived from logical cause/effect analysis. For anyone who's honestly studied the deliberate complexity of the ACA's full 2,074 page framework, it quickly becomes apparent that it is not at all designed to sustain a market-driven approach to healthcare reform but rather predictably forces the inevitable insolvency of the private health insurance industry creating reactionary consensus demand for a government-run single-payer system.

 

[Gut Shot]

Thats the thing though. If Obama gets his way, there will be no "other insurance."

Wanna bet?

 

[Gut Shot]

You must like cliff notes and reading usa today

I'm just enjoying some tasty lithium and haldol. Perhaps you should try some.

Edit: Yeah, I just don't know what the hell to do with your posts. The series of marginally connected statements, one line apart, with no ending periods, is rather odd.

 

[Perrotfish]

Thats the thing though. If Obama gets his way, there will be no "other insurance."

Have you ever skimmed over the entirety of the Affordable Care Act’s provisions including years 2014 through 2018? *It essentially micromanages from the Dept of Health and Human Services every aspect of US healthcare insurance making the financial operation of private insurance companies a practical impossibility. I defy any objective person to look at just the 2014 provisions alone and then tell me that private insurers will not invariably be driven out of the industry:

- Insurers are prohibited from charging higher plan rates based on pre-existing conditions

- Insurers are prohibited from imposing annual spending caps

- Mandatory maximums imposed on annual deductibles required by insurers

- Pharmaceuticals charged multi-$B annual excise tax relative to market share of Co.

- Private insurers charged multi-$B annual excise tax relative to market share of Co.

Once all of these^^ regulations take hold Jan 2014, it becomes impossible for private insurers to offer anything but high cost Cadillac plans to the wealthiest private employers and enrollees. That of course will only last until the Jan 2018 effective date introducing the provision of a new 40% excise tax charged to insurers on each and every Cadillac plan they provide.

These are not theories about nationalizing the health insurance industry, these are facts derived from logical cause/effect analysis. For anyone who’s honestly studied the deliberate complexity of the ACA’s full 2,074 page framework, it quickly becomes apparent that it is not at all designed to sustain a market-driven approach to healthcare reform but rather predictably forces the inevitable insolvency of the private health insurance industry creating reactionary consensus demand for a government-run single-payer system.

I don't think that it will go quite that far. Healthcare will just develop the dichotomy we have right now with K-12 education: a robust private market for he top quartile of workers, and a morass of public.sector mediocrity for every one else.

 

[JackShephard MD]

I'm just enjoying some tasty lithium and haldol. Perhaps you should try some.

Edit: Yeah, I just don't know what the hell to do with your posts. The series of marginally connected statements, one line apart, with no ending periods, is rather odd.

Yeah, those posts are weird.

 

[jonmadden]

I don't think that it will go quite that far. Healthcare will just develop the dichotomy we have right now with K-12 education: a robust private market for he top quartile of workers, and a morass of public.sector mediocrity for every one else.

The insurance companies have been preparing, past several years cutting people and raising premiums at unprecedented rates in anticipation

Example, "nonprofit" kaiser NW increased in liquid capital from 50 mill to 500 mill in 5 years. They arent required to hold that much on hand so these guys are guying to use money they saved to buy the rates of their premiums down to undercut new competitors

Private companies will secure better risk profiles, leave the rest for the government, I mean us, to pay for and whatever else they fold into it

Theyres a few hundred mill, maybe a billion for insurance companies in the reform bill. The fed made sure they wont starve.

Private insurance will likely cater to wealthier companies exclusively, nothing forbids them from only being open to companies with a certain number of employees i think.

So the highest risk insurance profiles, poor/working class/small business, will be left in the crap government insurance plan. Which will provide very little and cost alot as they show their "bronze" estimates at 5k and doesnt look like it provides ****

Same way when they let ups and fedex in. post office will continue picking up grandmas $2 birthday check in wyomying while they can become some of the wealthiest companies in the world off the profitable routes

Its how government steals without stealing. Pave the way for corporations and pass the laws to set them up for profits.

 

[jonmadden]

I don't think that it will go quite that far. Healthcare will just develop the dichotomy we have right now with K-12 education: a robust private market for he top quartile of workers, and a morass of public.sector mediocrity for every one else.

Yea thats how americas class system works, the top quartile of workers who enjoy the good things in life

 

[Dave89]

the number of people willing to pay for health care out if pocket when they already have healthcare covered by insurance is quite low, and rapidly decreasing in this bad economy, which may persist for some time. And physicians who go the concierge route are likely going to have to forego covered patients. so basically the economy is going to support very very few concierge types in each geographic region. For most, it will be sort of like trying to open up a plastic surgery or derm boutique in Beverly Hills today -- you are too late to the party and the economics of the region simply won't support another player.

Concierge services only work in very wealthy and untapped areas, and only if you offer better services than either folks get from insurance plans or folks can get at the local Minute Clinic. So it's really a tiny customer base, and wont support nearly as many players as might want to play that game. Market research and a cooperative economy are going to make or break you.

Folks earning $44k don't use concierge services. Only folks pulling in about four times that and above will realistically consider paying for healthcare above their insurance premiums.

Depends. If the concierge doc is willing to charge just $50-70 per appt., I think there are many areas where it could work. Especially now that there will be much more strain on the system and people will want to see their doctor without waiting for weeks.

Yea thats how americas class system works, the top quartile of workers who enjoy the good things in life

Isn't that the way every country/society works?

 

[Perrotfish]

Isn't that the way every country/society works?

In a more capitalist society its not a dichotomy, its a sliding scale. If you earn 100k you're getting better stuff than the guy who earns 80, who earns more than the guy who earns 60, etc. The advantage of this system is that the middle class are better off, its generallybmore sustainable, and free market competition drives prices down and quality up for everyone. The disadvantage is that the bottom quartile are often left with nothing.

 

[Laplace]

1) the bill as it is written doesn't cost you any thing. Actually the bill increases reimbursement for many specialties and procedures. That may change in the future, but as if right now this bill is only hurting you as a taxpayer, not as a physician.

2). The reason the government so easily became such a large part of the healthcare system is because they're the only organization insane enough to pay for the majority of he things we do. Million dollar transplants for alcholoics? Million dollar intensive care stqys for the demented elderly? The insane biling structure of emergency medicine? This is where all the profits margin is in the hospital, and no sane person woukd use their own bank account to pay for any of it.

Physicians salaries skyrocketed after the advent if Medicare in 1965. Back when the US was on a truely cash market physicians were paid a fraction of what they were today in inflation adjusted dollars. If we go back to a cash market I suspect we will go back to the same reimbursement levels.

Source??

 

[Lokhtar]

This would be coercion and illegal. Also take a peak on one of those Federal Reserve Notes in your pocket, "this is legal tender for all debts public and private".

No, it wouldn't be illegal. They could make it part of your licencing requirement that you must accept insurance.

They won't do that. But if they wanted, they could.


Secondly, I don't understand the big deal about individual mandate. Since the sixteenth amendment, the government has always had pretty much unlimited taxing power:

"The Congress shall have power to lay and collect taxes on incomes, from whatever source derived, without apportionment among the several States, and without regard to any census or enumeration."

Wanna change it? You need an amendment.

The dissent in this case dealt with whether the current law as written was written as a tax, and not about whether the tax would be legal. It is a given, and accepted by everyone that such a tax would be legal. No conservative or liberal justice has argued that if Congress were to enact a tax on not buying or buying health insurance, that it would be illegal. Just read the dissent - they accuse the majority of rewriting the statute as a tax so that it would be legal. The conservative justices argued that Congress did not write it as a tax, and did not mean it to be a tax and therefore it is invalid under the commerce clause. It is not applicable under the taxing power because it wasn't written as such.

If it was written in a way that explicitely made it a tax, there would be no legal controversy (but the Democrats didn't want to write it that way because due to the political downsides of calling it a tax).


This supreme court did not expand the power of the federal government - if you agreed with the four dissenting conservative justices, the supreme court made something into a legal tax when it should have been an illegal exercise of the commerce power. According to the four liberal members, this act would have been legal under the commerce power as well. Roberts agreed with the conservative justices that this was illegal under the commerce power but said that since it is in fact a tax, it's legal under the taxing power.

If the democrats had explicitly made it a tax, there would be no legal grounds by anyone to overturn it.


I personally support Obamacare, but I thought they wrote the statue not as a tax so I disagree with the tax reasoning of the court even though I would have supported the decision under the commerce clause.

if we're going to argue about something, let's at least get the facts straight shall we?

 

[Gut Shot]

Source??

Here's one: ACP please with rule to increase Medicaid payments.

Part of the deal with expanding Medicaid was to increase payment levels to match Medicare for primary care docs (FM, general IM, and general peds) as well as some targeted groups of surgeons. The only reimbursement cut specified in the whole PPACA deals with utilization rate calculations for diagnostic imaging equipment.

The big variable in our future salaries is IPAB, which will replace the toothless MEDPAC. Most people I have spoken with think IPAB will ultimately level the field somewhat between primary care and specialist reimbursement.

A good summary: http://www.kevinmd.com/blog/2011/04/ipab-takes-policy-puts-hands-health-care-experts.html

 

[Laplace]

Here's one: ACP please with rule to increase Medicaid payments.

Part of the deal with expanding Medicaid was to increase payment levels to match Medicare for primary care docs (FM, general IM, and general peds) as well as some targeted groups of surgeons. The only reimbursement cut specified in the whole PPACA deals with utilization rate calculations for diagnostic imaging equipment.

The big variable in our future salaries is IPAB, which will replace the toothless MEDPAC. Most people I have spoken with think IPAB will ultimately level the field somewhat between primary care and specialist reimbursement.

A good summary: http://www.kevinmd.com/blog/2011/04/ipab-takes-policy-puts-hands-health-care-experts.html

This definetly goes against what I heard many people saying about medicare/medicaid reimbursements being cut 27% by the end of the year. I guess I should really read from more credible sources than going off of word of mouth :/

ACP is particularly pleased that CMS is proposing that all physicians with the specialty designations of family medicine, general internal medicine, or pediatric medicine—as well as all subspecialists within those three specialty designations, as recognized by the American Board of Medical Specialties—be eligible for increased payment

I wonder whether this means whether IM sub-specialties such as GI and Cardiology will also see increased reimbursements?

 

[calvnandhobbs68]

This definetly goes against what I heard many people saying about medicare/medicaid reimbursements being cut 27% by the end of the year. I guess I should really read from more credible sources than going off of word of mouth :/



I wonder whether this means whether IM sub-specialties such as GI and Cardiology will also see increased reimbursements?

Those cuts are the scheduled cuts that come up every year. What happens is they're actually supposed to get cut by a couple percent every year but instead of doing it they always defer it to the next year which brings us to the most recent number of 27%. We'll see if they put it off as usual or actually put some cut in place this time but in any case its unlikely to get cut by the full amount.

 

[jonmadden]

Whatever Im paying my taxes in ACO valued bundles, based on education improvements, a living wage strategy, paying back debts owed to the public

Theyll get metrics and payment based on the what other developed countries provide, for a fraction of the funding they get

I'll only pay a set amount based on this comparable average for certain services and for comparable returns to the public

Id honestly give 50%plus of every cent I made, straight up no deductions, for life for that

If patients could be expected to have a certain standard of living obtainable based on ACO tax bundling, their cholesterol level and BP would be something more in control of by a physician