legit question about reform and its implication on anesthesiology

[paintstick]

Hey guys (and gals),
I was wondering if someone could help me understand exactly how the proposed (and most likely soon to be approved) changes will "kill" our field. I must admit I am very novice when it comes to politics/policy, but I have done my fair share of reading and digging in attempts to understand what changes our country (and practices) will be facing. I know that SGR formula completely, and insultingly, undervalues anesthesiology services - however, if under the new plan (as I understand it) there are more subsidies for individuals to buy private insurance, wont there be more people with private plans that were previously showing up at hospitals with no coverage whatsoever? I also understand that private plans base their rates on what medicare is currently paying, but as of right now even under this influence the private rates are not horrible. Now *disclaimer*, I am NOT saying i understanding this whole process, but what I am asking is for someone to help me (and probably many others) understand how this major Bill will cause so many problems (assuming that the included medicare cuts of 20% will actually not happen - which is good for us, but completes destroys the $940 billion dollar estimates).

I also know it is a "slippery slope" and that once change like this occurs we could be moving to a single payer - but, as things stand now what are the implications for 2010 and 2014?

Thank you very much, I appreciate the insight of those who understand this much better than I.

have a great day

PS - I have just matched in what I still consider a great field. I hope to be able to make a "nice" living and pay back my considerable loans, but at least I know I enjoy what I do.

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[RxBoy]

http://www.asahq.org/news/asanews031710.htm

"ASA believes that the bills currently under consideration advance multiple provisions that marginalize physicians. As an example, H.R. 3590 finances its reforms largely on the backs of the physician community. The lack of provisions to repeal the broken Medicare SGR formula – the funds for which were directed to other purposes during the reform debate – is exacerbated by multiple other provisions that could result in additional payment reductions for physicians under Medicare and in the commercial insurance marketplace over the next decade. Other provisions rely on Medicaid programs to cover the uninsured without adequate remedy to the widely recognized inadequacy of the financial underpinnings of this program. Still other language would establish an Independent Payment Advisory Board (IPAB) with sweeping powers to cut Medicare payments. And meanwhile, the so-called “non-discrimination” provisions seek to elevate paraprofessionals in the health care marketplace by prohibiting health plans from appropriately differentiating between physicians and those paraprofessionals. The hope that the reform effort would recognize physicians’ unique and indispensible role in the health care system appears to have come to naught in these flawed reform bills."

 

[Dirtball]

follow a few cases through the OR. code them , do the math based on $17/u and $55/u . Then fight the Pt's for their co-pay/ deductible that falls on you . Stomach the cases that fall out of your network , the pt's refuse to pay you nothing, siting they didnt know a choly yielded an anesthesia bill and they pay you nothing for your work, they ignore your bills , you may turn over to collections and subtract another 50% for collector, most folks who dont pay bills have no fear of collection agency and already have bad credit.... I average <40% of what I bill. When this figure goes down , I will make less money. Most of us charge $75-100+/ u , the MCR number of $17 is almost free work after your overhead and billing fee. Your car mechanic nets more $ per hour.

 

[paintstick]

Thank you very much for the replies thus far, they are very informative (and sadly scary). I guess where I am still unclear is on the concept that more people will have private insurance.

As I understand it the 32 million who will not "get coverage" where those who had no coverage before so hospitals were swallowing the costs. If some of those 32 million purchase private insurance (as mandated by Bill), wont there be "more" people with private plans?

I could see the "plans" that people end up buying having HUGE co-pays and deductibles, however, if those individuals ever end up in one of "your" ORs wont you be able to bill their private insurance company (and be reimbursed) at a rate that is higher than the 17$ MCR? I guess what I am "hoping/assuming" is that even a crappy private plan is better than medicare. Again - this is a question, not a passive aggressive statement. I had previously read (and then subsequently re-read the ASA stance on the matter with specific regard to paraprofessionals and what implications that may have) and I am trying to read factual based articles on the bill in the attempts of being truly informed.

Thanks again for all your help in trying to understand and digest this complicated matter.

 

[BLADEMDA]

Thank you very much for the replies thus far, they are very informative (and sadly scary). I guess where I am still unclear is on the concept that more people will have private insurance.

As I understand it the 32 million who will not "get coverage" where those who had no coverage before so hospitals were swallowing the costs. If some of those 32 million purchase private insurance (as mandated by Bill), wont there be "more" people with private plans?

I could see the "plans" that people end up buying having HUGE co-pays and deductibles, however, if those individuals ever end up in one of "your" ORs wont you be able to bill their private insurance company (and be reimbursed) at a rate that is higher than the 17$ MCR? I guess what I am "hoping/assuming" is that even a crappy private plan is better than medicare. Again - this is a question, not a passive aggressive statement. I had previously read (and then subsequently re-read the ASA stance on the matter with specific regard to paraprofessionals and what implications that may have) and I am trying to read factual based articles on the bill in the attempts of being truly informed.

Thanks again for all your help in trying to understand and digest this complicated matter.

Let me break it down for you Slim.

1. Obamacare means the Sec. of Health is now the big Cheese of health care. She will decide circa 2014 how much insurance companies should reimburse you for your services. Insurance companies will be told what type of policies they need to issue (coverage) and allowed into the exchange. The Sec. of Health will have broad, sweeping powers to make policy on reimbursement, allowed procedures and type of provider (e.g. CRNA) billing for the work.

Some will say the new "health care laws" don't give that much power to the Sec. of Health. They are wrong.

2. Sebelius is no friend of the ASA or MD/DO Anesthesiology. She is bad for medicine and worse for Anesthesiology. She has supported solo, independent CRNA practice in the past and will likely do so again at the national level.

3. Medicare rates- Dems. believe that Physicians should be reimbursed at about 110% of Medicare rates. For most Specialists they can do fine wit that amount. For "gas" it is a death sentence unless you are a CRNA.

4. Contrary to what you may read elsewhere the Sec. of Health will SLASH surgical procedures in order to save money in an otherwise "broke" Medicare system. This means less cases and less need for your services.

5. The Anesthesia Care team is dead circa 2020. Hence, we will need 50% fewer Board Certified Anesthesiologists in 2020 than we have today.


6. If given the choice between Obamacare in 2020 or Canadian health care I would choose the later. This is exactly what Obama is hoping for; a transition to Canadian style single payer system.

7. Make sure you want to be an Anesthesiologist even if only pays $150K per year as that is all you are guaranteed to earn.

8. Those with outstanding Board scores and grades should choose another career.

9. Republicans can't or won't save Medicine. Stop wishing upon a star.

10. Those who like to sue should still be happy as Obamacare has NO Tort reform. So, that Medicare/Medicaid patient who isn't even covering the cost of your overhead can still sue the crap out of you.

Only in Obama's America.

Blade

 

[secretasianman]

This is depressing. What do you propose we do? Us residents are stuck in debt up to our knees, it's not like we have a way out of this mess? Move to Australia or Canada?

Let me break it down for you Slim.

1. Obamacare means the Sec. of Health is now the big Cheese of health care. She will decide circa 2014 how much insurance companies should reimburse you for your services. Insurance companies will be told what type of policies they need to issue (coverage) and allowed into the exchange. The Sec. of Health will have broad, sweeping powers to make policy on reimbursement, allowed procedures and type of provider (e.g. CRNA) billing for the work.

Some will say the new "health care laws" don't give that much power to the Sec. of Health. They are wrong.

2. Sebelius is no friend of the ASA or MD/DO Anesthesiology. She is bad for medicine and worse for Anesthesiology. She has supported solo, independent CRNA practice in the past and will likely do so again at the national level.

3. Medicare rates- Dems. believe that Physicians should be reimbursed at about 110% of Medicare rates. For most Specialists they can do fine wit that amount. For "gas" it is a death sentence unless you are a CRNA.

4. Contrary to what you may read elsewhere the Sec. of Health will SLASH surgical procedures in order to save money in an otherwise "broke" Medicare system. This means less cases and less need for your services.

5. The Anesthesia Care team is dead circa 2020. Hence, we will need 50% fewer Board Certified Anesthesiologists in 2020 than we have today.


6. If given the choice between Obamacare in 2020 or Canadian health care I would choose the later. This is exactly what Obama is hoping for; a transition to Canadian style single payer system.

7. Make sure you want to be an Anesthesiologist even if only pays $150K per year as that is all you are guaranteed to earn.

8. Those with outstanding Board scores and grades should choose another career.

9. Republicans can't or won't save Medicine. Stop wishing upon a star.

10. Those who like to sue should still be happy as Obamacare has NO Tort reform. So, that Medicare/Medicaid patient who isn't even covering the cost of your overhead can still sue the crap out of you.

Only in Obama's America.

Blade

 

[GoodmanBrown]

7. Make sure you want to be an Anesthesiologist even if only pays $150K per year as that is all you are guaranteed to earn.

Does anyone on the board feel like this isn't really that bad a wage to earn?

 

[Leverage]

What i am hearing is game-set-match...super depressing

 

[Arch Guillotti]

Does anyone on the board feel like this isn't really that bad a wage to earn?

In the grand scheme of things and compared to the vast majority of Americans, no it isn't bad.

HOWEVER, it sucks when you hump it for 10 years and have a ton of debt.

I don't have an extravagent lifestyle by any means but when you have school loans, retirement, mortgage, car payment, kids, school, college funds, disability, health bills, etc etc etc 150K sure does seem to get used up pretty fast.

 

[RedAnesthesia]

Does anyone on the board feel like this isn't really that bad a wage to earn?

That is a fine salary but as another poster mentioned it doesn't go very far if you have about 200 grand worth of debt that is accruing interest at 6.8% and have kids, mortgage, etc. I understand medicine is about delayed gratification but crap I would like to buy some nice things before I hit 40 years of age. This bill will change medicine forever and it isn't a good change.

 

[karizma098]

Does anyone on the board feel like this isn't really that bad a wage to earn?

yes. it's great money. it's about what my girlfriend makes. she's a pharmacist. works 40 hours a week, low stress. oh yeah, and she's 25.

so no, it's not great money to start making after a ****-tacular amount of dedication and work , and at the age of 30-32.

i doubt we'll wind up in the 150k arena. primary care docs probably will stay in this range and i'm guessing gas will wind up in the low 200s or so. not terrible but definitely will destroy it's competitiveness in the coming years, i think. what blade said about sebelius is 100% right.

maybe i should consider ER med? ugh.

 

[RedAnesthesia]

yes. it's great money. it's about what my girlfriend makes. she's a pharmacist. works 40 hours a week, low stress. oh yeah, and she's 25.

so no, it's not great money to start making after a ****-tacular amount of dedication and work , and at the age of 30-32.

i doubt we'll wind up in the 150k arena. primary care docs probably will stay in this range and i'm guessing gas will wind up in the low 200s or so. not terrible but definitely will destroy it's competitiveness in the coming years, i think. what blade said about sebelius is 100% right.

maybe i should consider ER med? ugh.

Yeah, I wonder if many med students will think like you and it will be very interesting to see the number of applicants there will be next year for anesthesia.

 

[urge]

I wonder how many people will apply to medicine school from now on.

 

[gas passer]

Ugh. This is so depressing. Anybody else that just matched considering switching to something else? If it wasn't so hard to do I think I seriously would. What a nightmare.

 

[karizma098]

i spent a few hours today looking over the bill.

for the most part, blade is right, paycuts are on the horizon. if you're in gas now, work your tail off is my best advice, specialize in pain or something and try to make money there? i dunno.


the ONLY fields safe from a salary chop appear to be FP/ER. this is because they are already compensated like crap based on the fact that they often have a high amount of patients who either:

1) don't pay
2) have medicaid
3.) have medicare

for them, the medicaid patients will now reimburise 110% of medicare, and the ones that don't pay will magically have insurance. this will offset the decreasing amount of payouts they'll get from companies for whatever procedures they do - so essentially their salaries will stay the same.

gas, rads, surgery, they are not safe. theses are procedure based professions, insurance companies are going to be pressured to avoid procedures as much as possible to decrease costs, also a lot less money will be allocated for procedures - ie, if u got 10 bucks before, you'll likely get 5 now, so you may be better off not doing it at all.

i see gas salaries in PP probably falling to the 200 range, 250 or so for rads. it can get worse than that but i don't think thats likely.

300+ a year is going to be a tough make. fields like ER can do this with extra shifts, but outside of that based on the formulas for payouts and eventual (2014+ ) plans for reimbursement, i don't see how gas can stay in this financial ballpark in the next decade.

as a side note, i'll probably still do gas. my old mans an anesthesiologist and i genuinely enjoy the work. i'll readjust my expectations/lifestyle/amount of time to pay off loans to the newer standard '200k' salary. could be worse i guess. sigh.

 

[BeBlessedMD]

And let history repeat itself. Med students become scared of anesthesia because of decreasing salaries. Supply goes down. Demand goes obviously up since 32 more million americans can now afford surgery now. And my bank acct does the same. Sounds like the 90's right??? So hurry on and skidaddle....lets not slow the process down

 

[Narcotized]

I wonder how many people will apply to medicine school from now on.

Might still get a few here and there that got rejected from plumbing and electrician school.

 

[Narcotized]

What do you propose we do? Us residents are stuck in debt up to our knees.

President Handout in his infinite givings of money we don't have is graciously capping what you have to pay back on your student loans. So don't sweat the debt. Rather sweat the civil unrest when this unsustainable joke of fiscal irresponsibility collapses.

 

[Laurel123]

Might still get a few here and there that got rejected from plumbing and electrician school.

I just had a huge leak in my kitchen. Plumber came in. Worked for about 5 house. And then I wrote him a $1500 check. Plumbing school is no joke. Unlike medical school now.

 

[DrCurious]

And let history repeat itself. Med students become scared of anesthesia because of decreasing salaries. Supply goes down. Demand goes obviously up since 32 more million americans can now afford surgery now. And my bank acct does the same. Sounds like the 90's right??? So hurry on and skidaddle....lets not slow the process down

True, this is a possibility. I am glad someone is being optimistic.

 

[Jeff05]

True, this is a possibility. I am glad someone is being optimistic.

i wish. however, in the 90s there was a false alarm. the surgical volume didn't go down as thought and in conjunction with decreased supply of anesthesiologists things got better. this is the real thing. this is what clinton didn't achieve.

this increases our taxes and pays us less. insurance companies will profit for now, pharma will profit for now, hospitals will profit for now. the only people who will be hurt will be the providers - specifically, the specialist physicians. current medicare recipients who pay for supplemental insurance may also suffer as their out of pocket expenses will increase.

unfortunately, this legislation does NOTHING to realistically address the healthcare situation, it just throws a trillion to the masses - another unaffordable entitlement.





"To pay for the changes, the legislation includes more than $400 billion in higher taxes over a decade, roughly half of it from a new Medicare payroll tax on individuals with incomes over $200,000 and couples over $250,000. A new excise tax on high-cost insurance policies was significantly scaled back in deference to complaints from organized labor.
In addition, the bills cut more than $500 billion from planned payments to hospitals, nursing homes, hospices and other providers that treat Medicare patients. An estimated $200 billion would reduce planned subsidies to insurance companies that offer a private alternative to traditional Medicare."

 

[welovelamarodom]

President Handout in his infinite givings of money we don't have is graciously capping what you have to pay back on your student loans. So don't sweat the debt. Rather sweat the civil unrest when this unsustainable joke of fiscal irresponsibility collapses.

this i hadnt heard anything specific about. the student loan bill supposedly attached to the senate/reconciliation bill doesnt address current outstanding loans does it? if it did, perhaps this wouldnt be so bad. yeah, no, its pretty bad.

 

[furfur]

President Handout in his infinite givings of money we don't have is graciously capping what you have to pay back on your student loans. So don't sweat the debt. Rather sweat the civil unrest when this unsustainable joke of fiscal irresponsibility collapses.

Couldn't have said it better myself. Guns, gold, food, and water.

 

[avatarftw]

a

 

[AnesFuture]

I will start by saying I am by far not an expert....

But it seems that this anesthesiology board in particular is always full of so much doom and gloom with people just making up random guesswork speculative salaries of 150k or 200k etc and scaring off high quality medical school candidates.

The rads board is definitely not like this and so you still have med students not scared off by these unsupported speculations.

If you want anesthesiology to get more competitive and have higher and higher quality applicants applying in the future I would suggest (imho) to not have so much doom and gloom and speculate about future salaries that no one on this board can accurately predict.

We all know what happened with this same doom and gloom stuff from the mid 90's.

 

[pinipig523]

7. Make sure you want to be an Anesthesiologist even if only pays $150K per year as that is all you are guaranteed to earn.

Does anyone on the board feel like this isn't really that bad a wage to earn?

Are you effing kidding me?

You must be a bonehead.

Let me break it down to you, buddy.

150,000 gross - 33% tax = 100,000 net
100K/12 months = ~8000/month.
If you have 200,000 debt from medical school - $2000/mo x 30y

8000-2000 = 6000/month

That's assuming you only owe 200K in loans. And that's assuming you don't accumulate interest during residency.

AND let's not forget that there is NO MORE economic hardship! So from the getgo, you get to do FORBEARANCE which means you get slapped the interest from the getgo.

You know who makes 5-6K a month, your neighborhood carsalesman.

Oops... I forgot malpractice!!

Doh.

Better bring that number closer to 4-5K a month.

Enjoy.

 

[Eta Carinae]

Are you effing kidding me?

You must be a bonehead.

Let me break it down to you, buddy.

150,000 gross - 33% tax = 100,000 net
100K/12 months = ~8000/month.
If you have 200,000 debt from medical school - $2000/mo x 30y

8000-2000 = 6000/month

That's assuming you only owe 200K in loans. And that's assuming you don't accumulate interest during residency.

AND let's not forget that there is NO MORE economic hardship! So from the getgo, you get to do FORBEARANCE which means you get slapped the interest from the getgo.

You know who makes 5-6K a month, your neighborhood carsalesman.

Oops... I forgot malpractice!!

Doh.

Better bring that number closer to 4-5K a month.

Enjoy.

 

[BLADEMDA]

I will start by saying I am by far not an expert....

But it seems that this anesthesiology board in particular is always full of so much doom and gloom with people just making up random guesswork speculative salaries of 150k or 200k etc and scaring off high quality medical school candidates.

The rads board is definitely not like this and so you still have med students not scared off by these unsupported speculations.

If you want anesthesiology to get more competitive and have higher and higher quality applicants applying in the future I would suggest (imho) to not have so much doom and gloom and speculate about future salaries that no one on this board can accurately predict.

We all know what happened with this same doom and gloom stuff from the mid 90's.

\

My prediction is for $250K plus benefits salary level not $150K. I just wanted to get out the range for gas pay circa 2020. On the low end you have $150K and the high end you have $350k. Most likely wage is about $250k (provided the ASA can make the case we deserve more than Medicare rates).

 

[Dirtball]

Tort Reform would have saved money. The lack of tort reform in this quickly thrown together mess speaks the truth. Alot of you students mention salaries here that are unrealisticaly high. I worked very hard in a MCR/MA population with OB , 1:3 or 1:2 call , 3 weeks off anually , solo , did my billing , paid insurance , IRA and the net income would scare you all the hell off this board back to trade school. .....more to come

 

[notinkansas]

I don't think that there will be a huge increase in the number of patients with private insurance.

Since the bill has no provisions to allow insurance to be sold across state lines, or to allow small employers to pool together to form groups, or to allow self employed individuals to form groups, the cost of insurance cannot go down.

Add to this the fact that companies will be required to accept and keep patients with pre-existing conditions. So as the number of people in the insurance pool with high costs increases, costs will go up, therefore premiums will go up.

I predict that many people without pre-existing conditions will find that paying the fine for not having insurance will cost them less than health insurance premiums, and will therefore opt to pay the fine (read: tax) instead. Or, as suggested above, they will buy a crappy plan that doesn't cover much.

Why would anybody buy insurance if the fine is cheaper, until they develop a pre-existing condition- since the insurance company won't be able to deny them coverage.

The purpose of this bill is not to improve health care coverage.

The purpose of this bill is to collapse the health care system as we know it, in order to give the government the chance to save the day by implementing socialized medicine. (google Cloward and Pivens- they laid out this strategy in the 1960's)

I'm afraid Ben Franklin was right: looks like we may not be able to keep the repubilc.

 

[paintstick]

gentleman and ladies,
Your responses have been very helpful for me in understanding the implications of the reform (as well as general billing practices/administration details/all the other stuff NO ONE teaches you about in medical school). I have one more question to pose to the group:

Will this reform have as dramatic of an effect on academic anesthesiologists? It is my assumption (albeit probably wrong) that attendings in academic hospitals often earn a salary +/- extra compensation for volume/overnight call as well as varying benefits packages. It is also my understanding that hospitals often compensate anesthesiologist (regardless of the pts insurance) because even if they break-even/lose money on the anesthesia delivery having high-end specialists is important for hospitals in attracting patients. With all this said, will academic anesthesiologist also take a significant pay-cut (or will hospitals continue to subsidize their salaries), or is the reform mainly going to bring the days of well-compensated private practice to extinction without as dramatic an influence on academics?


Thanks again for all the help.

 

[RabbMD]

This bill is purely about expanding access to care. There is very little that bends the cost curve down. Adding more people that don't care what that MRI on their r knee costs, when the real reason they have knee pain is because they are 5'6" and 275, will only exacerbate the problem.

The only provision I see that decreases cost is the excise tax or "cadallac plan" tax, and Obama neutered that. All the savings I see on this plan relies on cutting reimbursement by fiat (continuing sgr cuts to doctors), or fiction. This fiction relies on "bundling" to decrease costs in part, and Medicare advisory boards deciding what to reimburse. Bundling is something anyone who has ever negotiated with a hospital or insurance company should dread. Basically it just is code for pay hospitals only for surgeries, and make anesthesiologists beg for the scraps. You will either see decreased payments to anesthesia groups, required to provide more services, be straight hospital employees, and or, elimination of subsidies. Just wait till you start getting all the "hospitalists calls at 3am to do their lp for menigitis pts, or place alines for their urosepsis pts.

Can anyone honestly believe preventative care will save money as this bill proposes? Sure, it may save lives, and be an overall benefit to society, but this bill assumes it will save MONEY. That sounds great and seems to "make sense", but we as clinicians are taught that any hypothesis has to be tested. This one is tough, to test admittedly, but every test I can find, including the feb 14, 2008 nejm article clearly shows preventative doctor care costs money in general. If you believe doctors can make people, quit smoking, eat less and
excercise more, I have a bridge in New York to sell you.

Most of the uninsured added to this bill also go to expanded Medicaid coverage, which states that are already broke must pay for. The federal goverment pays for the early years of this Medicaid by collecting taxes for a few years before they extend the coverage. But once the federal government begins to decease payments to the states in the mid to later part of this decade, in order to make the cost look less than it really is for the cbo, where are the broke states going to come up with this money? Ca. You say stimulus bill??

Can anyone who supports this bill explain to me where these cost savings are going to come? And please do not insult our intelligence with that talk point waste/fraud/abuse nonsense. Do not say "preventative care" unless you come with a better source than the nejm. Do not say decreased er uses for primary care by the uninsured, unless you can explain why er visits are not decreased in the universal coverage land of Massachusetts.

 

[GoodmanBrown]

Are you effing kidding me?

No, not really. I think it's largely a matter of perspective. I'm finding that having neither parent who's a doctor puts me in the minority in a lot of interview and second look situations, as is being a non-traditional student. (I graduated in '04.)

 

[GoodmanBrown]

This bill is purely about expanding access to care. There is very little that bends the cost curve down. Adding more people that don't care what that MRI on their r knee costs, when the real reason they have knee pain is because they are 5'6" and 275, will only exacerbate the problem.

The only provision I see that decreases cost is the excise tax or "cadallac plan" tax, and Obama neutered that. All the savings I see on this plan relies on cutting reimbursement by fiat (continuing sgr cuts to doctors), or fiction. This fiction relies on "bundling" to decrease costs in part, and Medicare advisory boards deciding what to reimburse. Bundling is something anyone who has ever negotiated with a hospital or insurance company should dread. Basically it just is code for pay hospitals only for surgeries, and make anesthesiologists beg for the scraps. You will either see decreased payments to anesthesia groups, required to provide more services, be straight hospital employees, and or, elimination of subsidies. Just wait till you start getting all the "hospitalists calls at 3am to do their lp for menigitis pts, or place alines for their urosepsis pts.

Can anyone honestly believe preventative care will save money as this bill proposes? Sure, it may save lives, and be an overall benefit to society, but this bill assumes it will save MONEY. That sounds great and seems to "make sense", but we as clinicians are taught that any hypothesis has to be tested. This one is tough, to test admittedly, but every test I can find, including the feb 14, 2008 nejm article clearly shows preventative doctor care costs money in general. If you believe doctors can make people, quit smoking, eat less and
excercise more, I have a bridge in New York to sell you.

Most of the uninsured added to this bill also go to expanded Medicaid coverage, which states that are already broke must pay for. The federal goverment pays for the early years of this Medicaid by collecting taxes for a few years before they extend the coverage. But once the federal government begins to decease payments to the states in the mid to later part of this decade, in order to make the cost look less than it really is for the cbo, where are the broke states going to come up with this money? Ca. You say stimulus bill??

Can anyone who supports this bill explain to me where these cost savings are going to come? And please do not insult our intelligence with that talk point waste/fraud/abuse nonsense. Do not say "preventative care" unless you come with a better source than the nejm. Do not say decreased er uses for primary care by the uninsured, unless you can explain why er visits are not decreased in the universal coverage land of Massachusetts.

+1

I agree. However marketed, this bill is purely an "access to health care" reform.

As several others have mentioned, I have very significant doubts about its sustainability. All that said, I still largely agree with the intent of the bill, if not some of the details.

 

[RapidSequence]

I do not agree with most of you guys on this threard because we really have NO IDEA how this is all going to play out. Sure we're getting huge cuts in reimbursements but do you realize doctors and anesthesiologists are going to finally get paid for all the time and procedures that went uncompensated before!?!? Doing an epidural for a medicaid patient will pay more now, providing anesthesia for the uninsured will pay more now, we will have so much greater volume that is being reimbursed. We will be in much greater demand, we will have an easier time finding jobs. If we don't have to refuse medicaid or medicare patients it will be easier for a doctor to open their own practice and get the patients necessary to thrive.

Now I'm not saying this is all going to come true, but for every doomsday scenario previously posted I could bring up a positive to counter. In truth no one has any idea what is going to happen. No one!

The devil is in the details.

 

[RabbMD]

What part of this bill pays more for a Medicaid epidural? Why would you say something like that without facts? Do you know what a Medicaid epidural pays even? If you get 3 base units for placing it, and say over 6 hours you cover the patient you get only anoth 3 units for 45 minutes actual face time, that is 6 units. Medicaid pays about $18 a unit in my state. That means for cover an epidural for 6 hours I get paid $18x6 = $128. That is $128/6= $18/hour... Ya I went to 12 years of post high school education for $18/hour. That's before expenses too. Let's say the government raises Medicaid rates 10%, but market share of Medicaid goes from 25% to 50%. Weeeee now I make $19.80 an hour for providing epidurals for half of my ob patients.

If you doubt what government would do if they got a true monopoly single payer system, just look at what they pay anesthesia already, which they do because they can, and anesthesia can not not accept Medicare pts or balance bill them. I can justify that statement if needed, but because of most contracts with hospitals it is a fact.

 

[2win]

I do not agree with most of you guys on this threard because we really have NO IDEA how this is all going to play out. Sure we're getting huge cuts in reimbursements but do you realize doctors and anesthesiologists are going to finally get paid for all the time and procedures that went uncompensated before!?!? Doing an epidural for a medicaid patient will pay more now, providing anesthesia for the uninsured will pay more now, we will have so much greater volume that is being reimbursed. We will be in much greater demand, we will have an easier time finding jobs. If we don't have to refuse medicaid or medicare patients it will be easier for a doctor to open their own practice and get the patients necessary to thrive.

Now I'm not saying this is all going to come true, but for every doomsday scenario previously posted I could bring up a positive to counter. In truth no one has any idea what is going to happen. No one!

The devil is in the details.

False - read some history books dude. What I can say - seems that ignorance is a bliss....

 

[GoodmanBrown]

Do you also largely agree with the intent to spend another...
$940 BILLION dollars?

This country can totally afford this right now.

"A wise and frugal government, which shall leave men free to regulate their own pursuits of industry and improvement, and shall not take from the mouth of labor the bread it has earned - this is the sum of good government." -Thomas Jefferson

I would readily admit I'm pretty ambivalent about it. I honestly believe that if John McCain had become president, he and Congress would have passed similar bills as what has been passed under Obama. Wherever those billions and trillions of dollars went, I think it's pretty widely accepted that it kept the U.S. economy from experiencing a considerably worse depression. If you have economists that you've read that feel differently, please link as I'd enjoy reading it.

As for this specific, 1 trillion, it's actually over 10 years. So, annually, it will cost ~$100 billion. Not chump change by any stretch. But, it's partially already paid for with some additional taxes on pharmaceuticals, device makers etc. I do in fact see the inherent silliness in charging people money who's products you'll 2 second later indirectly pay for. I see how they'll immediately just pass the cost onto people needing the devices and drugs. But, apart from straight income tax, I don't see how else to pay.

That said, $100 billion is only about 4% of our current healthcare spending in the U.S. Again, adding that in top of what we already spend is clearly going to strain a system that already is straining mightily. Will it break the camel's back? Mil clearly thinks it will. I don't know. Eventually something gotta give, but I can't predict how and what all the ramifications will be.

I personally believe health care is a right, not a privilege. That's why I support this bill. Others on the board disagree. But, I think no one here would just step over a man seizing on the ground and walk on past without calling an ambulance. So, I think that speaks to a certain amount of agreement.

I don't believe everyone deserves Lasik surgery or even the absolute latest, cutting edge chemotherapy. But what about access to a PCP and a generic drug formulary? Basic surgeries like an appy? Maybe more? I don't know how, but I think we need to set some sort of price point or some sort of limit, but then provide that for everyone.

EDIT: I don't mean that no one else could get any sort of supplemental insurance that would pay for any other desired treatment. I simply mean that everyone could get basic levels of care, and anything in addition is on your own.

 

[GoodmanBrown]

False - read some history books dude. What I can say - seems that ignorance is a bliss....

What history books do you suggest?

 

[pgg]

II personally believe health care is a right, not a privilege. That's why I support this bill.

[...]

I simply mean that everyone could get basic levels of care, and anything in addition is on your own.

It's not clear to me why you "support" a bill that doesn't actually do what you later clarified you "mean" ...


As for health care being a right, how about housing? I could make a very compelling (but equally wrong) argument that shelter is far more important than a screening colonoscopy, and that it ought to be provided for everyone.


It's kind of sad. The more charity the government doles out at my expense, the less charitable I feel, the less I'm likely to donate to deserving organizations from my discretionary funds, and the more I just want to say "Screw the poor, I don't care any more, they're just going to howl about how they're entitled to my services and take my time and money anyway."

 

[GoodmanBrown]

It's not clear to me why you "support" a bill that doesn't actually do what you later clarified you "mean" ...

As for health care being a right, how about housing? I could make a very compelling (but equally wrong) argument that shelter is far more important than a screening colonoscopy, and that it ought to be provided for everyone.

It's kind of sad. The more charity the government doles out at my expense, the less charitable I feel, the less I'm likely to donate to deserving organizations from my discretionary funds, and the more I just want to say "Screw the poor, I don't care any more, they're just going to howl about how they're entitled to my services and take my time and money anyway."

I guess we disagree on the bill. My "meaning" was that people deserve access to health care. (The details are mostly my pet idea.) This bill increases access to insurance and subsequently the healthcare. Hence my support of it.

As for housing being a right, I'd have to think about it and probably get pretty detailed. I know I'm against the 2 extremes being A) The government owns all land and you pay them taxes to pay for your living space and B) the government offers no assistance and if you can't afford housing or find someone willing to give it to you, tough ****. But how housing vouchers work and who exactly gets them would need a lot of thought.

Instead of donating extra money, do you feel you have any extra time to donate?

 

[GoodmanBrown]

WE ARE F*CKED.

So, I'm hearing you say you're not as ambivalent.

 

[lfesiam]

I guess we disagree on the bill. My "meaning" was that people deserve access to health care. (The details are mostly my pet idea.) This bill increases access to insurance and subsequently the healthcare. Hence my support of it.

As for housing being a right, I'd have to think about it and probably get pretty detailed. I know I'm against the 2 extremes being A) The government owns all land and you pay them taxes to pay for your living space and B) the government offers no assistance and if you can't afford housing or find someone willing to give it to you, tough ****. But how housing vouchers work and who exactly gets them would need a lot of thought.

Instead of donating extra money, do you feel you have any extra time to donate?

Usually I don't do political thread...but GoodmanBrown, keep up the benevolence, self-sacrifice, idealistic view up buddy.

Medical school + Residency will sadden you down... don't let the hours, monetary gains and politics bitter your heart.

At the end of the day, Patient care always come first.

 

[GoodmanBrown]

Usually I don't do political thread...but GoodmanBrown, keep up the benevolence, self-sacrifice, idealistic view up buddy.

Medical school + Residency will sadden you down... don't let the hours, monetary gains and politics bitter your heart.

In the end of the day, Patient care always come first.

Hey, Ifesiam. Appreciate the shout out. I've likewise enjoyed your posts and the positive attitude on life.

 

[2win]

What history books do you suggest?

The Black Book of Communism: Crimes, Terror, Repression


SOCIALISM (Lib Works Ludwig Von Mises PB)


Lenin, Stalin, and Hitler: The Age of Social Catastrophe

 

[GoodmanBrown]

The Black Book of Communism: Crimes, Terror, Repression


SOCIALISM (Lib Works Ludwig Von Mises PB)


Lenin, Stalin, and Hitler: The Age of Social Catastrophe

Will jot them down and see if they're in the local library.

 

[countingdays]

+1

I agree. However marketed, this bill is purely an "access to health care" reform.

As several others have mentioned, I have very significant doubts about its sustainability. All that said, I still largely agree with the intent of the bill, if not some of the details.

This is not an 'access to health care' bill. It is a government control bill.
Half the 30 million people who could gain coverage already qualified for medicaid but didn't even bother signing up for their handouts. Most of the rest could buy insurance if they wanted but don't because it is too expensive. No meaningful cost controls were in the bill, on the contrary, you can be sure it will drive costs up. So all together, it forces people to buy a product that they don't want at that price. Hopefully the supreme court has more integrity than the congress.

 

[pgg]

I guess we disagree on the bill. My "meaning" was that people deserve access to health care.

People deserve life, liberty, and the pursuit of happiness. None of those things are really guaranteed in life; all we have is a promise that our government won't kill us, enslave us, or impede our own efforts to find fulfillment in life ... and that the government will take firm steps to prevent others from doing the same (national defense for foreign threats, law enforcement for domestic threats).

What you and your side are missing with all this talk of what people "deserve" is that casting health care in the context of a human right is WRONG. It is logically flawed and weak thinking.

The fundamental basis of a human right is that they are things we already have. Human rights are things that can be taken away by tyrants and criminals. A tyrant can take away your right to speak. He can imprison you. A thief can kill you. These are bad things. No human being should have to endure or suffer any of these things.

A government's failure to GIVE something to a citizen is not a violation of that citizen's rights, however cleverly and carefully the citizen argues that he's entitled to receive something. An annual health checkup, a statin, a hernia repair, an epidural for labor, a dobutamine echo, or $200,000 in ICU care for an 85-year-old guy admitted with an Apache of 42 ... these are not things that people HAVE that the government can take. These are things that you apparently believe the government is obligated to GIVE them.

And of course, another point that's lost in this debate ... anything the government gives to someone has to first be taken from someone else.


Now - it is entirely defensible and maybe even reasonable to argue that we, as a society, collectively feel that providing a certain level of social services and medical care to everyone is a reasonable burden that, despite its costs, will enrich our society as a whole. There's room for debate there, and I'm not so far off on the libertarian horizon that I reflexively denounce all tax-supported subsidies to feed, house, and care for the poor.

But let's not pretend health care is a human right. It's flawed thinking, and really just disrespectful to those people who are suffering actual human rights abuses.

Instead of donating extra money, do you feel you have any extra time to donate?

No. I don't.

And after further review, I think all of my cash donations for the forseeable future will go to ASAPAC (hooray for monthly set-and-forget credit card donations!), a couple of pro-2A organizations, and neighborhood kids selling girl scout cookies. And the Humane Society. They do good work. Feral cats deserve orchiectomies and hysterectomies, you know.

 

[Narcotized]

.

 

[GoodmanBrown]

With a larger post, cutting and pasting quotes takes awhile, so I simply posted in red. Hope that's not a huge hassle for any color-blind folks.

People deserve life, liberty, and the pursuit of happiness. None of those things are really guaranteed in life... I couldn't agree more.

...all we have is a promise that our government won't kill us, enslave us, or impede our own efforts to find fulfillment in life ... and that the government will take firm steps to prevent others from doing the same (national defense for foreign threats, law enforcement for domestic threats). Personally, I think our government occasionally breaks its promise of not killing, enslaving, or impeding us, but it is a system run by humans, and I am a strong believer in the fallibility of humans.

What you and your side are missing with all this talk of what people "deserve" is that casting health care in the context of a human right is WRONG. It is logically flawed and weak thinking. I'm not sure what side you subscribe me to. The world is filled with shades of gray, and I feel like many sides like to view things in black & white only. Regardless, I think our main issue is the definition of the word "right." Wikipedia has a thorough overview of rights. Webster merely describes it as

2 : something to which one has a just claim: as a : the power or privilege to which one is justly entitled <voting rights> <his right to decide> b (1) : the interest that one has in a piece of property —often used in plural <mineral rights> (2) plural : the property interest possessed under law or custom and agreement in an intangible thing especially of a literary and artistic nature <film rights of the novel>
3 : something that one may properly claim as due <knowing the truth is her right>

All the bluster aside, in this context, by "right" I mean, something I believe everyone should be able to access.

The fundamental basis of a human right is that they are things we already have. Human rights are things that can be taken away by tyrants and criminals. A tyrant can take away your right to speak. He can imprison you. A thief can kill you. These are bad things. No human being should have to endure or suffer any of these things. But what is "the pursuit of happiness"? Is this something I have in my possession? Do I have a "pursuit"? Also, the second amendment gives me the right to own a gun. I do not currently own one. Has my right been extinguished given its lack of use?

A government's failure to GIVE something to a citizen is not a violation of that citizen's rights, however cleverly and carefully the citizen argues that he's entitled to receive something. An annual health checkup, a statin, a hernia repair, an epidural for labor, a dobutamine echo, or $200,000 in ICU care for an 85-year-old guy admitted with an Apache of 42 ... these are not things that people HAVE that the government can take. These are things that you apparently believe the government is obligated to GIVE them. I disagree. I don't think the government is obliged to give anyone health care. However, I think it is a laudible goal for the government to make it easier for people to obtain access to something as vital to happiness (or the pursuit thereof) as healthcare. I'd be perfectly happy with a German-style system where the government tightly regulates health insurance companies, but doesn't necessarily directly pay for health care.

And of course, another point that's lost in this debate ... anything the government gives to someone has to first be taken from someone else. If not foremost, this is certainly a concern. I will be well in debt by the time I'm done with school, so I'm cognizant that the money comes from somewhere.

Now - it is entirely defensible and maybe even reasonable to argue that we, as a society, collectively feel that providing a certain level of social services and medical care to everyone is a reasonable burden that, despite its costs, will enrich our society as a whole. There's room for debate there, and I'm not so far off on the libertarian horizon that I reflexively denounce all tax-supported subsidies to feed, house, and care for the poor.

But let's not pretend health care is a human right. It's flawed thinking, and really just disrespectful to those people who are suffering actual human rights abuses. I definitely don't mean to offend by using the word "right" in regards to healthcare. But, I do feel that basic healthcare is something every should have access to. I am not arguing that healthcare is on par with freedom of speech, or liberty, or any number of things.

No. I don't. Fair enough.

And after further review, I think all of my cash donations for the forseeable future will go to ASAPAC (hooray for monthly set-and-forget credit card donations!), a couple of pro-2A organizations, and neighborhood kids selling girl scout cookies. And the Humane Society. They do good work. Feral cats deserve orchiectomies and hysterectomies, you know. All good choices. I somehow missed the girl scouts this past fall, but my favorite cookies are the samoas and the peanut butter patties!