Plan B if things go down the drain?

[deleted941485]

Why does it have to be across the border? I think under some versions of Medicare for All, private insurance will be abolished; are we assuming that cash-only practice will be prohibited as well?

The only way you’ll be opening up a cash practice is if you rent a cruise ship and head into international waters cause it ain’t gonna be allowed on US soil when dems get through with you.

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[Franzd'Epinay]

The only way you’ll be opening up a cash practice is if you rent a cruise ship and head into international waters cause it ain’t gonna be allowed on US soil when dems get through with you.

I may be wrong, but I thought only Sanders and Warren had proposals to get rid of private insurance. I haven't heard anyone mention cash practices at all. Would love to hear any details on that if anyone has them.

 

[KeikoTanaka]

What Medicare for all means for doctors and hospitals

Americans generally don't like the idea of giving up their private health insurance. Hospitals and doctors don't want them to, either.

www.cnn.com

According to this article, Sanders had an advisor state physicians wouldn't see their salaries drop, but, they also have no idea how any of it would play out lol. They even tried to swing the point that you'd spend less time with paper work and more time seeing patients which could bring in more money...

 

[cyanide12345678]

What Medicare for all means for doctors and hospitals

Americans generally don't like the idea of giving up their private health insurance. Hospitals and doctors don't want them to, either.

www.cnn.com

According to this article, Sanders had an advisor state physicians wouldn't see their salaries drop, but, they also have no idea how any of it would play out lol. They even tried to swing the point that you'd spend less time with paper work and more time seeing patients which could bring in more money...

I don't want to see more whiny patients who can't deal with a viral uri

 

[deleted941485]

I may be wrong, but I thought only Sanders and Warren had proposals to get rid of private insurance. I haven't heard anyone mention cash practices at all. Would love to hear any details on that if anyone has them.

Cash pay just like private insurance is an anathema to these plans. They both undermine their ability to completely control the system

 

[KeikoTanaka]

Cash pay just like private insurance is an anathema to these plans. They both undermine their ability to completely control the system

I don't ever foresee them completely removing private insurance or cash models. This is America. Enough wealthy people will fight it to make it work. There's ALWAYS a loophole in America for the wealthy to get more out of anything.

 

[Franzd'Epinay]

Cash pay just like private insurance is an anathema to these plans. They both undermine their ability to completely control the system

It's not anathema to the Canadian, British, or any other system in the developed world, though. I'm not sure why you are so convinced it will be different in America.

 

[KGflyboy]

Why does it have to be across the border? I think under some versions of Medicare for All, private insurance will be abolished; are we assuming that cash-only practice will be prohibited as well?

Many reasons come to mind. Liability, overhead, regulations are less. There are many reasons why paints travel to find doctors doing back alley elective procedures in Mexico that aren't feasibly done in a similar cash based practice in the U.S.

 

[GeneralVeers]

I don't ever foresee them completely removing private insurance or cash models. This is America. Enough wealthy people will fight it to make it work. There's ALWAYS a loophole in America for the wealthy to get more out of anything.

The text of Medicare-For-All states it will be illegal for any "covered services" to be rendered period, except under the new government run plan. It's in plain English what their intentions are

 

[VA Hopeful Dr]

The text of Medicare-For-All states it will be illegal for any "covered services" to be rendered period, except under the new government run plan. It's in plain English what their intentions are

Its like Medicare is now except no opting out

 

[deleted941485]

It's not anathema to the Canadian, British, or any other system in the developed world, though. I'm not sure why you are so convinced it will be different in America.

You cannot offer services on a private basis that are already covered by the national plan. They aren't going to suddenly start turning over services to the private sector like EM or oncology care. When we end up with socialized HC, its going to probably look more like Canada than the UK anyway. There will be few if any exceptions.

I dont understand this fixation with looking at private clinics in the midst of socialised medicine. Its like trying to find little undigested bits of food in feces.

 

[Rekt]

Since the EM market is in the gutter, how's the CCM world?

 

[GonnaBeADoc2222]

Since the EM market is in the gutter, how's the CCM world?

The EM market is fine.

What we are seeing is a reduction of locums rates as of about 2 or 3 years ago. This may signal a general reduction of rates but so far to my knowledge it hasn't happened.

If you're not dumb you can easily get a job paying 200/hr or more. At 1500/hrs/yr that's 300k. If you are single, you are fine at this income. Sure you won't be buying a yacht but you are verrrrry comfortable.

Even if married with kids, if your spouse works for even a third of 300k and you have to pay for child care you are still doing great.

Things may change in the future but who knows.

Contrast this to some other fields (esp in academia) where even getting a job is a problem.

The days of 500/hr locums are probably done for good but we are still doing well.

 

[iqe2010]

The text of Medicare-For-All states it will be illegal for any "covered services" to be rendered period, except under the new government run plan. It's in plain English what their intentions are

I would assume this would be struck down by a federal judge or the SCOTUS. Not allowing physicians to render services outside of a government system and accept cash payment is too strict of a rule and IMO unconstitutional.

 

[GeneralVeers]

I would assume this would be struck down by a federal judge or the SCOTUS. Not allowing physicians to render services outside of a government system and accept cash payment is too strict of a rule and IMO unconstitutional.

So are a lot of other taxes and regulations, but they have always been upheld. It all depends on what judges see the complaint. Whether or not something is unconstitutional seems change with the direction of the wind.

 

[deleted109597]

They've declared war on us, and Congress is, as usual, too stupid to see it.

Congress is bullying doctors because insurance companies told them to - Washington Examiner

There are some stories that almost everyone hears when they first start working in Washington, D.C. One of these stories is about Microsoft and their lobbying spending — or more specifically, the lack of lobbying in the company’s early days. Microsoft originally hardly lobbied at all, much to...

www.washingtonexaminer.com

 

[cyanide12345678]

They've declared war on us, and Congress is, as usual, too stupid to see it.

Congress is bullying doctors because insurance companies told them to - Washington Examiner

There are some stories that almost everyone hears when they first start working in Washington, D.C. One of these stories is about Microsoft and their lobbying spending — or more specifically, the lack of lobbying in the company’s early days. Microsoft originally hardly lobbied at all, much to...

www.washingtonexaminer.com

Insurance companies are juggernauts when it comes to lobbying at capital Hill. They will probably win against us.

I just need 5-6 more years of great income and 1-1.5 million savings, then plan B for me will be a possibility at any point of my life.

My new plan B - 1+ mil in savings and FIRE. 2.5-3 percent withdrawal rate. Live in the subcontinent at a bargain cost, have a maid ($40/month), a cook ($70/month), a driver ($70/month), a Gardener (40-50/month), never have to do household chores again that i absolutely hate. Live an absolutely luxurious life. Send kids to damn good private schools (my own school private high school was $50/month 12 years ago when i lived there - At least they won't be surrounded by drugs and alcohol as well). $8 steaks at a fancy restaurant, yes please. Or $5 steaks at a medium level restaurant, sure why not. Plus healthcare that is really damn affordable - dad's CABG 20 years ago - $1500 (in a nicer private hospital). Quality of care isn't bad either in the nice private hospitals. I personally got 4 stitches 12 or 13 years ago from a government hospital- cost about 10 cents then.

Im far more successful here, but i think i was far happier there. Maybe because i was a teenager without any responsibilities? I guess my parents were on to something when they dropped their successful careers in the US in the 80s and moved back (one was a chemical engineer for a mega corp, the other a psychiatrist with a successful private practice and had trained at vandy)

 

[TooMuchResearch]

Hmm, that sounds nicer than what 1.5 mil will get here...

Insurance companies are juggernauts when it comes to lobbying at capital Hill. They will probably win against us.

I just need 5-6 more years of great income and 1-1.5 million savings, then plan B for me will be a possibility at any point of my life.

My new plan B - 1+ mil in savings and FIRE. 2.5-3 percent withdrawal rate. Live in the subcontinent at a bargain cost, have a maid ($40/month), a cook ($70/month), a driver ($70/month), a Gardener (40-50/month), never have to do household chores again that i absolutely hate. Live an absolutely luxurious life. Send kids to damn good private schools (my own school private high school was $50/month 12 years ago when i lived there - At least they won't be surrounded by drugs and alcohol as well). $8 steaks at a fancy restaurant, yes please. Or $5 steaks at a medium level restaurant, sure why not. Plus healthcare that is really damn affordable - dad's CABG 20 years ago - $1500 (in a nicer private hospital). Quality of care isn't bad either in the nice private hospitals. I personally got 4 stitches 12 or 13 years ago from a government hospital- cost about 10 cents then.

Im far more successful here, but i think i was far happier there. Maybe because i was a teenager without any responsibilities? I guess my parents were on to something when they dropped their successful careers in the US in the 80s and moved back (one was a chemical engineer for a mega corp, the other a psychiatrist with a successful private practice and had trained at vandy)

 

[cyanide12345678]

Hmm, that sounds nicer than what 1.5 mil will get here...

Actually that's what 1 mil will get there. Maybe even 750k. The 1.5 mil number just makes the withdrawal rate around 2 percent basically for ultimate luxury and you theoretically should never run out of your portfolio.

I grew up in a middle upper class and had all of that at home. I mean the per capita income back home is still around 5-6k a year. So living on anything more than 20k annually is sheer luxury.

 

[miacomet]

Geographic arbitrage will become an even bigger thing, I think, with the necessities of life (health, education, housing) becoming so expensive here. It's still a place to make money, but if that goes....

 

[cyanide12345678]

Geographic arbitrage will become an even bigger thing, I think, with the necessities of life (health, education, housing) becoming so expensive here. It's still a place to make money, but if that goes....

Agreed, education is ridiculously expensive. My pgy 2 family medicine wife, her medical education cost $150/year in the subcontinent. Mine cost $18k for tuition and fee.

 

[Apollyon]

$8 steaks at a fancy restaurant, yes please. Or $5 steaks at a medium level restaurant, sure why not.

I'm not prying or pushing, but I was just wondering - on the subcontinent, with 700million+ Hindus, can you actually get a steak? I'm not being pejorative, and I did not Google this. I'll do my research.

 

[Apollyon]

It looks like one would have to live in eastern India, or Pakistan, to have a steak. That is from VERY cursory research.

 

[cyanide12345678]

It looks like one would have to live in eastern India, or Pakistan, to have a steak. That is from VERY cursory research.

Lol I'm Pakistani, so who knows if you can get steak in india Steaks, beef, delicious food everywhere on the other side of the indian border everything except pork basically.

 

[deleted109597]

I'm not prying or pushing, but I was just wondering - on the subcontinent, with 700million+ Hindus, can you actually get a steak? I'm not being pejorative, and I did not Google this. I'll do my research.

I ate beef all the time in Kerala. It's very state dependent.

 

[Apollyon]

I ate beef all the time in Kerala. It's very state dependent.

24/29 Indian states ban beef slaughter. It's beyond "very state dependent" - 80% of the states, nada.

 

[miacomet]

With a COL of 40k or less a year and 1-1.5mm in savings, cyanide should be able to afford a regular flight to Japan to eat Kobe etc.

The US is really resting on its laurels in many ways. Salaries are high here (with Oz, Canada, and Switzerland in hot pursuit), but I see more and more people outsourcing their healthcare and their children's higher education abroad. Why go to Harvard when you can attend Cambridge for a fraction of the cost, after all?

 

[gro2001]

24/29 Indian states ban beef slaughter. It's beyond "very state dependent" - 80% of the states, nada.

Yeah, but for scale: 20% of states in the US context would be 10 states. That could be a lot of people if you pick the right states.

Also, though most states ban slaughtering cows, some allow slaughtering bulls. Though usually these exceptions are for older animals. Also some states allow buffaloes to be slaughtered. And Uttar Pradesh allows importation of beef from outside as long as it's only served to foreigners.

 

[Apollyon]

Yeah, but for scale: 20% of states in the US context would be 10 states. That could be a lot of people if you pick the right states.

That made me chuckle, just a little bit, because, as I thought about it, there are only 60%, roughly, of as many states in India as in the US, but, again, roughly, about 3x as many people!! The top 4 states have about 500 million!

 

[cyanide12345678]

That made me chuckle, just a little bit, because, as I thought about it, there are only 60%, roughly, of as many states in India as in the US, but, again, roughly, about 3x as many people!! The top 4 states have about 500 million!

4 states with 500 million. Damn. The folks in the subcontinent really need to focus on birth control -_-

 

[gro2001]

4 states with 500 million. Damn. The folks in the subcontinent really need to focus on birth control -_-

India's most recent population growth rate is 1.04% / year (and slowing), which is right around the world average of 1.05%./year.

India Population (2024) - Worldometer

Population of India: current, historical, and projected population, growth rate, immigration, median age, total fertility rate (TFR), population density, urbanization, urban population, country's share of world population, and global rank. Data tables, maps, charts, and live population clock

www.worldometers.info

World Population Clock: 8.1 Billion People (LIVE, 2024) - Worldometer

How many people are there in the world? World population has reached 8 billion on November 15, 2022 according to the United Nations. World population live counter with data sheets, graphs, maps, and census data regarding the current, historical, and future world population figures, estimates...

www.worldometers.info

 

[miacomet]

4 states with 500 million. Damn. The folks in the subcontinent really need to focus on birth control -_-

As noted above, the birth rate in India is fast approaching the US. We have lower infant mortality and use more of the world's resources; would be a bigger impact on the planet if Americans stopped reproducing.

 

[deuist]

As noted above, the birth rate in India is fast approaching the US. We have lower infant mortality and use more of the world's resources; would be a bigger impact on the planet if Americans stopped reproducing.

Americans already aren't reproducing. The only reason for population growth is immigration.

 

[miacomet]

Back to the original topic of this thread...ER does not have a good long-term outlook. My job is cutting hours and positions. ED visits are down across the country, midlevels and residency spots are expanding. The LT outlook is not great.

 

[bravotwozero]

ED visits are down across the country? If they are, I certainly haven't noticed, and still have to see patients out of a triage room because 'boarding, no beds'....

 

[miacomet]

Even in my state, which is growing at a rapid clip:

ED visits are down—but ED facility fee spending is up, Vox analysis suggests

A Vox and Health Care Cost Institute analysis of data from employer-sponsored plans found that spending on ED facility fees rose by more than $3 billion between 2009 and 2015, but the American College of Emergency Physicians is pushing back against the findings, arguing the analysis's data set

www.advisory.com

Urgent care visits increase as emergency room visits fall, study finds

Visits to the emergency room to treat low-acuity conditions decreased by 36 percent; Use of non-emergency room centers increased by 140 percent.

www.healthcarefinancenews.com

Telehealth and UC are having an effect. More stupid visits with noctors. More useless antibiotics.

 

[DrGasPasser]

Even in my state, which is growing at a rapid clip:

ED visits are down—but ED facility fee spending is up, Vox analysis suggests

A Vox and Health Care Cost Institute analysis of data from employer-sponsored plans found that spending on ED facility fees rose by more than $3 billion between 2009 and 2015, but the American College of Emergency Physicians is pushing back against the findings, arguing the analysis's data set

www.advisory.com

Urgent care visits increase as emergency room visits fall, study finds

Visits to the emergency room to treat low-acuity conditions decreased by 36 percent; Use of non-emergency room centers increased by 140 percent.

www.healthcarefinancenews.com

Telehealth and UC are having an effect. More stupid visits with noctors. More useless antibiotics.

Those are studies of facility fees and health plan enrollees that do not represent the total number of ED visits in the US which are up according to the most recent NHAMCS data: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf

Total ED visits in 2016, the most recent reporting year, was at a record 145.6 million visits. That is up from 141.4 million in 2014.

 

[NITRAS]

Forgive me if I demand at THE VERY LEAST 200 an hour to do the life-saving work that I do at any hot second.

I’m know I’m late to the party, but I think it’s short sighted to say you’ll never take less than $200/hour.

You are a trained physician now, you’ve already spent the time and money. It would be unlikely you could jump into something non-clinical for as near the money.

I do lots of annoying work for much less than $200/hour. Hell, I did land clearing in Texas In the summer for $10/hour because it beat working at Burger King for$6.50/hour.

Our medical training is primarily a trade specific training that doesn’t translate well to other areas.

I’m not predicting anything, I just saying that no one can predict the future. EM might not pay that in the future.

 

[miacomet]

I’m know I’m late to the party, but I think it’s short sighted to say you’ll never take less than $200/hour.

You are a trained physician now, you’ve already spent the time and money. It would be unlikely you could jump into something non-clinical for as near the money.

I do lots of annoying work for much less than $200/hour. Hell, I did land clearing in Texas In the summer for $10/hour because it beat working at Burger King for$6.50/hour.

Our medical training is primarily a trade specific training that doesn’t translate well to other areas.

I’m not predicting anything, I just saying that no one can predict the future. EM might not pay that in the future.

I don't think that's what NITRAS is saying. Maybe it's just not worth it to them to do EM for less than 200 an hour and they would perhaps prefer to do something else.

 

[emergentmd]

All Docs young and old need to have an exit plan with passive income.

Pay off deb, have passive income so you don't have to work another day. Do something to get passive income so you don't have to touch your retirement without working.

You have alot of disposable income, put some of that towards passive income.

I currently have about 100K in passive income. Once my debt is paid off, and I hit 200K/yr passive, I am going to watch paint dry until I get too bored.

 

[TheSingularity]

Where does your passive income come from? Help us youngins out!

All Docs young and old need to have an exit plan with passive income.

Pay off deb, have passive income so you don't have to work another day. Do something to get passive income so you don't have to touch your retirement without working.

You have alot of disposable income, put some of that towards passive income.

I currently have about 100K in passive income. Once my debt is paid off, and I hit 200K/yr passive, I am going to watch paint dry until I get too bored.

Sent from my Pixel 3 using SDN mobile

 

[Birdstrike]

Everyone on here needs to read The Millionaire Next Door. It's a quick, eye opening book that will change the way you think about money and lifestyle. It's explains the simple, often boring techniques regular people use to become wealthy. Often it's the guy next door you didn't even know was wealthy, who has a much greater net worth than the apparently rich guy flashing (false) wealth signals that more often are signs of money spent, than money in the bank.

 

[emergentmd]

Where does your passive income come from? Help us youngins out!

Sent from my Pixel 3 using SDN mobile

Most docs esp EM docs should be able to put aside 100K a year to invest.

Do that for 10 yrs then you have 1 million.

1. Put it in sold dividend stocks and you can get 50k/yr easy
2. apartment syndications - 8-10%
3. Buy rental properties
4. Open up a small business

There are risks and rewards. Save young, create good cash flow. It is slow to start but snowballs later on.

 

[Hercules]

Where does your passive income come from? Help us youngins out!

Sent from my Pixel 3 using SDN mobile

Lots of possibilities out there. I’ve posted mine before but it has been a few years. In addition to the standard passive income from ETFs here are my current sources:

Urgent Care (ownership not clinical work)
Commercial real estate
Timber property
Multifamily rental property
Crowd sourced real estate

I’ll second the usual recommendations for Rich Dad/ Poor Dad, Millionaire Next Door, and WCI. I think every ED doc should also listen to the choose FI podcast (especially the early ones).

 

[TheSingularity]

What equities are you in that you are making 50k a year on...?

Most docs esp EM docs should be able to put aside 100K a year to invest.

Do that for 10 yrs then you have 1 million.

1. Put it in sold dividend stocks and you can get 50k/yr easy
2. apartment syndications - 8-10%
3. Buy rental properties
4. Open up a small business

There are risks and rewards. Save young, create good cash flow. It is slow to start but snowballs later on.

Sent from my Pixel 3 using SDN mobile

 

[deuist]

Most docs esp EM docs should be able to put aside 100K a year to invest.

... so long as you are single or have a working spouse and no kids.

 

[TheSingularity]

... so long as you are single or have a working spouse and no kids.

Ha!

Sent from my Pixel 3 using SDN mobile

 

[Hercules]

... so long as you are single or have a working spouse and no kids.

I think having 100k to invest is going to be more of a function of your income and what kind of retirement plans your group has. If all 100k are pretax dollars then that’s the same impact on your monthly cash flow as investing 50k post tax (assuming highest tax bracket and state income tax). I’m married with 4 kids in private school and my wife stays at home. It’s still doable though definitely more challenging.

 

[TooMuchResearch]

We get to $90k just from my good 401k, wife's more standard 401k, Roth IRAs. Extra dollars going towards debt at the moment. This is as a non-partner of a democratic group.

I think having 100k to invest is going to be more of a function of your income and what kind of retirement plans your group has. If all 100k are pretax dollars then that’s the same impact on your monthly cash flow as investing 50k post tax (assuming highest tax bracket and state income tax). I’m married with 4 kids in private school and my wife stays at home. It’s still doable though definitely more challenging.

 

[miacomet]

It's harder as a W2 without the option of a solo 401k. Just can't get to 100k pretax, no matter what.
-30k including match for 401k
-15k or so that employer puts in pension plan
-4k in HSA (can't do family as they are on another plan due to network)

Especially with the new tax laws, 1099 is the way to go.