Salary Men...

[drusso]

http://www.nytimes.com/2014/02/14/us/salaried-doctors-may-not-lead-to-cheaper-health-care.html?_r=0

“From the hospital end there’s a big feeding frenzy, a lot of bidding going on to bring in doctors,” Mr. Mechanic said. “And physicians are going in so they don’t have to worry — there’s a lot of uncertainty about how health reform is going to play out.”

We're probably the last generation that gets to practice in a private practice model...but its all up hill from now on. The default option is to become an employee.

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[Aether2000]

Of course the cost of health care skyrockets with employed docs. Referrals for MRI, CT, xray, and labs are done inside a hospital and are paid by insurers (and medicare) at 3 times the rate they pay in independent imaging centers or physician labs. Pain procedures are paid at 3-10 times the rate done in hospitals compared to physician offices. The self referrals in house are frequently mandated by the hospital for all these services (Stark doesn't apply to hospitals). Patients are also not infrequently charged facility fees for office visits in addition to the physician charge that triples the office visit charges ( and payments). physician retention and compensation are partially link to the number of tests being ordered and the number of in-house referrals made. so yes, overall the cost of patient care if astronomically higher under a doctor employed situation in a hospital verses private practice situation.

 

[SSdoc33]

the last 2 paragraphs say it all.

"quality measures" is bunch of horsesh$t right now. we are nowhere close to getting this figured out.

 

[drusso]

Of course the cost of health care skyrockets with employed docs. Referrals for MRI, CT, xray, and labs are done inside a hospital and are paid by insurers (and medicare) at 3 times the rate they pay in independent imaging centers or physician labs. Pain procedures are paid at 3-10 times the rate done in hospitals compared to physician offices. The self referrals in house are frequently mandated by the hospital for all these services (Stark doesn't apply to hospitals). Patients are also not infrequently charged facility fees for office visits in addition to the physician charge that triples the office visit charges ( and payments). physician retention and compensation are partially link to the number of tests being ordered and the number of in-house referrals made. so yes, overall the cost of patient care if astronomically higher under a doctor employed situation in a hospital verses private practice situation.

Yes. As usual, you have accurately condensed the problem down to it's economic essentials. It is so obvious for those of us "close to the numbers." Why don't others see this? There can be no real health care reform if site-of-service differentials favor ineffeciency. We will continue to tilt at windmills...

 

[Ducttape]

do you really know that fee for service is cheaper?

i mean, read the fourth paragraph,

Health economists are nearly unanimous that the United States should move away from fee-for-service payments to doctors, the traditional system where private physicians are paid for each procedure and test, because it drives up the nation’s $2.7 trillion health care bill by rewarding overuse. But experts caution that the change from private practice to salaried jobs may not yield better or cheaper care for patients.
“In many places, the trend will almost certainly lead to more expensive care in the short run,” said Robert Mechanic, an economist who studies health care at Brandeis University’s Heller School for Social Policy and Management.

 

[hyperalgesia]

http://www.nytimes.com/2014/02/14/us/salaried-doctors-may-not-lead-to-cheaper-health-care.html?_r=0

“From the hospital end there’s a big feeding frenzy, a lot of bidding going on to bring in doctors,” Mr. Mechanic said. “And physicians are going in so they don’t have to worry — there’s a lot of uncertainty about how health reform is going to play out.”

We're probably the last generation that gets to practice in a private practice model...but its all up hill from now on. The default option is to become an employee.

I know what you're saying and the trend is clear. I just don't think it will be sustained. It's like the house of cards hasn't collapsed yet and we're still adding to it. With the obviously higher cost (and I think we're just seeing the tip of the iceberg here), increased deductibles and copays to compensate, etc, I believe there will be a resurgence of office based care for specialties that are amenable to it.

What was it that I read a few weeks ago about some kind of Medicare advisory committee or something? - that eviscerated the current policy of higher hospital reimbursements for the same procedures (just because they're done on the same campus).

I think, after this trend runs its course, hospitals will be the place you go when you need acute physician and nursing care. Everything that is non-acute, will be in a place that is open from 8-5.

 

[Sig123]

I know what you're saying and the trend is clear. I just don't think it will be sustained. It's like the house of cards hasn't collapsed yet and we're still adding to it. With the obviously higher cost (and I think we're just seeing the tip of the iceberg here), increased deductibles and copays to compensate, etc, I believe there will be a resurgence of office based care for specialties that are amenable to it.

What was it that I read a few weeks ago about some kind of Medicare advisory committee or something? - that eviscerated the current policy of higher hospital reimbursements for the same procedures (just because they're done on the same campus).

I think, after this trend runs its course, hospitals will be the place you go when you need acute physician and nursing care. Everything that is non-acute, will be in a place that is open from 8-5.

I tend to agree.

How can the hospital fee schedule be reasonably sustained over the long run? It simply can't.

 

[emd123]

We may see a big backlash on this. In the short term the push is towed hospital employment. If this bubble bursts, as it might since hospital based care is astronomically more expensive, the pendulum may indeed swing back to the outpatient doc. It's too early to tell.

Remember the HMO revolution? They were going to pull all the docs into those, ration care and pay for nothing. It didn't work. There was a big backlash.

This new trend may bust: "patient centered home," "ACO's," "Pay for quality instead of pay for quantity."

These are all buzzwords that are keeping lots of government desk sitters employed now, but there's no guarantee any of it is going to work or that they are any more than just made-up feel-good marketing slogans to promote policy change. In fact, there's lots of signs their big master plan may be unravelling before it even gets off the ground. The fall elections will be big. Does America double down for more or the insanity, or throw the Obamacare crew (remaining House/Senate that voted for it) out? 2016 will be even bigger.

We'll see.

 

[hyperalgesia]

Hopefully people will actually be feeling the sting of Obamacare when they vote. As in they have to make personal sacrifices to subsidize it. Otherwise, they will continue to vote symbolism over substance. In 2016, when Obama delays the business mandate again, to pave the way for Hillary, it's gonna be "OMG the FIRST FEMALE PRESIDENT!!!" Gonna need some Zofran for this...

 

[Jcm800]

the facility fee for an OFFICE visit, says it all. I experienced this when I worked for a hospital. If your "office" is really set up as an outpatient facility, they charge a facility fee for the office visit as well. Poor sucker patients bringing in their EOBs and asking me about it. I referred them on to administration, who eventually asked me to stop doing that...

 

[yankeeh8r]

Of course having the hospitals control the physicians is going to drive up healthcare. As this article denotes, the hospital would likely drive up rates by 60% for outpatient services and 30-35% for labs and imaging. http://www.modernhealthcare.com/article/20140130/NEWS/301299961

Then take SimonMED imaging centers. As a patient pointed out to me, because they are owned by Dignity Health (i.e. Catholic Health West, one of the largest hospital systems in the country), their imaging centers bill as HOSPITAL site of service. She got her EOB and was promptly like "WTF"? Considering that she'd never had an MRI cost her that much before. Of course, she was then told that if she'd paid cash out-of-pocket and not used her insurance they would've charged her $300 for the MRI and $75 for the read.

The whole dang thing is a racket.

 

[Disciple]

I think we all realize that this is not solely about "saving money", but fulfilling different agendas.

The government wants control of healthcare, insurance companies/hospitals want to continue the current system, but with control of doctors, and doctors want to continue the current system, but cut out (or gain leverage over) the middle-man.

With their leverage and moment of opportunity right now, the government wants doctors (the weakest stake-holder) under control and then will deal with the insurance companies/hospitals (probably hitting them with major cuts in the coming years).

I just don't forsee any movement of physicians banding together against this. Most will concede and become employees. The rest will look for ways to hide or escape. For the older physicians, it's make your practice an attractive piece, sell and get out. Not sure what the rest of us will do.

 

[Sig123]

I think we all realize that this is not solely about "saving money", but fulfilling different agendas.

The government wants control of healthcare, insurance companies/hospitals want to continue the current system, but with control of doctors, and doctors want to continue the current system, but cut out (or gain leverage over) the middle-man.

With their leverage and moment of opportunity right now, the government want doctors (the weakest stake-holder) under control and then will deal with the insurance companies/hospitals (probably hitting them with major cuts in the coming years).

I just don't forsee any movement of physicians banding together against this. Most will concede and become employees. The rest will look for ways to hide or escape. For the older physicians, it's make your practice an attractive piece, sell and get out. Not sure what the rest of us will do.

I do agree with you as I think we are headed in that direction.

But make no mistake about it -- when its CMS vs. Hospitals, I'm sure there will be a much bigger, drawn out fight. The hospitals have far too much to lose to sit back at these drastic and draconian cuts.

 

[Disciple]

Yes, that's why I think it's--dis-incentivize private practice while throwing a bone to the hospitals to give them the necessary resources to round up the doctors, let the system collapse, then take on the hospitals.

 

[Ducttape]

i agree with Disciple completely.

health care costs have skyrocketed with fee-for-service, that we know. the private market is thought to be too expensive and too out of control and not in the hands of big money (CMS, govn't, big insurance, big hospital). this is akin to the industrial revolution in the late 1800s. instead of Carnegie, Mellon, US Steel, etc. we have CMS, Kaiser, Blues, et al.

the excuse to take over is the skyrocketing costs. will it go down with hospital based care? doubtful. but we, unwittingly, gave them the ammo they needed...

 

[drusso]

http://www.nytimes.com/2014/03/03/u...doctors-have-many-seeking-a-network.html?_r=0

Increasingly, the monopolizing effects of Obama Care are looking less like socialized medicine and more like organized crime.

 

[stim4u]

its all a lie.
There will never be health cost savings,.
Only doctors salaries directly transferred to hospital administrators and surgical center management companies.

Obamacare is truly Obamacaid, the payments are miserable and not even guaranteed as >30% have not even paid their premiums yet.
most knowledgeable specialists are not taking it.

This is what happens when half the population voted against this reform, and Obama's crew never consulted specialists....
I truly enjoy everyday it continues to sink.

FYI some obamacare plans allow for out of network benefits. For a dozen of patients, we are charging the deductible, and taking 60% of the out of network payments, writing of the 40% (assuming your bills are high like me and hospitals....lol). the system is broken...

 

[hyperalgesia]

http://www.nytimes.com/2014/03/03/u...doctors-have-many-seeking-a-network.html?_r=0

Increasingly, the monopolizing effects of Obama Care are looking less like socialized medicine and more like organized crime.

It's a fine line indeed. Because the govt is supposedly "non-profit", people seem to feel that it should be free to use monopolistic leverage to "drive down the cost of healthcare". But the corrosive effects on the marketplace are just as devastating as they would be with a corporation.

 

[Doctodd]

Don't forget that PCP's are getting expanded Medicaid rates that are 2x Medicare for 2 years. After that, who knows what happens.

 

[lonelobo]

http://www.businessweek.com/article...e-investors-bet-billions-the-aca-will-succeed

 

[stim4u]

http://www.businessweek.com/article...e-investors-bet-billions-the-aca-will-succeed

doesn't matter what wall street projects.
IF specialist continue to not accept obamcare reimbursement, it will fail.
Networks are terrible, patients are fed up.
who cares what stocks do...

 

[emd123]

doesn't matter what wall street projects.
IF specialist continue to not accept obamcare reimbursement, it will fail.
Networks are terrible, patients are fed up.
who cares what stocks do...

Here's to hoping, but specialists refusing Medicaid hasn't deep-sixed that program yet.

Does anyone know yet what the private ACA plans reimburse? Good, bad, in between?

 

[stim4u]

Here's to hoping, but specialists refusing Medicaid hasn't deep-sixed that program yet.

Does anyone know yet what the private ACA plans reimburse? Good, bad, in between?

nobody takes medicaid in my area but hospitals subsidized by the state.
Most ACA plans in my area pay 10% less than medicare.

 

[lonelobo]

[quote="stim4u, post: 14976006, member: 84690"]doesn't matter what wall street projects.
do...[/quote]

Really, the people who love making money betting it will succeed doesn't matter?

 

[Ducttape]

nobody takes medicaid in my area but hospitals subsidized by the state.
Most ACA plans in my area pay 10% less than medicare.

That is essentially the case all around. The lack of specialists taking ACA won't make a diff because there already is a lack of specialists taking Medicaid right now.

If the remaining few Private PCPs don't take ACA, that might make a diff....

 

[hyperalgesia]

So are your carriers like UHA and BCBS offering an "ACA Plan" like a PPO, HMO , etc? I just haven't ever seen it. I'm curious to know the fee schedule. It seems like it will end up somewhere midway between 'Caid and 'Care.

 

[stim4u]

That is essentially the case all around. The lack of specialists taking ACA won't make a diff because there already is a lack of specialists taking Medicaid right now.

If the remaining few Private PCPs don't take ACA, that might make a diff....

I think you are missing the point. People who buy ACA plans think they are getting PPO plans. They don't realize they are buying glorified medicaid....
We have had to educate several dozen patients to this fact. Patients tend to say 'but I bought the platinum plan'..... Platinum medicaid that is to say.

 

[stim4u]

[quote="stim4u, post: 14976006, member: 84690"]doesn't matter what wall street projects.
do...

Really, the people who love making money betting it will succeed doesn't matter?[/quote]
no not really. why don't you invest your hard earned money in the market if you are so confident in the ACA act.
By the way Kaiser OBama just kick the can to 2017, no employee mandate. Future looks good for Obamacare....

 

[Ducttape]

my point is that specialists are not taking medicaid, and they wont take ACA plans (except hospital based ones).

your comment previously is as follows:

doesn't matter what wall street projects.
IF specialist continue to not accept obamcare reimbursement, it will fail.

they already arent accepting these patients. what does it matter if a patient has ACA vs. no insurance? he would never have gotten to see a specialist anyways.

 

[lonelobo]

Really, the people who love making money betting it will succeed doesn't matter?

no not really. why don't you invest your hard earned money in the market if you are so confident in the ACA act.
By the way Kaiser OBama just kick the can to 2017, no employee mandate. Future looks good for Obamacare....[/quote]

Didn't say I liked the law, but it is here to stay in some form or another. You can bitch all you want on Blogs or you can find a way
to try to become successful with the new changes. I will try the latter

 

[lonelobo]

I think you are missing the point. People who buy ACA plans think they are getting PPO plans. They don't realize they are buying glorified medicaid....
We have had to educate several dozen patients to this fact. Patients tend to say 'but I bought the platinum plan'..... Platinum medicaid that is to say.

This is location dependent,
of the 4 major state run ACA plans available here,

one pays same as their commercial plan
one pays slightly above medicare
one pays medicare
one pays medicaid

 

[stim4u]

how are you going to be 'successful' with ACA plans that pay like medicaid?
What alternative universe are you living in. You will be more successful if you don't take ACA plans and dilute your throughput with good insurance payers. Agree?

Ductappe, as for patients not having specialists in the first place. This is one scenario. The more meaningful scenario is that people are choosing a cheaper ACA plans with the idea that these plans are somehow equivalent to a commercial plan. This is the majority of what I am seeing because I am in PP and not a hospital employee or medicaid clinic. These patients are in shock when their specialists refuse to take their insurance. It is not just pain management, OB/GYN/onc etc. in my area are not taking these plans. I have even had patients reprimanding me for not taking ACA..... I always find that amusing.

 

[stim4u]

This is location dependent,
of the 4 major state run ACA plans available here,

one pays same as their commercial plan
one pays slightly above medicare
one pays medicare
one pays medicaid

In our state, 3 pay below medicare, one pays above medicare but at a much higher cost.
At least you are looking at your eob's and contracts. Good for you

 

[emd123]

As much as I dislike the ACA, right now I've contracted with a couple of them that pay Medicare rates. If they ever drop below that, I'll definitely dump them. But since I take MC, and right now they pay the same, I see no reason not to take it. Any of the ones paying less than MC are a no go. They are private plans technically, and as long as they pay same or better than plans I'm already accepting, I'll par. I've already picked up a few patients whose Pain docs dropped them due to non-par status, so they're a win for me so far. Will re-evaluate periodically, and adjust as needed.


Sent from my iPhone using SDN Mobile

 

[stim4u]

there are always winners and losers. I cannot increase my medicare/ACA population. Not worth the economic impact, and I am not adding physicians for more medicare/ACA patients....

 

[stim4u]

When your pediatrician doesn't take ACA, you know u have problems.... Little scary
Sent from my iPhone

Important Insurance Information!!
NEW HEALTH EXCHANGE INSURANCE PLANS
New Pediatrics DOES NOT
currently participate in any insurance plans purchased through the Affordable Care Act Health Exchange.
If you have insurance through a health exchange, we cannot see your child "in network" even if the plan is through an insurance company with which we do participate, such as a commercial planwith
Anthem, Aetna, or United Health.
While we hope you will continue under our care, you will be expected to make all payments at the time of each visit. If applicable, we will provide a bill/claim for you to submit to your insurance plan for possible reimbursement.
Insurance cards do not always clearly indicate whether a plan is acommercial plan or an exchange plan. It is the patient/parent's responsibility to know if their plan is an exchange plan. The following companies offer health exchange plans in
Anthem, Aetna, United Health and Connecticare.
If you are unsure, please contact your insurance company to confirm
if your plan is a commercial or an exchange plan.
We thank you for your understanding and apologize for any inconvenience

Doctors and Staff, Pediatrics

March 7th 2014

​

 

[lonelobo]

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