What is you're position on Medicare for all ?

[Carbon13]

Medicare trust funding is projected to become insolvent in the next 10-12 yrs.

It has been well documented that the physician pay is less than 10% of all US healthcare expenditure. Some people believe it will never happen because US healthcare profit is driven by physician driven incentives to provide care. Merrit Hawkins has data on how much revenue each type of physician generates. Some people believe that if you take away that incentive and healthcare systems also lose money.

A lot of people are confusing Medicare for all and Universal healthcare. Universal healthcare (Obamacare) means every person has to have some form of health insurance be it private or government. Medicare for all transitions everyone to government sponsored insurance.

Now, a booked out doctor of any specialty would likely see a decline in reimbursement.
However, how would a typically Podiatry practice see change ?
Do you think it would be a wash? Would we all see full schedules but with lower reimbursement ? Or would there be any increase in pay?

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[pod squad]

I think Medicare for all would be quite terrible for Podiatry. Medicare has steadily been cutting the Physician Fee Schedule for years now. If all of your patients were Medicare and they decide to cut another 3%, boom your entire revenue just went down 3%. Essentially, we'd all be government employees, unless you were to opt-out of Medicare and go direct care (which may not be the worst idea).

 

[air bud]

So there are more toenails to cut?

 

[Adam Smasher]

Medicare pays only 80%. I think what most people want when they say "Medicare for All" is "VA for All"

My preference would be "universal catastrophic insurance" so govt picks up everything over whatever we decide is a maximum out of pocket (probably a sliding number tied to income). Leave everything else to private sector.

 

[Sole Badguy]

As it stands, the Medicare pot is already stressed. Adding more patients via MfA will drain it faster. The current solution is to cut reimbursements - obviously not good for us, so funding needs to come someplace: usually through taxes or reallocation of current government spending. Reallocation is a non-starter given how government sub-entities look out for their own (see: politicians won't raise the minimum wage but WILL raise their own salaries). Taxes are unpopular but MfA is not (in theory), so popular opinion may balance itself out. Funding over the long term can come from a stronger future base of taxpayers alongside strengthening of other social programs - but nobody is interested in the long term. Patients want the quick fix now, providers want the money now, politicians want their moment of glory now.

If MfA comes to pass (which seems likely?), cutting Medicare reimbursements is going to be an even more unpopular open position for politicians to take. Providers are already more disincentivized to perform certain care. But more patients will be affected since they won't, or are significantly less likely to, have a private insurance to fall back on. If more people hurt, that will be reflected in the vote; the TV ads will make sure of it.

I'll propose a best case scenario: with time and careful planning, Medicare funding is increased to where everybody is covered. Physicians are compensated better, with incentives for preventive care to save on future costs and keep Medicare going for the long run (translation: more for toenails please...haha but for real, this could extend to most things we do from in-office procedures to limb salvage surgeries. Podiatric political advocacy would be the key here).

 

[Feli]

Ngl, I would probably retire if dems win and they acutally did roll out a true MfA (I would predict neither in near term)...
That paying to have insurance (even catastrophic) between age XX retirement and age 65yo MCR is really expensive when you can't get insurance from partner job, own employer, or at least pay it pre-tax benefit as owner or 1099.

But, yeah... the bigger reason to get out would be that, as a podiatrist (or most types of doc), it'd just plain suck. More pts, same money.
It'd feel like working in a VA... yet needing to see 30+/d to stay afloat (and we know how often that happens, lol).
Even worse, there are tons of cancels and no-shows and last minute rescheds with insurance ppl don't respect (it's "free").
You'd have to just get very fast at doing a few things (already sorta the way to make $$ in PP) and trying to filter out time-consuming visits.

...The MfA-type stuff (single payer) works in countries that have doctors come out of training with basically no education debt (selectivity, scholarships paid by govt). They make a decent but not great living, and they can supplement it doing "private patients" if they want. There is no going back from that switch, though, so I doubt it'd ever happen. Also, in USA, with massive student loans, super-sized tuitions, and the higher American education universities and financial system the way it is, it's not viable. There has to be some [lifestyle] carrot at the end of the stick for people to take that plunge.

 

[Adam Smasher]

I don't buy the preventative care argument. There's a reason car insurance doesn't cover oil changes. People do it because they know they need to, not because insurance pays for it.

Besides, (correct me if I'm wrong) most health expenditures occur in the last 5 years of patients' lives, so free screening for healthy 25-year-olds is not going to do anything to reduce that.

 

[mandrew]

Medicare trust funding is projected to become insolvent in the next 10-12 yrs.

It has been well documented that the physician pay is less than 10% of all US healthcare expenditure. Some people believe it will never happen because US healthcare profit is driven by physician driven incentives to provide care. Merrit Hawkins has data on how much revenue each type of physician generates. Some people believe that if you take away that incentive and healthcare systems also lose money.

A lot of people are confusing Medicare for all and Universal healthcare. Universal healthcare (Obamacare) means every person has to have some form of health insurance be it private or government. Medicare for all transitions everyone to government sponsored insurance.

Now, a booked out doctor of any specialty would likely see a decline in reimbursement.
However, how would a typically Podiatry practice see change ?
Do you think it would be a wash? Would we all see full schedules but with lower reimbursement ? Or would there be any increase in pay?

Medicare for all could be easily achieved in a stepwise approach. Start by gradually lowering the qualifying age for Medicare and allowing people to opt into it by paying a monthly fee. A 60 year old should be able to buy Medicare coverage at the same rate that a 65 year old beneficiary pays based on income. Medicare is already in place and this would be a great step towards expanding coverage for the uninsured 60-64 year olds. If necessary a very small tax increase, of .1% or something similar could help fund it.
We just need some reasonable people in our government to get these common sense policies approved. I think Podiatry would do just fine if Medicare was expanded in this way.

 

[HardRoadPaved]

Medicare for all could be easily achieved in a stepwise approach. Start by gradually lowering the qualifying age for Medicare and allowing people to opt into it by paying a monthly fee. A 60 year old should be able to buy Medicare coverage at the same rate that a 65 year old beneficiary pays based on income. Medicare is already in place and this would be a great step towards expanding coverage for the uninsured 60-64 year olds.

The older you get (after 18 and you gotta pay the bills) the lower the chance you're uninsured. Also this age class should have more wealth by in large and is at the end of their earning potential career wise.

Also no insurance company wants to give a discount to people 60-64. Clearly that is a demographic that by in large spends on their health.

If necessary a very small tax increase, of .1% or something similar could help fund it.
We just need some reasonable people in our government to get these common sense policies approved.

You trust.... government..... to something without a tax increase and without overbloated bureaucracy and rules/regulations and tons of oversight committees?

 

[mandrew]

As I said, Medicare is already in place so simply lowering the eligibility age would be fairly simple without the need for additional bureaucracy.
I don't know the statistics of how many uninsured there are in the age group 60-64, but I have seen quite a few in my office over the past 20 years.
These people are just waiting for their 65th birthday so they can get Medicare. To me this is a no brainer. I cannot understand why anyone would be opposed to it. Mind boggling.

 

[heybrother]

As I said, Medicare is already in place so simply lowering the eligibility age would be fairly simple without the need for additional bureaucracy.
I don't know the statistics of how many uninsured there are in the age group 60-64, but I have seen quite a few in my office over the past 20 years.
These people are just waiting for their 65th birthday so they can get Medicare. To me this is a no brainer. I cannot understand why anyone would be opposed to it. Mind boggling.

How would you feel if everyone was on Medicaid ?

 

[HardRoadPaved]

As I said, Medicare is already in place so simply lowering the eligibility age would be fairly simple without the need for additional bureaucracy.

So the issue is that Medicare is not managed by the government but instead by contractors. They dont work for "free" so they would charge a fee for this additional work load since they have to hire everything from registration officials to claims adjusters. Since its the government, it would need then oversight to manage the contractors as well. So your oversimplification has large ramifications since the government doesnt do anything with "lean intent and execution."

I don't know the statistics of how many uninsured there are in the age group 60-64, but I have seen quite a few in my office over the past 20 years.

~7% of the population which is about 24 million Americans.

To me this is a no brainer. I cannot understand why anyone would be opposed to it. Mind boggling.

There are 82 million on just medicaid alone and look how difficult that is to provide access and care to those people. So you want to tack on a third of Medicaid's size onto government contractors which to you is "easy!" Just sign them up!

Whats mind boggling is how you propose a plan and have no research behind it.

I have already said that the lowest class of uninsured patients are 60-64. Is it due to poverty? Probably not; by that age you should know the "system" if you want free stuff. If you go on your state exchange and look how much premiums are, many patients are like I'll take my chances and get a non-ACA plan like Freedom Life or Church Charity plans. They are thinking with their wallet and taking risks.

 

[mandrew]

So the issue is that Medicare is not managed by the government but instead by contractors. They dont work for "free" so they would charge a fee for this additional work load since they have to hire everything from registration officials to claims adjusters. Since its the government, it would need then oversight to manage the contractors as well. So your oversimplification has large ramifications since the government doesnt do anything with "lean intent and execution."


~7% of the population which is about 24 million Americans.


There are 82 million on just medicaid alone and look how difficult that is to provide access and care to those people. So you want to tack on a third of Medicaid's size onto government contractors which to you is "easy!" Just sign them up!

Whats mind boggling is how you propose a plan and have no research behind it.

I have already said that the lowest class of uninsured patients are 60-64. Is it due to poverty? Probably not; by that age you should know the "system" if you want free stuff. If you go on your state exchange and look how much premiums are, many patients are like I'll take my chances and get a non-ACA plan like Freedom Life or Church Charity plans. They are thinking with their wallet and taking risks.

So you feel it is just a bad idea and essentially too difficult to lower the eligibility age for Medicare?

 

[mandrew]

So the issue is that Medicare is not managed by the government but instead by contractors. They dont work for "free" so they would charge a fee for this additional work load since they have to hire everything from registration officials to claims adjusters. Since its the government, it would need then oversight to manage the contractors as well. So your oversimplification has large ramifications since the government doesnt do anything with "lean intent and execution."


~7% of the population which is about 24 million Americans.


There are 82 million on just medicaid alone and look how difficult that is to provide access and care to those people. So you want to tack on a third of Medicaid's size onto government contractors which to you is "easy!" Just sign them up!

Whats mind boggling is how you propose a plan and have no research behind it.

I have already said that the lowest class of uninsured patients are 60-64. Is it due to poverty? Probably not; by that age you should know the "system" if you want free stuff. If you go on your state exchange and look how much premiums are, many patients are like I'll take my chances and get a non-ACA plan like Freedom Life or Church Charity plans. They are thinking with their wallet and taking risks.

You sound like you might have been against the Medicare and Medicaid act back in 1965.

 

[HardRoadPaved]

So you feel it is just a bad idea and essentially too difficult to lower the eligibility age for Medicare?

It's an idea, I'll give you that. But when put to the litmus test of the real world, is it essential? No.

The Emerging Older Workforce - Understanding the Aging Workforce - NCBI Bookshelf

The unemployment rate of 60-64 year olds is 2.7%. By in large this is still an able bodied group of people that do not need to retire and can still provide work to society.

You sound like you might have been against the Medicare and Medicaid act back in 1965.

Yes. I am against the nationalization/federalization of health care and I do not believe the government is the best one to satisfy this mission. Please find me in the Constitution where those powers were granted.

The Unconstitutionality of Social Security and Medicare - Mike Rappaport

Government social insurance creates some of the most serious problems in western style democracies. At best, these government insurance programs place tremendous strain on the economy and reduce work incentives. At worst, they may result in the bankrupting of the society. In the United...

lawliberty.org

Trust me I get it, I would love to live in a world of unicorns and fairies and have student loan debt just magically forgiven. However, we dont.

 

[mandrew]

It's an idea, I'll give you that. But when put to the litmus test of the real world, is it essential? No.

The Emerging Older Workforce - Understanding the Aging Workforce - NCBI Bookshelf

The unemployment rate of 60-64 year olds is 2.7%. By in large this is still an able bodied group of people that do not need to retire and can still provide work to society.

Yes. I am against the nationalization/federalization of health care and I do not believe the government is the best one to satisfy this mission. Please find me in the Constitution where those powers were granted.

The Unconstitutionality of Social Security and Medicare - Mike Rappaport

Government social insurance creates some of the most serious problems in western style democracies. At best, these government insurance programs place tremendous strain on the economy and reduce work incentives. At worst, they may result in the bankrupting of the society. In the United...

lawliberty.org

Trust me I get it, I would love to live in a world of unicorns and fairies and have student loan debt just magically forgiven. However, we dont.

Interesting

 

[mandrew]

How would you feel if everyone was on Medicaid ?

Medicare and Medicaid are very different programs

 

[heybrother]

Medicare and Medicaid are very different programs

You are never going to convince anyone of anything if you act obtuse towards their viewpoint and interests. Some of these patients have commercial insurance that pays a premium over Medicare. Our practices are dependent on this additional reimbursement to stay in business. The direction of insurance reimbursement in total is downwards, but inflation persists You complained in another thread that no one pays enough for surgery, but then you advocate for increasing the percentage of patients who have Medicare which is the chief rate setter and anchor for bringing down surgical reimbursement and reimbursement in general.

Consider the expression - a 20% loss of revenue can result in a 100% loss of profit.

 

[HardRoadPaved]

Medicare and Medicaid are very different programs

The trees and grass are both found outside but are very different plants.

 

[mandrew]

You are never going to convince anyone of anything if you act obtuse towards their viewpoint and interests. Some of these patients have commercial insurance that pays a premium over Medicare. Our practices are dependent on this additional reimbursement to stay in business. The direction of insurance reimbursement in total is downwards, but inflation persists You complained in another thread that no one pays enough for surgery, but then you advocate for increasing the percentage of patients who have Medicare which is the chief rate setter and anchor for bringing down surgical reimbursement and reimbursement in general.

Consider the expression - a 20% loss of revenue can result in a 100% loss of profit.

How am I acting obtuse? I participate with many insurance plans that pay less than the Medicare fee schedule. Medicare is one of the better payors in my area.

 

[mandrew]

You are never going to convince anyone of anything if you act obtuse towards their viewpoint and interests. Some of these patients have commercial insurance that pays a premium over Medicare. Our practices are dependent on this additional reimbursement to stay in business. The direction of insurance reimbursement in total is downwards, but inflation persists You complained in another thread that no one pays enough for surgery, but then you advocate for increasing the percentage of patients who have Medicare which is the chief rate setter and anchor for bringing down surgical reimbursement and reimbursement in general.

Consider the expression - a 20% loss of revenue can result in a 100% loss of profit.

Medicare pays more for a 28296 than most commercial plans I participate with, and no preauthorization is necessary.

 

[DYK343]

As an RVU employee I would personally love Medicare for all.

Its so easy to deal with.

Getting an MRI with some of these private plans is ridiculous.

Surgery no prior auth.

The convenience is unmatched.

But im sure my RVU rate would go down

Canada has a backbone to improve on. Theirs isnt perfect by any means and needs significant improvement.

What the patient actually needs and what insurance pays are two very different things. Medicare does solve that issue (within reason). I would love to show up and do what I think is best then go home. But that solution is very difficult - which is why it hasnt been done yet.

My state medicaid is awful. Nothing is covered. I certainly would not want medicaid for all. Medicaid for all would very much suck.

 

[heybrother]

Medicare pays more for a 28296 than most commercial plans I participate with, and no preauthorization is necessary.

How am I acting obtuse? I participate with many insurance plans that pay less than the Medicare fee schedule. Medicare is one of the better payors in my area.

Just lead with this. You find Medicare to be a good payor. It does have its perks. I've been in your situation before. When I was seeing a lot of Humana and UHC I thought - wow, I'd be better off if every patient just had Novitas Medicare. Our decisions to disagree with you are not mind boggling - they are merely in our interests which we are in general transparent about.

Everytime a NY podiatrists posts about what they have to do to stay in business the rest of the country gags a little. A prior poster on here described how he used to get $30 for a 99213 but every year he could charge the patient's insurance for $700 orthotics. You apparently suffer from a lot of low reimbursing payors. I do too, but I'm getting rid of them because my town is saturated, but not so saturated that I have to see Humana to stay in business. By eliminating poorly reimbursing payors I increase the overall reimbursement of the practice. I've posted this before, but patient's and doctors interests are not always aligned. I would like to be reimbursed more than Medicare. Patients obviously would like their bills to be reasonable. Were Medicare to be the law of the land there are things I would have to change or give up.

 

[Feli]

We should just be able to charge per hour... like attorneys (and almost any other higher level professionals... even most other health professionals).

The docs who are in demand, efficient, and get consistently good results could charge a bit more and have a fuller schedule.

It would solve a lot.

 

[Hybrocure]

Won’t happen - if it could it would’ve already happened over the last 4 years. It’s just a talking point for election sake.

Same reason why we know our loans won’t be forgiven.

That being said, I am still voting whichever way will make these loans get easier and not screw me more. And Trump hasn’t sold me on that..

 

[heybrother]

As an RVU employee I would personally love Medicare for all.

Its so easy to deal with.

Getting an MRI with some of these private plans is ridiculous.

Surgery no prior auth.

The convenience is unmatched.

But im sure my RVU rate would go down

Canada has a backbone to improve on. Theirs isnt perfect by any means and needs significant improvement.

What the patient actually needs and what insurance pays are two very different things. Medicare does solve that issue (within reason). I would love to show up and do what I think is best then go home. But that solution is very difficult - which is why it hasnt been done yet.

My state medicaid is awful. Nothing is covered. I certainly would not want medicaid for all. Medicaid for all would very much suck.

The problem is that when we talk about the future we make assumptions based on the present

-It is entirely possible that in a Medicare for all world - we would have to have prior authorizations for MRIs. This wouldn't just be for cost savings. It would also be to limit access because there would be so many people trying to acquire an MRI.

-If some sort of Medicare for all system happens - there is no world this passes without a hard targetting of the current OPPS system for paying facilities. Some sort of hard site neutral payment alignment would assuredly roll down the pipe. Site neutrality is going to keep coming up and hospitals are the only ones currently benefiting from it.

 

[Feli]

Won’t happen - if it could it would’ve already happened over the last 4 years. It’s just a talking point for election sake.

Same reason why we know our loans won’t be forgiven.

That being said, I am still voting whichever way will make these loans get easier and not screw me more. And Trump hasn’t sold me on that..

Do you mean interest rates? Forgiveness?
I think the Biden forgive stuff was shot down every way, every form, every try.
...but then again, I'm just biting the bullet and paying mine about $5k/mo avg (for many many years), so I don't keep up on it.

 

[heybrother]

Since I've already posted one I'll post a few more with 2018 and 2024 rates. So let's say you are a podiatrist pounding out 11042s at your hospital wound healing center. I used to wonder why my residency hospital let some non-surgical lady pod who was married to another doctor do a few half days a momnth. I assumed it was nepotism, but the answer was - facility fees.

 

[DYK343]

Had an inservice on this recently. They bill out a facility fee but only collect about 25% of it. Its stilll extra cash but, at least where I work, medicare does not pay anywhere near full price for facility fee. I might be able to get the exact stats tomorrow if I have time.

I estimated 25% I cant really remember the exact percent. I could be off on this estimate - but its significant reduction in billed vs payout.

 

[heybrother]

Had an inservice on this recently. They bill out a facility fee but only collect about 25% of it. Its stilll extra cash but, at least where I work, medicare does not pay anywhere near full price for facility fee. I might be able to get the exact stats tomorrow if I have time.

I estimated 25% I cant really remember the exact percent. I could be off on this estimate - but its significant reduction in billed vs payout.

The WHC that I refer to bills $2000-2500 a visit for 11042 type visits. By that logic - $374/2000 is 18%. The point of an inflated fee schedule is to ensure that no money is left behind on the table. Their price is set high because BCBS apparently pays something approaching it. With like one exception, there is no metric more meaningless than allowed payment or collections as a percentage of gross charges because gross charges is a made up number. The only time the metric matters is if its 100% because it means your fee schedule is too low since you are collecting everything you are charging. I increased my 28005 fee schedule today by $600. This will result in my collections as a percentage of charges decreasing, but the whole point is to simply ensure that I am paid my full fee schedule price should a patient come around with well paying insurance and infected bone. Consider that my wife's c-section was billed at $52,000 and ultimately paid out at $10K. Should they drop the price to increase the ratio?

What's relevant here is that Medicare is paying $250 more per 11042 to a hospital WHC than it is to a doctor's office for what is potentially the same service.

On a historic note, when I was a student I visited a program that was putting Mepilex Ag on like every wound. I remember thinking - how do they afford this. I'd already been told that "the dressings are included in the debridement". The answer was - because they had an extra $250 to pay for it.

 

[DYK343]

The WHC that I refer to bills $2000-2500 a visit for 11042 type visits. By that logic - $374/2000 is 18%. The point of an inflated fee schedule is to ensure that no money is left behind on the table. Their price is set high because BCBS apparently pays something approaching it. With like one exception, there is no metric more meaningless than allowed payment or collections as a percentage of gross charges because gross charges is a made up number. The only time the metric matters is if its 100% because it means your fee schedule is too low since you are collecting everything you are charging. I increased my 28005 fee schedule today by $600. This will result in my collections as a percentage of charges decreasing, but the whole point is to simply ensure that I am paid my full fee schedule price should a patient come around with well paying insurance and infected bone. Consider that my wife's c-section was billed at $52,000 and ultimately paid out at $10K. Should they drop the price to increase the ratio?

What's relevant here is that Medicare is paying $250 more per 11042 to a hospital WHC than it is to a doctor's office for what is potentially the same service.

On a historic note, when I was a student I visited a program that was putting Mepilex Ag on like every wound. I remember thinking - how do they afford this. I'd already been told that "the dressings are included in the debridement". The answer was - because they had an extra $250 to pay for it.

I dont want to write that I am an expert in wound center reimbursements. Because I am not. But I do have some insider knowledge of billing/reimbursement for the wound center I work for.

Our reimbursements and bill outs are not nearly that substantial. I have a busy day tomorrow but if I get time ill try to find the slides and post more.

I believe we bill that much for grafts. Flexor tenotomies they bill about that much. But 11042 we do not bill nearly that much out (2-2.5k with 374 facility fee reimbursement). I dont want to give an exact number because its been awhile since ive seen the data. But I believe it is substantially less.

Many wound centers in the USA break even or lose money. They are often hospital owned because they are essential to keep the ERs running, surgeons somewhere to dump patients, etc. The hospital loses money on wound centers to make money elsewhere.

There are not a lot of private owned wound centers. I know of a few. They exist. But there are not a ton of them.

The wound center I work for (my hospital owns) breaks even yearly for about 10 years. We have a high medicaid population so that doesnt help. But we are not super profitable as a center. I will say as a provider though it is a RVU machine for me, I make good money. But cost of stocking the wound supplies. Paying RN salary instead of MA salary. Etc is not cheap.

Hyperbarics reimbursement continues to tank yearly.

Obviously some wound centers run at a profit. They have to be very well managed with good payer mix.

Ill try to find those slides on financials. They were quite good.

 

[Feli]

... Hyperbarics reimbursement continues to tank yearly. ...

 

[DYK343]

Too slammed today. Ill try again tomorrow

 

[heybrother]

Too slammed today. Ill try again tomorrow

Do it when you can. I started to respond and then figured I'd wait for your post.