What's going on with the healthcare bill being voted on tomorrow (3/21)?

pinipig523

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I stopped following for a few days and I find that they're voting via a reconciliation process, whereby they are taking the existing Senate bill and voting on it as it stands then voting on a revision bill after.

So, what's going on and how come I don't see any SDN topics on this?

Is NO ONE concerned??
 

pinipig523

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It's interesting that on the eve of something that could change our practice/compensation, no one has anything to add.

Or maybe people are still hammered from last night's post-match party...
 
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why in the world are they voting on something like this on a Sunday? Is it so less people will notice?
 

docB

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There are a bazillion threads on this in other SDN forums like Topics In Healthcare, Sociopolitical and others. Most of the regulars are kind of tired of these debates. They inevitably devolve into socialized healthcare arguments and most folks on either side are not going to be swayed.

As for why it will happen on Sunday it has to do with the rule that the bill must be voted on within 72 hours of the CBO issuing its report on the fiscal impact of the bill.
 

pinipig523

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As for why it will happen on Sunday it has to do with the rule that the bill must be voted on within 72 hours of the CBO issuing its report on the fiscal impact of the bill.
Ah, so they can use the "budget" argument to bring the Senate bill to the House floor. Tactical, Mr. Obama.
 

GeneralVeers

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There are two options being discussed right now:

Option 1: Straight up or down vote by the house, whereby 216 votes will pass the Senate bill. They will vote at the same time using reconciliation on a bill that will make changes to the Senate bill.

OPtion 2: They will vote using reconciliation on a bill that would change the Senate bill, and it will contain a self-executing clause that will "deem" the Senate bill to have passed the Senate. It's political cover for members who don't have to have a recorded "yes" on the unpopular Senate bill.

Either way this is no bueno for our country.
 

strongboy2005

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There are two options being discussed right now:

Option 1: Straight up or down vote by the house, whereby 216 votes will pass the Senate bill. They will vote at the same time using reconciliation on a bill that will make changes to the Senate bill.

OPtion 2: They will vote using reconciliation on a bill that would change the Senate bill, and it will contain a self-executing clause that will "deem" the Senate bill to have passed the Senate. It's political cover for members who don't have to have a recorded "yes" on the unpopular Senate bill.

Either way this is no bueno for our country.
Looks like they're no longer considering option #2.

What will this bill do for emergency physicians? Won't this now ensure all patients are paying patients?
 

GeneralVeers

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Looks like they're no longer considering option #2.

What will this bill do for emergency physicians? Won't this now ensure all patients are paying patients?
It depends. The bill's "deficit reduction" estimate of $136 billion assumes that Medicare reimbursement will undergo a 21% cut. If that happens it will mean significant cuts to our bottom line. The "deficit reduction" of this bill is basically a lie though, as the Medicare cuts are unlikely and will cost $200 billion if not enacted, thereby actually increasing the deficit.

In terms of more people being insured it's hard to say. A good number of the 20-30 million people who will be "insured" will be put onto the Medicaid rolls, which pays us very little anyway.

At best this bill will be revenue neutral for us......at least in the short term until they enact the other portions of their "plan".
 

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As far as Emergency medicine, I found this pdf interesting. http://www.kff.org/healthreform/upload/housesenatebill_final.pdf

look on page 38. " Trauma care - Establish a new trauma center program to strengthen emergency department and trauma center capacity. Fund research on emergency medicine, including pediatric emergency medical research, and develop demonstration programs to design, implement, and evaluate innovative models for emergency care systems. (Funds appropriated beginning in fiscal year 2011)"
 

GeneralVeers

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As far as Emergency medicine, I found this pdf interesting. http://www.kff.org/healthreform/upload/housesenatebill_final.pdf

look on page 38. " Trauma care - Establish a new trauma center program to strengthen emergency department and trauma center capacity. Fund research on emergency medicine, including pediatric emergency medical research, and develop demonstration programs to design, implement, and evaluate innovative models for emergency care systems. (Funds appropriated beginning in fiscal year 2011)"
Admirable, but is it really worth $1 trillion and nationalization of the insurance industry to get a few bucks for EM/Trauma research?
 

pinipig523

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Will they repeal the current SGR thereby not cutting our reimbursements by 21%?

So who gets hit the hardest by Obamacare?
 

countthestars

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Admirable, but is it really worth $1 trillion and nationalization of the insurance industry to get a few bucks for EM/Trauma research?
Nope, not worth it at all. Just thought I'd point to something interesting in the bill that relates to EM.

I also think the reform will be largely revenue neutral for EM. Payments will be less overall but just about every person that walks into the ED will have insurance. I think the specialties that rely heavily on procedures will be screwed the most. On the other hand, I feel that FM/Peds will get better compensation that what they are getting now. All physicians will be hurt by the taxation to pay for this bill though. Since most EM docs make over 200k, they will be taxed like crazy to pay for these 30 million newly insured Americans.
 

GeneralVeers

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All physicians will be hurt by the taxation to pay for this bill though. Since most EM docs make over 200k, they will be taxed like crazy to pay for these 30 million newly insured Americans.
Exactly right. While we will make out okay on the front end in terms of reimbursement, most of us are part of the "evil rich" and thus will be paying part of the the $500B that this bill raises in tax revenues. For starters there's an increase in the Medicare tax, a 3.8% tax on capital gains, the tax on Cadillac health insurance (which may not kick in until 2018).

BTW we're already going to take a significant hit next year when the Bush tax cuts expire, and our top rate goes from 36% to 39%.

Long term though is the problem. Obama, Pelosi, and other Democrats have stated that this is the "first stage" in the plan to go to a national single payer system. I'm not making that up, they have stated it numerous times, and Obama has said that you can't create a single payer system overnight, but it takes years, and a series of steps. Step one is to control the insurance companies and put them out of business.
 

strongboy2005

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Stupak and his colleagues decided to vote for the healthcare bill. The bill will be passed.

This is some scary stuff... I'm a first year medical student and really don't know what to think...
 

pinipig523

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I'm depressed.

First, I learned that when I graduated I'd only get 2 instead of the 3 years of economic hardship for my loans.

Then, just before I turn into a 3rd year resident, I learn that there is a healthcare bill that will probably pass that will limit me even further.

It's great to live in a country full of wasteful spenders but still believe they deserve the right to "free" healthcare. I'm going to be very grumpy at work tomorrow.

I don't know about you guys, but this sucks. Where's the reward for those of us who put in the hard work, the long hours studying, the weeks praying that we get accepted to medical school/match into residency.

Where's the reward for all the contingency plans we all had to think up or actually pursue because of Plan B (if I don't match here but instead there)? What about all the uprooting and all the BS we put up with?

What is the point?
 

GeneralVeers

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It's great to live in a country full of wasteful spenders but still believe they deserve the right to "free" healthcare. I'm going to be very grumpy at work tomorrow.
You hit the nail on the head. The overarching problem with our medical system is that the vast majority of the costs are paid for by 3rd parties, which promotes overconsumption. This bill does nothing to address that, and by supposedly adding 30 million to the insurance rolls actually exacerbates the problem.

I don't know about you guys, but this sucks. Where's the reward for those of us who put in the hard work, the long hours studying, the weeks praying that we get accepted to medical school/match into residency.
Hard work is not valued in the socialist utopia they envision. They'd say you were born with unfair advantages, and that now you have to "pay your fair share". Although in America (the most charitable country in the world BTW) charity has traditionally been at the local and individual level, not something enforced by the Feds.
 

strongboy2005

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No more uninsured people in the ED? Any benefits from this for the profession?
 

GeneralVeers

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I'm not sure...those that don't want any insurance will have to pay a penalty so they will still remain uninsured. I'm sure many homeless people will still remain uninsured and they will still be seen in the ER.
This is a sad day for the Constitution. The Federal government cannot compel you to buy an item or a service. It would be the same as if the Federal government said: "We need to help Ford, so we want all Americans to buy a Ford car. Those that do not, or buy some unapproved brand will have to pay a fine".

Even the much abused commerce clause doesn't give the Feds the legal authority for this kind of power grab. It's essentially using the power of the Federal government to compel people to buy a service from a vested interest, i.e. the insurance companies.
 

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I have enjoyed reading the theories and predictions that various posters have made in regards to this health care reform as it pertains to the field of Emergency Medicine, and its physicians. I would like others to chime in as well, as I have matched into EM, and would like to read other people's opinions on what my future job outlook will be.
 

pinipig523

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Sad day... the worst thing is that people don't even know why it's a sad day. Lots of docs, students included.
 

EM2BE

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Sad day... the worst thing is that people don't even know why it's a sad day. Lots of docs, students included.
I completely agree.

I'm hoping those states that said they would sue the fed gov for being unconstitutional if this passed will now follow through.
 

GeneralVeers

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I completely agree.

I'm hoping those states that said they would sue the fed gov for being unconstitutional if this passed will now follow through.
39 State's Attorneys General have announced plans to launch suits in the Federal appeals courts concerning the constitutionality of the individual mandate. My guess is that the suits won't get far as the courts in the past have given the Feds wide discretion when it comes to interpretation of the commerce clause.

Of course Obama's snub of the Supreme Court at the SOTU address may come back to haunt him now......
 

pinipig523

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39 State's Attorneys General have announced plans to launch suits in the Federal appeals courts concerning the constitutionality of the individual mandate. My guess is that the suits won't get far as the courts in the past have given the Feds wide discretion when it comes to interpretation of the commerce clause.

Of course Obama's snub of the Supreme Court at the SOTU address may come back to haunt him now......
So if they're only attacking the individual mandate, does that mean that they repeal the entire bill?
 

GeneralVeers

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So if they're only attacking the individual mandate, does that mean that they repeal the entire bill?
The individual mandate is the cornerstone of the bill. Without it none of the other parts concerning pre-existing conditions or risk pools would work.

Why buy insurance if you're healthy and have guaranteed issue? Hence the government has to force the young and healthy to buy insurance in order to subsidize the old and sick.
 

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This is a sad day for the Constitution. The Federal government cannot compel you to buy an item or a service. It would be the same as if the Federal government said: "We need to help Ford, so we want all Americans to buy a Ford car. Those that do not, or buy some unapproved brand will have to pay a fine".

Even the much abused commerce clause doesn't give the Feds the legal authority for this kind of power grab. It's essentially using the power of the Federal government to compel people to buy a service from a vested interest, i.e. the insurance companies.
Well sure they can, this has been the case with auto insurance for years....

The fact of the matter is, the socialism needs to end. I almost threw up when Pelosi said 'We are all created equal' during her smug speech. Sorry, but we're just not. I believe that every one should be given equal rights, however that and her statement are completely different. Agree with GeneralVeers, indeed a sad day when your 'elected officials' can impose their will on the American people.:thumbdown:
 

GeneralVeers

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Well sure they can, this has been the case with auto insurance for years....

The fact of the matter is, the socialism needs to end. I almost threw up when Pelosi said 'We are all created equal' during her smug speech. Sorry, but we're just not. I believe that every one should be given equal rights, however that and her statement are completely different. Agree with GeneralVeers, indeed a sad day when your 'elected officials' can impose their will on the American people.:thumbdown:
It really is a sad day when someone agrees with me :confused:

At any rate auto insurance is completely different. It's mandated by the STATES not the Federal government. Furthermore it's a condition of being able to drive. You can choose not to drive, and therefore don't have to buy insurance.

As far as I know there's no way around the mandate unless you want to kill yourself (also illegal).
 

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If everyone is insured, might fewer people end up coming to the ED for care, resulting in less work for EPs? I guess that assumes that things improve enough for FP/IM for more people to enter those specialties and reduce the supply shortage.
 

GeneralVeers

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If everyone is insured, might fewer people end up coming to the ED for care, resulting in less work for EPs? I guess that assumes that things improve enough for FP/IM for more people to enter those specialties and reduce the supply shortage.
One would think so, however in Massachusetts where they have a state-enforced version of the individual mandate, and 97% of people have insurance the experience has been the opposite. ED visits went up 11% annually after implementing Romneycare. State costs have exploded far beyond what was anticipated.

Yet this will somehow work on a national level. :rolleyes:
 

theunc31

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It really is a sad day when someone agrees with me :confused:

At any rate auto insurance is completely different. It's mandated by the STATES not the Federal government. Furthermore it's a condition of being able to drive. You can choose not to drive, and therefore don't have to buy insurance.

As far as I know there's no way around the mandate unless you want to kill yourself (also illegal).
State vs federal government mandate is simply verbiage, it's government run, just on another level.

I will buy your 'you can choose not to drive' argument. Very fair point.

I just love the 'we're going to give you all healthcare and at the same time save you money' argument. If anyone honestly believes that, I have a bridge to sell ya.
 

pinipig523

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One would think so, however in Massachusetts where they have a state-enforced version of the individual mandate, and 97% of people have insurance the experience has been the opposite. ED visits went up 11% annually after implementing Romneycare. State costs have exploded far beyond what was anticipated.

Yet this will somehow work on a national level. :rolleyes:
So I suppose the 800lb gorilla is:

Do EP's make more now or before Romneycare?
 

GeneralVeers

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So I suppose the 800lb gorilla is:

Do EP's make more now or before Romneycare?

I'm not sure. You'd have to ask one who's been working in Boston for a while.

I guess it's great that EM docs are making more money, and bankrupting their state in the process. I don't think I can feel good about that one.....
 

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Well sure they can, this has been the case with auto insurance for years....

The fact of the matter is, the socialism needs to end. I almost threw up when Pelosi said 'We are all created equal' during her smug speech. Sorry, but we're just not. I believe that every one should be given equal rights, however that and her statement are completely different. Agree with GeneralVeers, indeed a sad day when your 'elected officials' can impose their will on the American people.:thumbdown:
Obviously we're not created equal, but equal rights is relative to how society defines it and it is an ever changing concept.

As for officials "forcing" their will on the people. Obama ran on a much more "socialistic" bill, and was elected by a comfortable margin. Congress is not a polling institute; it is elected to enact the will of the people as it sees fit. The people can enforce their will at the next election.

At any rate auto insurance is completely different. It's mandated by the STATES not the Federal government. Furthermore it's a condition of being able to drive. You can choose not to drive, and therefore don't have to buy insurance.

As far as I know there's no way around the mandate unless you want to kill yourself (also illegal).
I will buy your 'you can choose not to drive' argument. Very fair point.
Where in the constitution does it say the government has a right to restrict your driving? I doubt it exists in any state constitution either. Outrageous.

Regardless, It's gonna be fun watching Romney try to weasel his way out of his past in Massachusetts as he appeals to the uber-extremes of the party faithful...almost as much fun as watching Republicans decry 'government run health care being forced on us' and Medicare cuts in the same sentence. I would respect the opposition if they had the principle to stand against all "socialism" such as social security, medicare, senior-citizen discounts, wheelchair parking passes, car insurance, public universities, public schools, highways, the military, eh what am I missing here?
 

pinipig523

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I spoke with a Cook County grad who went to practice in Boston under Romneycare. This is what he had to say:

Boston ER doc: i dont know, i havent really talked to others about it. i mean, well in mass, we already have the govt issued insurance
me: oh right and you practice in boston right?
Boston ER doc: yup
me: that's right... i forgot
Boston ER doc: so i dont know if im experiencing a little bit of what it's gonna be like in the future
me: so how is it with govt issued insurance?
Boston ER doc: it's not bad
me: what's it like? and what don't you like about it?
Boston ER doc: it's nice bc most specialists dont turn people away like in chicago bc of insurance reasons
me: compensation is good?
Boston ER doc: it's better than chicago
 

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http://blogs.wsj.com/health/2010/03/...to-a-hospital/

While there is no EM data in this Wall Street Journal article that was posted in the FM forum by BlueDog, but I thought you all might be interested. I'm curious what you all think of these numbers. I'm sure they are flawed in some way, but if they are even close to anything resembling what actually happens to the cash flow, someone (many people) are getting rich off our efforts. I guess this really comes as no surprise. I also wonder if EM or any other specialty, or medicine as a whole has any consultants crunch these numbers in order to negotiate fair reimbursement (in similar fashion to an agent, sports or otherwise). It seems as though our collective lack of organisation and our willingness to undercut each other is the market working itself out to a "fair market price" for our work. If this is what we will accept then maybe this is what we are worth. Perhaps we would even accept much less if thats what they counter offered. One thing that I think EM has going for it is that we earn our keep and have a skill set that is very difficult to outsource/undercut with less training and I think this will certainly serve us well. Thanks for your comments!
 

GeneralVeers

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Obviously we're not created equal, but equal rights is relative to how society defines it and it is an ever changing concept.

As for officials "forcing" their will on the people. Obama ran on a much more "socialistic" bill, and was elected by a comfortable margin. Congress is not a polling institute; it is elected to enact the will of the people as it sees fit. The people can enforce their will at the next election.
I agree completely. Obama said during the election that he wanted to implement more socialist policies. The general public as usuaul wasn't paying attention. I don't think most of them voted for Obama because they wanted socialist policies, rather they were mad at Republicans and were casting a protest vote against them.

Where in the constitution does it say the government has a right to restrict your driving? I doubt it exists in any state constitution either. Outrageous.
Driving is a privilege, not a right. The Constitution doesn't apply in this case, as it's not the Federal government enforcing it, and it doesn't interfere with any language in the Constitution. It would purely be up to what it's in the individual state constitutions. I can't speak to what's in each one.

Regardless, It's gonna be fun watching Romney try to weasel his way out of his past in Massachusetts as he appeals to the uber-extremes of the party faithful...almost as much fun as watching Republicans decry 'government run health care being forced on us' and Medicare cuts in the same sentence. I would respect the opposition if they had the principle to stand against all "socialism" such as social security, medicare, senior-citizen discounts, wheelchair parking passes, car insurance, public universities, public schools, highways, the military, eh what am I missing here?
Romney has a real problem (besides the magic underwear) and it'll be interesting to see how he explains this to the GOP in the primaries. I agree that Republicans need to take more of a stand against ALL socialism. We can see that Social Security and Medicare were good-sounding ideas at the time, and had broad bi-partisan support. Both of these plans have already led to fiscal ruin, and now we're going to add a third.

BTW I'm consistent in my opposition to ALL socialism. The Federal government should only be there to make sure the States place nice with each other, and to maintain relations with foreign governments. That's it.
 

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http://blogs.wsj.com/health/2010/03/...to-a-hospital/

QUOTE]

Osprey this is interesting!

I always hear that "residents cost the hospital a lot of money." Meanwhile we seem to be doing a lot of work for a very discounted price compared to attendings and even midlevels such as PA's NPs etc. AND we take shifts (because we must!) that those midlevels would get overtime or special reimbursement for. I would love to see an analysis of what residents actually "cost."

Also - in this whole healthcare debate no politicians seem to be talking about the $200k+ debt and many hours of hard work and sacrifice people put in to become physicians. Who will do this if reimbursement continues to decline?
 

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willow18

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I agree completely. Obama said during the election that he wanted to implement more socialist policies. The general public as usuaul wasn't paying attention. I don't think most of them voted for Obama because they wanted socialist policies, rather they were mad at Republicans and were casting a protest vote against them.
So you're saying that the public aren't really policy wonks and just burp out at the pollsters whatever is making them most angry at the moment? That just strengthens my point; congress shouldn't listen to polls. In either case, the public is split on this bill, not "completely against it" as the opposition claims.

Driving is a privilege, not a right. The Constitution doesn't apply in this case, as it's not the Federal government enforcing it, and it doesn't interfere with any language in the Constitution. It would purely be up to what it's in the individual state constitutions. I can't speak to what's in each one.
Oh is that right? So thinking in constitutional terms, you think our "founding fathers" would've been okay with restricting who can ride their horses? Horses then were as crucial to many peoples' livelihoods as cars are to many today. Hence, forcing people to have insurance on themselves interferes with the constitution as much as car insurance does. It's simply another tax. We're not saying you 'have to' have it, but you will pay a penalty if you don't. It's sorta like saying the govt is forcing people to have babies and amputations by giving tax breaks (nicely worded, but essentially a penalty to all us childless and limb-full ones) to people who have children or to amputees.

Every constitutional scholar I have seen quoted doesn't see an issue here. Having said that, the Roberts court is turning out to be quite radical of late in its willingness to overturn long established precedent, so who knows.


Romney has a real problem (besides the magic underwear) and it'll be interesting to see how he explains this to the GOP in the primaries. I agree that Republicans need to take more of a stand against ALL socialism. We can see that Social Security and Medicare were good-sounding ideas at the time, and had broad bi-partisan support. Both of these plans have already led to fiscal ruin, and now we're going to add a third.

BTW I'm consistent in my opposition to ALL socialism. The Federal government should only be there to make sure the States place nice with each other, and to maintain relations with foreign governments. That's it.
I think the ship has sailed on your dream of a purely socialism free system. People in 2010 simply don't have the gumption/stomach/morals? to watch old people, poor people, and disabled people die in the streets. Yes, we're weaklings.

Social security and Medicare's problem are entirely different yet similar. The problem with SS is that it was designed for a time when people lived to age 60 or so. With Medicare it was again designed for an age when medical costs kept up with general inflation, not for the runaway costs of today. In both cases politics has prevented solutions from being enacted. In that you are right to criticize these big federal programs...the Congress problem. If we put these programs into somewhat of an independent framework (a la NICE in the UK), many of the issues would be solved (via rationing, of course; push retiree age to 70 and limit extraordinary medical interventions). As it is, that won't happen until we are at the brink of ruin; that's the way this country operates of late.
 

willow18

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EM is not listed; we must be "off the charts". hee hee

Note that the numbers are revenue, not net profit. Profit could be negative for all we know.

"The most powerful tool in healthcare remains the physician's pen," President Mark Smith of Merritt Hawkins, a unit of AMN Healthcare, said in a statement with the survey. "Patients are not admitted to the hospital or discharged, tests ordered, or procedures performed without a physician's signature."
Hear hear, and that's why the 'health care reform' is useless in terms of saving money because it doesn't do much in terms of influencing the doctor's pen.
 

EctopicFetus

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We generate a ton of revenue for the hospital. but you are right there is nothing there about profit. Depending on your payor mix it may or may not be profitable.

In the end you need an "ER" because while the ER isnt profitable we admit patients and thats "profitable". FWIW I would never work for a for profit hospital unless it was my only option.
 

EctopicFetus

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http://blogs.wsj.com/health/2010/03/...to-a-hospital/

QUOTE]

Osprey this is interesting!

I always hear that "residents cost the hospital a lot of money." Meanwhile we seem to be doing a lot of work for a very discounted price compared to attendings and even midlevels such as PA's NPs etc. AND we take shifts (because we must!) that those midlevels would get overtime or special reimbursement for. I would love to see an analysis of what residents actually "cost."

Also - in this whole healthcare debate no politicians seem to be talking about the $200k+ debt and many hours of hard work and sacrifice people put in to become physicians. Who will do this if reimbursement continues to decline?
BTW whoever told you that you dont make the hospital money is a total liar. Your salary is supplemented by the federal government and you allow them to pay their attendings less etc etc.
 

EctopicFetus

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So I suppose the 800lb gorilla is:

Do EP's make more now or before Romneycare?
Depends on where you were before then. BTW Mass has the 2nd highest insurance premiums in the US, behind NYC. Overall the NE with NH, RI, CT and Maine near the top as well.

Waits to see outpatient docs has gone way way up and their premiums have been going up as well.

Lose, Lose, lose.

Yes I think ED docs will make more assuming hospitals dont get screwed over in this. If they do they will get money from doctors.
 

sublime447

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I think the argument on the constitutionality of this bill lies in the fact that the FEDERAL government is mandating you buy an intangible good. Federal regulation over state commerce, through the interstate commerce act, has been limited recently by the conservative supreme court. In the example of auto insurance, the STATES have the right to mandate the purchase of auto insurance within their own borders through the 10th amendment.
 

skontroller

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Anyone feel these numbers are inflated? I know we're talking about averages and not medians but the numbers seem a bit high for the non-operative specialities.

SK

http://blogs.wsj.com/health/2010/03/...to-a-hospital/

While there is no EM data in this Wall Street Journal article that was posted in the FM forum by BlueDog, but I thought you all might be interested. I'm curious what you all think of these numbers. I'm sure they are flawed in some way, but if they are even close to anything resembling what actually happens to the cash flow, someone (many people) are getting rich off our efforts. I guess this really comes as no surprise. I also wonder if EM or any other specialty, or medicine as a whole has any consultants crunch these numbers in order to negotiate fair reimbursement (in similar fashion to an agent, sports or otherwise). It seems as though our collective lack of organisation and our willingness to undercut each other is the market working itself out to a "fair market price" for our work. If this is what we will accept then maybe this is what we are worth. Perhaps we would even accept much less if thats what they counter offered. One thing that I think EM has going for it is that we earn our keep and have a skill set that is very difficult to outsource/undercut with less training and I think this will certainly serve us well. Thanks for your comments!