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wowzer

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Uncle Wig
As for having a clear understanding of ACA, I would agree. But then again, I doubt anyone clearly understands all 2700+ pages of the law.

If you don't understand what the law will do, then you don't get to predict the unintended consequences.

Does this mean that you clearly understand all 2700 pages of the new law? If not, then you don't get to predict the unintended consequences either. However, since it makes sense that the IRS will have to increase their staff (by exactly how much, I'm more than willing to adjust), I'd say that my prediction is on much firmer grounds than yours.

If you don't understand what the law will do, you shouldn't get to vote and enact it either with that logic.



You don't have to guess at what unintended consequences will be, one only has to read the back pages of the Boston Globe and the front pages of the Herald.

Here's a decent synopsis of some of what no one wants to hear.
[money.cnn.com]

---

[www.freethegrapes.org]

norwegian wood reality TV

[www.youtube.com]

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wowzer

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Uncle Wig
As for having a clear understanding of ACA, I would agree. But then again, I doubt anyone clearly understands all 2700+ pages of the law.

If you don't understand what the law will do, then you don't get to predict the unintended consequences.

Does this mean that you clearly understand all 2700 pages of the new law? If not, then you don't get to predict the unintended consequences either. However, since it makes sense that the IRS will have to increase their staff (by exactly how much, I'm more than willing to adjust), I'd say that my prediction is on much firmer grounds than yours.

Wowzer, of course I don't clearly understand all 2700 pages. That the bill is long is a red herring. Anything written in legislative-ese is going to be a long read. Most people who are against this law are against it because of the flood of misinformation. I'm going to assume that includes you, with the caveat that I could be wrong.

There probably will be hidden costs and unintended consequences. I don't think that is cause to strike down the law. If there are problems with it, make adjustments.

Here is a post which sums up the law very nicely:
[www.reddit.com]

A cartoon that sums up much of the opposition nicely:

---

[www.flickr.com] [picasaweb.google.com]

"Getting people out of the ER and into primary care saves money."
" Getting preventative care saves money. "
"Managing diseases like asthma, high blood pressure, and diabetes in a primary care setting over ER visits saves money."
"Eventually something will have to be done about profits. The whole FDA-pharma-medical equipment symbiosis has got to be reeled in."

Pam, you are right and I agree entirely. Teach a man to fish and all that. But i fear (and hope I'm wrong) that the system is based upon treating existing maladies rather than maintaining a decent level of health.
My feeling is that money is better spent at the beginning of life, vaccinating, educating, preventing disease, rather than at the end when (so often it seems) it is about prolonging and not being able to let go.
I know the American population is aging fast and that the old have the majority of the money and that if a business wants to succeed it has to follow the money. And that's the problem with the American system. It follows the money. It doesn't put the money in the best place, where it can make the most difference for the most amount of time. It sees that the rich old white people who are scared to die is where the money is. And so that's where it is.

I foresee the 'death panel' chants coming! The Liverpool system mocking us from a few days posts ago!
This is what I meant when I talked about selfishness in another post. I believe and would prefer that money be spent ensuring my child can live a decent and healthy life rather than that same money being spent to cure Alzheimers, which 3 of my grandparents had and I'll most likely get one day.

We cannot cure death, but we sure can throw a hell of a lot of money away trying to!

The complaint that the law has soooooo many pages sounds like opponents can't scrape up any Big Boy complaints.

---

"You can believe me because I never lie and I'm always right."

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Manlove
"Getting people out of the ER and into primary care saves money."
" Getting preventative care saves money. "
"Managing diseases like asthma, high blood pressure, and diabetes in a primary care setting over ER visits saves money."
"Eventually something will have to be done about profits. The whole FDA-pharma-medical equipment symbiosis has got to be reeled in."

Pam, you are right and I agree entirely. Teach a man to fish and all that. But i fear (and hope I'm wrong) that the system is based upon treating existing maladies rather than maintaining a decent level of health.
My feeling is that money is better spent at the beginning of life, vaccinating, educating, preventing disease, rather than at the end when (so often it seems) it is about prolonging and not being able to let go.
I know the American population is aging fast and that the old have the majority of the money and that if a business wants to succeed it has to follow the money. And that's the problem with the American system. It follows the money. It doesn't put the money in the best place, where it can make the most difference for the most amount of time. It sees that the rich old white people who are scared to die is where the money is. And so that's where it is.

I foresee the 'death panel' chants coming! The Liverpool system mocking us from a few days posts ago!
This is what I meant when I talked about selfishness in another post. I believe and would prefer that money be spent ensuring my child can live a decent and healthy life rather than that same money being spent to cure Alzheimers, which 3 of my grandparents had and I'll most likely get one day.

We cannot cure death, but we sure can throw a hell of a lot of money away trying to!

It's not in the best interest of pharma to have people take care of their health before medication is needed. They want you to take a pill instead. Even for something as basic as vitamin needs. Prevention means less income on treatment and cures.

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Pam
It's not in the best interest of pharma to have people take care of their health before medication is needed. They want you to take a pill instead. Even for something as basic as vitamin needs. Prevention means less income on treatment and cures.

Absolutely. I was amazed by how frequent and strident the adverts were on tv for drugs when I first came here.
There was one -for the purple pill, I think- that didn't even tell me what it was for, just that I needed it- mainly because it was purple as far as i could tell!
Still not sure what it's for.

So many adverts telling us we are sad and depressed or suffering from heartbeats and heartburn and that 'they' can relieve us of the symptoms they've convinced us we have.
So clever. So sad.

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Manlove

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Pam
It's not in the best interest of pharma to have people take care of their health before medication is needed. They want you to take a pill instead. Even for something as basic as vitamin needs. Prevention means less income on treatment and cures.

Absolutely. I was amazed by how frequent and strident the adverts were on tv for drugs when I first came here.
There was one -for the purple pill, I think- that didn't even tell me what it was for, just that I needed it- mainly because it was purple as far as i could tell!
Still not sure what it's for.

So many adverts telling us we are sad and depressed or suffering from heartbeats and heartburn and that 'they' can relieve us of the symptoms they've convinced us we have.
So clever. So sad.

If you need it, then you know what it is...

hahahahahha

Is there anything you liked when you first came here? Why did you leave the best healthcare system in the world?

I liked (loved) my soon to be wife. I liked New York because I was a twenty something and it was exciting. In fact I liked America, because it is an amazingly vast and beautiful country (that just so happens to have a really @#$%& healthcare system).
I don't tend to stay in places because of the healthcare or lack of. And I'm not sure that the UK has what you say it does. I would think one of the Low Countries or Scandinavia might though.

In the interest of full disclosure, I drove a Lotus in my college days so I have a soft spot for(gasp) British cars, particularly TR6.

I knew you weren't all bad Avenger!

My stepfather had a nice MGB Roadster pretty much identical to this- [en.wikipedia.org] - sitting in his garage in Dorset. He had it shipped to Australia when he was a young man and drove it around there for 2 years, before coming back with it.
As a kid I really wanted to drive it, but even though he'd let it rust out and turn to crap I was never allowed. He still has it, sitting unused. I hope one day that he gets his @#$%& together to fix it up and take my mum on a Grand Tour of Europe in it.
Actually, I think they are both used to higher levels of creature comfort than the MGB offers, but the romance of the idea is fun to think of.



Edited 1 time(s). Last edit at 07/01/2012 08:15PM by Manlove.

Since we are on a roll. Actually, I have driven this too.

*shudders*
That might as well be a Morris Marina!

It is a Hillman, and what a dog it was.

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billb
If you don't understand what the law will do, you shouldn't get to vote and enact it either with that logic.

You don't have to guess at what unintended consequences will be, one only has to read the back pages of the Boston Globe and the front pages of the Herald.

Here's a decent synopsis of some of what no one wants to hear.
[money.cnn.com]

I hope all that is in that article comes to pass because it means single-payer will be closer than ever.

---

Saint Cloud, Minnesota, where the weather is wonderful even when it isn't.

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Speedy

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billb
If you don't understand what the law will do, you shouldn't get to vote and enact it either with that logic.

You don't have to guess at what unintended consequences will be, one only has to read the back pages of the Boston Globe and the front pages of the Herald.

Here's a decent synopsis of some of what no one wants to hear.
[money.cnn.com]

I hope all that is in that article comes to pass because it means single-payer will be closer than ever.

If our experience with car insurance controls is an indication down the same tracks we'll end up with fewer and fewer options for carriers and higher and higher premiums.
But politicians can sell snow to esquimaux.

---

[www.freethegrapes.org]

norwegian wood reality TV

[www.youtube.com]

Insurance companies aren't complaining. Wonder why?

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Uncle Wig

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wowzer

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Uncle Wig
As for having a clear understanding of ACA, I would agree. But then again, I doubt anyone clearly understands all 2700+ pages of the law.

If you don't understand what the law will do, then you don't get to predict the unintended consequences.

Does this mean that you clearly understand all 2700 pages of the new law? If not, then you don't get to predict the unintended consequences either. However, since it makes sense that the IRS will have to increase their staff (by exactly how much, I'm more than willing to adjust), I'd say that my prediction is on much firmer grounds than yours.

Wowzer, of course I don't clearly understand all 2700 pages. That the bill is long is a red herring. Anything written in legislative-ese is going to be a long read. Most people who are against this law are against it because of the flood of misinformation. I'm going to assume that includes you, with the caveat that I could be wrong.

There probably will be hidden costs and unintended consequences. I don't think that is cause to strike down the law. If there are problems with it, make adjustments.

Here is a post which sums up the law very nicely:
[www.reddit.com]

A cartoon that sums up much of the opposition nicely:

I don't mind that Obama and the congress passed the law (i.e. I don't have an ideological problem with the law or the democratic party). I am just concerned over how we are going to pay for it all. I'm sure all of the inclusive areas and mandatory coverage will net some positive results for individuals and families. However, I am also sure that costs will have to go up.

From the link you've supplied, these are the concerning areas:

It renews some old policies, and calls for the appointment of various positions.
New ways to stop fraud are created.
Any health plans sold after this date must provide preventative care (mammograms, colonoscopies, etc.) without requiring any sort of co-pay or charge.
Small businesses get some tax credits for two years.
Businesses with over 50 employees must offer health insurance to full-time employees, or pay a penalty.
Cut some Medicare spending
Place a $2500 limit on tax-free spending on FSAs (accounts for medical spending). Basically, people using these accounts now have to pay taxes on any money over $2500 they put into them.
Establish health insurance exchanges and rebates for the lower and middle-class, basically making it so they have an easier time getting affordable medical coverage.A new tax on pharmaceutical companies.
A new tax on the purchase of medical devices.
A new tax on insurance companies based on their market share. Basically, the more of the market they control, the more they'll get taxed.
The amount you can deduct from your taxes for medical expenses increases.
If any state can come up with their own plan, one which gives citizens the same level of care at the same price as the PPACA, they can ask the Secretary of Health and Human Resources for permission to do their plan instead of the PPACA. So if they can get the same results without, say, the mandate, they can be allowed to do so. Vermont, for example, has expressed a desire to just go straight to single-payer (in simple terms, everyone is covered, and medical expenses are paid by taxpayers).
All health care plans must now cover preventative care (not just the new ones).
A new tax on "Cadillac" health care plans (more expensive plans for rich people who want fancier coverage).



The areas that I'm concerned about all increase costs through hidden means:

The costs for additional agents/rules/regulations can be astronomical---if you have ever seen a hospital's policies and procedures manual, you would begin to appreciate how many extra people it takes just to implement a single new rule. These hidden cost employees are not the government hired new employees--rather, they are hired to help keep your business adherent to the new rules. When you factor in the new government employees needed to enforce and review these new rules, the number of new hires will increase the costs of services and goods from the US. Of course, the costs are passed onto the consumers and in this case, the tax payers.

The 'cadillac' health plan would include many union plans...guess who pays for that? The businesses--each service and product will now cost more.

If Vermont is applying for a single payor system, then the state medical expenses will be huge taxes to the taxpayers (if Vermont defaults on their bad debts, we all get to pay for it--otherwise, who else will pay it?). I sure hope that they do not go broke with this.

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY

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wowzer
I don't mind that Obama and the congress passed the law (i.e. I don't have an ideological problem with the law or the democratic party). I am just concerned over how we are going to pay for it all. I'm sure all of the inclusive areas and mandatory coverage will net some positive results for individuals and families. However, I am also sure that costs will have to go up.

Wowzer, you've listed a whole slew of cost items without listing any of the cost-reduction items that go with them. Although it is appropriate to be concerned that those things won't balance, and to hope that the folks who spent several years working these things out did their homework properly, I think you are being a bit paranoid in only looking at things on the debit side of the balance sheet. Here are a few examples:

You list preventative care as a cost, whereas there have been a number of studies that show that this reduces overall lifetime medical costs, so it should actually be a credit.

You ignore the fact that pretty much all of those uninsured folks do end up getting (often very expensive) medical care when they show up at ERs due to the Emergency Medical Treatment and Active Labor Act (EMTALA) which was passed by a bipartisan vote in 1986. Currently we all pay through the nose for those folks via a combination of 1) our tax money that goes to subsidizing hospitals operating in the red due to giving these folks free treatment, and 2) by hospitals raising prices on all services to cover uncompensated charges, which ends up raising the premiums on insurance. Transferring the access to healthcare of those folks into subsidized insurance where they can get preventative care combined with making all the freeloaders pay at least some portion of their fair share is most certainly on the credit side of the sheet. I think the concept that uninsured people don't consume healthcare and that therefore insuring them will cost us extra money is a complete fiction propagated by those on the right purely for political purposes.

Your statement "The costs for additional agents/rules/regulations can be astronomical" is such a catch all that it can't be addressed. Yes, any change in policy requires expenditures. So what? The current non-system of healthcare is broken so rules and regulations need to be changed, whether it be via "ACA" or some alternative (which the republicans conveniently avoid providing specifics on).

---

"So be proud to be a decent American instead of just a w'anker whipping up fear!" - Michael D. Higgins, President of Ireland



Edited 2 time(s). Last edit at 07/02/2012 02:13PM by davester.

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davester


You ignore the fact that pretty much all of those uninsured folks do end up getting (often very expensive) medical care when they show up at ERs

Babbling talking points again?

"Medicaid enrollees were three times as likely (15 percent vs. 5 percent) as the privately insured, and twice as likely as the uninsured (15 percent vs. 7 percent), to have visited an ER twice in the previous year."

[news.heartland.org]

I'm saying it again, being smitten by 'facts' and statistics lessens ones ability to see, understand and adopt new and as yet untried ideas.
One can always find supporting evidence if one looks hard enough. But this political stuff is not science...it's opinions, loosely clothed with factual robes.
Facts are great, really they are. But great ideas don't necessarily stem from knowing a bunch of them.

"I can prove this- can you prove that?"
The answer is never to complete satisfaction because total reliance on fact has lessened the ability to see the other point of view.
I know arguing is fun- that's why Avenger is necessary. If he weren't here we would have to invent him so that we can continue to play the game. I know for some of you I fulfilled that role.

We are all like the relatively smart Repubs that were alluded to elsewhere- just smart enough that we know what we know and will not accept 'facts' from the other side that disagree with our own.

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davester
Wowzer, you've listed a whole slew of cost items without listing any of the cost-reduction items that go with them. Although it is appropriate to be concerned that those things won't balance, and to hope that the folks who spent several years working these things out did their homework properly, I think you are being a bit paranoid in only looking at things on the debit side of the balance sheet. Here are a few examples:

You list preventative care as a cost, whereas there have been a number of studies that show that this reduces overall lifetime medical costs, so it should actually be a credit.

You ignore the fact that pretty much all of those uninsured folks do end up getting (often very expensive) medical care when they show up at ERs due to the Emergency Medical Treatment and Active Labor Act (EMTALA) which was passed by a bipartisan vote in 1986. Currently we all pay through the nose for those folks via a combination of 1) our tax money that goes to subsidizing hospitals operating in the red due to giving these folks free treatment, and 2) by hospitals raising prices on all services to cover uncompensated charges, which ends up raising the premiums on insurance. Transferring the access to healthcare of those folks into subsidized insurance where they can get preventative care combined with making all the freeloaders pay at least some portion of their fair share is most certainly on the credit side of the sheet. I think the concept that uninsured people don't consume healthcare and that therefore insuring them will cost us extra money is a complete fiction propagated by those on the right purely for political purposes.

Your statement "The costs for additional agents/rules/regulations can be astronomical" is such a catch all that it can't be addressed. Yes, any change in policy requires expenditures. So what? The current non-system of healthcare is broken so rules and regulations need to be changed, whether it be via "ACA" or some alternative (which the republicans conveniently avoid providing specifics on).

Since I am an ER doc (or at least I used to be before becoming a suit), I can tell you that medicaid folks usually wind up in the ER because no one is able to make money on medicaid patients by having late office hours. In fact, almost the only way to make money on medicaid patients is to triple and quadruple book them. Thus, if any of these patients have a sick call, those medicaid primary docs will tell the patients to go to the ER. Everytime that medicaid is expanded, ER usage rises. Same goes true for managed care--the managed care primary care docs cannot make money as fast if they stop their routine to see a sick (unscheduled) patient. They usually tell the patients to go to the ER.

As for public payment patients (medicare and medicaid), their ER usage is very high, usually because their doctor's office wasn't opened or not available.
[www.cdc.gov]

Overall, I know that ER's throughout the country are bracing for the onslaught of additional patients. If you though ER overcrowding was an issue before ACA, be prepared for some truly long waits.

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY

Oh, I also forgot to mention that I am very uncertain if primary care will do anything to decrease medical usage or costs. My most difficult question is knowing when primary care ends. What do you do when your screening tests find a disease like cancer? Does your primary care treatment end? Also, since mortality is 100%, would better primary care just defer the mortality to a later time? If so, then would there be an even higher usage of healthcare each year in later life?

Of course, it could be argued that by finding cancer earlier, treatments may be less expensive, thereby reducing costs. However, I don't believe that all forms of primary care and physician intervention has been fully proven via economic analysis to be more beneficial in terms of cost:
[www.kevinmd.com]

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY

Here is another graph showing how manage care medicaid increases ER usage:

[www.ncqa.org]


bottom of page 23...

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY



Edited 1 time(s). Last edit at 07/02/2012 08:16PM by wowzer.

Here's another graph showing CDC data about Medicaid status and ER usage (surprise, ER usage goes up if you have medicaid versus non-insured):
[www.cdc.gov]

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY

"Same goes true for managed care--the managed care primary care docs cannot make money as fast if they stop their routine to see a sick (unscheduled) patient. They usually tell the patients to go to the ER."

It sounds like Doctors are really greedy!

I am trying to follow this but every other word needs defining for me- primary care, managed care- which slows me down. But you seem to be suggesting that the reason the ER gets full is because Doctors can't make enough money from Medicaid patients (and shut their offices early) so they ship them off to the ER!?
I don't think you mean that - or maybe you do and I am even more clueless than I thought.

Solution (?) - Doctors make slightly and keep their clinics open longer. Doctors don't deserve special treatment. They are part of the workforce like everyone else.

I am positive I am reading this wrong, but luckily there's a doctor on hand to explain it!

And is that why doctors become doctors, to make money off people? I thought there were oaths and things or am I hoplessly old fashioned?

Wowzer, what do you know about the business side of medicine? You are just a doctor. I have to wait for what the experts here have to say.

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Manlove
"Same goes true for managed care--the managed care primary care docs cannot make money as fast if they stop their routine to see a sick (unscheduled) patient. They usually tell the patients to go to the ER."

It sounds like Doctors are really greedy!

I am trying to follow this but every other word needs defining for me- primary care, managed care- which slows me down. But you seem to be suggesting that the reason the ER gets full is because Doctors can't make enough money from Medicaid patients (and shut their offices early) so they ship them off to the ER!?
I don't think you mean that - or maybe you do and I am even more clueless than I thought.

Solution (?) - Doctors make slightly and keep their clinics open longer. Doctors don't deserve special treatment. They are part of the workforce like everyone else.

I am positive I am reading this wrong, but luckily there's a doctor on hand to explain it!

And is that why doctors become doctors, to make money off people? I thought there were oaths and things or am I hoplessly old fashioned?

To answer your last question first, sure, doctors do plenty of free care (many patients without insurance at all). You aren't hopelessly old fashioned--just a little naive as to what is possible. The costs of maintaining an office (due to all of these hidden rules and regulations that you know absolutely nothing about) is unbelieveable. If an office closes, it wont help anyone, the doctor or the patients (insured or uninsured).

Here is approximately how the money plays out.


This is the cost side:

The cost of maintaining an office staff is very high. If you have 2 nurses working for you ($80,000-100,000 each), 2 clerks to make the appointments ($40-$60,000 each), 1-2 billing specialists to make claims to Medicare, Medicaid, & Private Insurance ($40,000-60,000 each), then your hourly rate of return has to be somewhere about $250-$300 per hour. This is working at 10 hours a day for 5 days a week for 52 weeks (no vacation), your gross revenue will be about $650,000-$780,000. After personnel, the office grosses about $250,000-$380,000. The office then has to pay the rent ($60-$80,000), malpractice insurance (about $30-$50,000 for primary care), health care plan for small group ($35,000-$50,000) and many physicians take out office loans to start/establish their practice ($250,000-$500,000). Thus, in total, the primary care doctor's take home salary is between $160,000-$250,000.

With this salary, he is working a minimum of 50 hours a week in his office, plus weekend call, and takes no vacation. This time also does not include the number of phone calls he has to make to patients at the 'end of office hours'. He must also review all laboratory and diagnostic testing in case a patient has an emergency. Those extra hours of work are completely uncompensated. Oh, did I mention what would happen if any of his patients are sick and are admitted to the hospital? The doctor has to attend his patients in the hospital--even though you are compensated better, travel between office and hospital expands your work day to about 12-14 hours. Of course, on weekends, the doctor has to show up to the hospital to attend his patients as well. How in the world do you expect doctors to work any longer?

Back to the money issue: he must pay off his medical school loans (which now ranges about $300,000-$400,000), house mortgage, and of course he has lost about 10 years of salaries while training to become a doctor. If you do the math on retirement savings--if you have 10 years extra salary and you maximize your retirement, you'll be about $500,000 ahead of the doctor who just came out of medical school.



Now for the revenue side:

If a physician were to take ONLY medicaid insured patients, then he'd have a near impossible task of maintaining his office. Here is an estimated revenue:

Medicaid pays about $30 per office visit (some pay more and some pay even less). If you have to make $250-$300 per hour in order to generate the gross office practice above, you need to see about 10 patients every hour--that's 1 person every 6 minutes. Of course, we haven't even factored in times when the doctor needs to go to the bathroom, take lunch, or even stop to call their spouse. What happens more frequently with medicaid patients is that they wont show for an appointment (they typically have lower incomes and have other life emergencies which must take precedence). Thus, your office will need to double book, just in case patients cancel. If they do not overbook, your office will close very, very quickly. The net effect of this low payment by medicaid is that most physicians will only take about 20% medicaid patients--their office will refuse to take additional because they'd go out of business.


Every doctor that I know (myself included) engages in philanthropy (which medicaid and non-insured patients are), I believe that he should be able to make enough money to make his time worthwhile. What do you think?


PS I'm on my last day of vacation (like I said, I'm more of a suit than a practicing clinician these days), and I wont be able to respond to many more posts...but I hope this helps clarify some of the concerns of small business owners.

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY



Edited 1 time(s). Last edit at 07/03/2012 10:15AM by wowzer.

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Avenger
Wowzer, what do you know about the business side of medicine? You are just a doctor. I have to wait for what the experts here have to say.

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY

I haven't read the rest of your last post ,but stop posting and enjoy your vacation!

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wowzer
Now for the revenue side:

If a physician were to take ONLY medicaid insured patients, then he'd have a near impossible task of maintaining his office. Here is an estimated revenue:

Medicaid pays about $30 per office visit (some pay more and some pay even less). If you have to make $250-$300 per hour in order to generate the gross office practice above, you need to see about 10 patients every hour--that's 1 person every 6 minutes. Of course, we haven't even factored in times when the doctor needs to go to the bathroom, take lunch, or even stop to call their spouse.

I was surprised at that figure. I climbed on the Medicare (not Medicaid) bandwagon just under the wire to pay for my AAA. Not sure about the specialists but my monthly statements indicate they pay my primary about $140/per 5/7 minute visit. Why would Medicaid differ so much from Medicare?

What do I think, wowzer?
That the cost of education (not only for medical school) in this country is ridiculous and that not having free healthcare available to all is also ridiculous.
I would like to see both healthcare and education become tax payer funded. If you need or want an education, you can get one, if you need a new hip, you can get one. Not everyone needs or wants to be educated. Not everyone needs a new hip, but when you do, you should be able to get one.
I can't argue your numbers because I have never been in the situation. I suspect you have somewhat overstated, but am in no position to argue.

"You aren't hopelessly old fashioned--just a little naive as to what is possible."
Not really. I just believe that what is possible given the present situation and system, is not the same as what is possible, period.
"The costs of maintaining an office (due to all of these hidden rules and regulations that you know absolutely nothing about) is unbelieveable. "
I believe it and also know that given any work place there are running costs that unless you are privy to them you know nothing about.
Doctors make their money just fine.
As far as I know very few Dr's are forced to live on the wrong side of the tracks.
I went to see an oral surgeon recently as a result of an automobile accident. He had a team of 12 people, receptionists and nurses and clerks etc as you mention. I was in his offices for a total of around 2.5 hours for which I was charged around $2500.
Mind blown.

I really do appreciate what the medical profession does- my daughter would be dead if not for them- but they work no harder than so many people, and get recompensed far more.

Please don't interpret any of the above as a personal sleight. It's certainly not intended to be, it's just that I find it hard to feel sorry for the doctors in all this, especially when there are (were) 50 million people in this country without health coverage.

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RgrF

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wowzer
Now for the revenue side:

If a physician were to take ONLY medicaid insured patients, then he'd have a near impossible task of maintaining his office. Here is an estimated revenue:

Medicaid pays about $30 per office visit (some pay more and some pay even less). If you have to make $250-$300 per hour in order to generate the gross office practice above, you need to see about 10 patients every hour--that's 1 person every 6 minutes. Of course, we haven't even factored in times when the doctor needs to go to the bathroom, take lunch, or even stop to call their spouse.

I was surprised at that figure. I climbed on the Medicare (not Medicaid) bandwagon just under the wire to pay for my AAA. Not sure about the specialists but my monthly statements indicate they pay my primary about $140/per 5/7 minute visit. Why would Medicaid differ so much from Medicare?

I could be wrong, but isn't the statement what the doc bills, rather than what medicaid actually ends up paying? kj.

No. It shows both. the billed and paid amount.

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RgrF

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wowzer
Now for the revenue side:

If a physician were to take ONLY medicaid insured patients, then he'd have a near impossible task of maintaining his office. Here is an estimated revenue:

Medicaid pays about $30 per office visit (some pay more and some pay even less). If you have to make $250-$300 per hour in order to generate the gross office practice above, you need to see about 10 patients every hour--that's 1 person every 6 minutes. Of course, we haven't even factored in times when the doctor needs to go to the bathroom, take lunch, or even stop to call their spouse.

I was surprised at that figure. I climbed on the Medicare (not Medicaid) bandwagon just under the wire to pay for my AAA. Not sure about the specialists but my monthly statements indicate they pay my primary about $140/per 5/7 minute visit. Why would Medicaid differ so much from Medicare?

Medicaid was designed to help the poor pay for supplies, prescriptions, and equipment (IIRC) and not as a means to pay physicians. However, over the years, CMS has re-tasked medicaid to pay for some physician services. Back in the old days, I used to get $7.50 for a medicaid patient seen in the ED, regardless of my level of service...when patients have bonafide emergencies (i.e. cardiac arrest), we did critical care and brought them back from the dead. We'd intubate, perform a central line, manage the emergency for over 2 hours...and medicaid would pay us $7.50. It's gotten better over the last decade, now we get about $25, but you have to remember that 250% increases over 10 years really increased the cost to medicaid, and definitely outpaces inflation.

Medicare was designed to pay physicians--and we get reasonable rates for medicare patients, which is priced just about enough to pay for the cost of seeing the patient and make a reasonable profit. But when you provide philanthropy, medicare wont make up the difference--that's where commercial insurance used to help pay for the difference.

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY



Edited 1 time(s). Last edit at 07/04/2012 07:55AM by wowzer.

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Manlove
What do I think, wowzer?
That the cost of education (not only for medical school) in this country is ridiculous and that not having free healthcare available to all is also ridiculous.
I would like to see both healthcare and education become tax payer funded. If you need or want an education, you can get one, if you need a new hip, you can get one. Not everyone needs or wants to be educated. Not everyone needs a new hip, but when you do, you should be able to get one.
I can't argue your numbers because I have never been in the situation. I suspect you have somewhat overstated, but am in no position to argue.

"You aren't hopelessly old fashioned--just a little naive as to what is possible."
Not really. I just believe that what is possible given the present situation and system, is not the same as what is possible, period.
"The costs of maintaining an office (due to all of these hidden rules and regulations that you know absolutely nothing about) is unbelieveable. "
I believe it and also know that given any work place there are running costs that unless you are privy to them you know nothing about.
Doctors make their money just fine.
As far as I know very few Dr's are forced to live on the wrong side of the tracks.
I went to see an oral surgeon recently as a result of an automobile accident. He had a team of 12 people, receptionists and nurses and clerks etc as you mention. I was in his offices for a total of around 2.5 hours for which I was charged around $2500.
Mind blown.

I really do appreciate what the medical profession does- my daughter would be dead if not for them- but they work no harder than so many people, and get recompensed far more.

Please don't interpret any of the above as a personal sleight. It's certainly not intended to be, it's just that I find it hard to feel sorry for the doctors in all this, especially when there are (were) 50 million people in this country without health coverage.

Oral Surgeons are not MD's. They are DDS. They have an entirely different pay schedule and are not in the same boat as physicians.

As for medical education and healthcare for free, I'm not convinced that that would work in the American way. You are supposed to believe in a market economy--which means that there's competition keeping the system going. If Med school were free, then we'll pay physicians less and less...eventually to the detriment of everyone. The only reason I know of why physicians work so many hours is because they have a private stake--if they work less hours, they wont generate the salaries that they earn. When hospitals buy out physician practices (more and more lately because of ACO's), the physician practice becomes less efficient (meaning less revenue per hour) because the doctors lose the incentive to work more hours and see more patients per hour. If we nationalize the healthcare workforce, we'll have a lot of people finding ways of how they can work less--not more.

The reason why you don't know of physicians who are bankrupt is because when their offices close, you don't notice. But that does not mean that there aren't doctors who are in bankruptcy because their practice has closed.
[money.cnn.com]
[www.kevinmd.com]

More importantly, doctors will not start their practice in areas with high poverty (AKA medicaid) because they wont be able to sustain their practice.

FYI, I've been working in a safety net hospital since I finished residency--I am a top of the class graduate of a top 25 medical school. However, I believe in our mission--to help those who are financially unable to pay for healthcare. But as a private practitioner, I don't blame other physicians when they do not want to return to our environment, as most of the physicians in my area are being paid way below market value (i.e. within the lower 15% of the market analysis).

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY

Why must the choices be framed only as "Primary Care" or "Emergency Room?" In these parts, we have "Urgent Care." The hours are not 24/7 necessarily, but they are better than the PCP.

If your PCP is closed, where the heck are you supposed to go if your kid develops a high fever, or you need a few stitches? It's not just a poor/uninsured people problem. Sounds to me like there's demand for these clinic-style facilities, where you can make money on low-profit, high volume like a supermarket (NOW THAT EVERYONE'S INSURED, of course.) What will keep the market from providing them under PPACA?



Edited 1 time(s). Last edit at 07/04/2012 10:14AM by Acer.

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wowzer
But when you provide philanthropy, medicare wont make up the difference--that's where commercial insurance used to help pay for the difference.

So we are right back to my premiums paying for the expense of treating uninsured people. It seems like all roads lead to this, in the end.

---

"You can believe me because I never lie and I'm always right."

Thanms wowzer.
As you appreciate I am sincerely grateful to you and your ilk, and you know what I am going to say next, but I'll say it anyway.
"You are supposed to believe in a market economy--which means that there's competition keeping the system going. "... except of course when it doesn't. So long as you have money in a market economy things are dandy, but woe betide you if you get fired from the job that you were forced to stay in because of the meagre insurance.
It's not the individuals that I see as being morally bankrupt. You are right, they have studied hard for years, and have exobitant school fees to payback. They work long hours dealing with the general public (yuck) when the gen pubs are at their worst. They get little thanks and mountains of paperwork.

I don't believe I'm afraid. I think the system is entirely broken and even when these new laws are passed, they don't really fix the problem, they just defer it. We need a new system. It can be done but it's painful in transition. I really don't think there is the heart and strength to do it.

And so we limp on into an uncertain future, field dressing our wounds, staunching the worst of the flow, keeping ourselves moving because we are too scared to stop and look in another direction.

8(

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Acer
Why must the choices be framed only as "Primary Care" or "Emergency Room?" In these parts, we have "Urgent Care." The hours are not 24/7 necessarily, but they are better than the PCP.

We've taken my daughter to urgent care with a broken elbow. Was slow, but the job was done.

But another time, a friend was visiting, on his way to burning man, and he cut himself badly and eventually fainted, so we took him to the ER- the only choice.
A few hours later he was stitched up and fine.
A few weeks later we got a call asking us if we knew a Mr. Andy H...... . He had unpaid medical bills.
Well, he was back in his homeland and we certainly weren't going to pay for him so the bills ($6 or $700), went unpaid.
Except they didn't go unpaid because everyone's premiums nudged up that millionth of a cent.
So I'd just like to say thank you to all for helping my friend in his time of need in a foreign land.

What surprises me the most is that people are extremely unwilling to help other people unless they know them or can directly experience the outcome of their generosity.

Swampy talks about giving money to the Humane Soc. and a local Hospice. But she would definitely not be the only one who felt that it was wrong for her tax money to be used to pay for an abortion in California for example.
We live in a society, we are communal animals. We work best when we look out for the interests of others. Enlightened self interest works, when it is allowed to.
"If it's good for you then the chances are high that it will eventually be good for me too."
I'll help pay for your medical college via my taxes so that you will be able to help me (or one of my friends, or indeed, a complete stranger) in 5 years.

I'll help pay for you to apprentice in a small electricians business, by paying through my taxes for your healthcare so that the electrician doesn't have to shoulder the burden alone, and in 3 years you can come and turn the lights back on after this godawful storm.

Why are people so reticent to help others?
Are they so scared of government (because they have been told to be) that they would rather shoot themselves in the foot than share the common good?

I've lived here for almost 1/3 of my life and am still utterly bemused by their lack of faith in each other.
America really is isolationist. States are isolationist. Counties are isolationist, and increasingly, people are individually becoming more separate and distinct from each other. The assumption seems to be as I have said in other posts, that unless I know you, you are likely to want to do me harm, therefore I will give you no quarter.

We have been successfully cornered into neat little marketing boxes that make us willing consumers. We have little political clout because we cannot organise ourselves into units of power (that used to be called Trade Unions). We are living in glass bubbles that we are so scared of breaking that we prefer to lock ourselves away in dark places rather than risk moving out into the community.

Happy 4th!

I've often wondered why a system such as ours, one that turns people who would otherwise be dedicated exclusively to the practice of medicine were slowly morphed into becoming businessmen/women who now had their eye on two separate and disparate goals, has not realized the damage that causes.

It would appear with the way we force them to pay for education that morphing begins, unfortunately it sometimes ends with some physicians balancing the managing of assets with the managing of patients - to the detriment of the patient.

If they'd wanted to go into business they'd have pursued an MBA, not an MD.



Edited 1 time(s). Last edit at 07/05/2012 02:49AM by RgrF.

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RgrF
I've often wondered why a system such as ours, one that turns people who would otherwise be dedicated exclusively to the practice of medicine were slowly morphed into becoming businessmen/women who now had their eye on two separate and disparate goals, has not realized the damage that causes.

It would appear with the way we force them to pay for education that morphing begins, unfortunately it sometimes ends with some physicians balancing the managing of assets with the managing of patients - to the detriment of the patient.

If they'd wanted to go into business they'd have pursued an MBA, not an MD.

I agree completely, but that is the capitalist system. As a physician, you also have to be a business person. Amazingly, I never received a s ingle formal class on the economics of medical practice. You have to learn this stuff all on your own. I think a few medical schools have started to incorporate this into their curricula as doctor's pay has dropped and more than a few have declared bankruptcy.

---

All I ever really needed to know, I learned from watching Star Trek.
Nassau County, NY

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wowzer
As a physician, you also have to be a business person.

If we had a single payer system, doctors could operate without all of that overhead, like dedicated staff to process insurance claims.

If doctors are going bankrupt, then they suck at the business part.



Edited 1 time(s). Last edit at 07/05/2012 01:55PM by Lux Interior.

You really long for the Stalinist system, don't you? They had guaranteed jobs, free college, free medicine and free housing. You'd love it. Imagine single payer everywhere. Oh, here is the future of single payer in another endeavor.


"The closure of Cabrini's high-rises marks the end of an ugly era in public housing. The 70-acre development was initially hailed as a salvation for the city's poor that was emulated nationwide. But it quickly decayed into a virtual war-zone, the kind of place where little boys were gunned down on their way to school and little girls were sexually assaulted and left for dead in stairwells."