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I'm a doctor.  I have a practice that's mostly Medicare.  For several years it has been a "loss leader" for my other job, that pays better -- being Medical Director for a company that does drug trials, paid for by big drug companies.  
In about 2003 Congress created a "sustainable growth rate" (SGR) formula for Medicare payments.  Basically, if Medicare expenses per person insured went up more than inflation, what Medicare paid the next year would be reduced by enough to bring it back down.  That passed the buck for staying within budget to doctors and patients -- collectively.  There's no way to enforce that "budget".
Every year, when the SGR reduction reared its ugly head, Congress kicked the can down the road.  
This year, I really don't trust them to do it.  
Below the orange Fleur de Kos, the email I wrote to my Congressman today:

Should I drop out of Medicare?

Today is MY deadline for deciding whether or not to "participate" in Medicare next year.  If you and your colleagues in Congress don't act today and meet YOUR (self-imposed) deadline, I will be faced with a 26.5% pay cut for seeing Medicare patients.  

I realize it's possible Congress will reverse that cut, even if it has to be done retroactively.  It has happened in the past, when the unreasonable cuts called for by the "sustained growth rate formula" were about to happen or did temporarily happen.  But can I trust Congress to do the reasonable thing again, this time around?  Trusting Congress to do the reasonable thing is a risky bet.  Just ask Standard and Poor why they cut their rating on United States bonds.  

Perhaps tomorrow I should ask my office manager to telephone all the Medicare patients who have appointments any time in 2013, and tell them not to come in until this is settled.  While she's talking to them, she or I should also give them the telephone numbers of their Congressmen.  

I realize you and other members of the Tea Party caucus may feel you "weren't elected to raise taxes".  Perhaps not, but you were elected to govern.  During the last campaign, at a town hall meeting, a voter who seems to have missed the big picture told the candidate, "Keep your government hands off my Medicare!"  My office manager and I may educate a few such folks that Medicare is in fact entirely in the hands of the Federal Government.  

Governing requires seeing the big picture, and if necessary, showing it to those being governed.  Are you up to that?

Originally posted to david78209 on Mon Dec 31, 2012 at 01:50 PM PST.

Also republished by Community Spotlight.


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Comment Preferences

  •  You are a small part in a grand scheme (31+ / 0-)

    of austerity designed to enrich the 1%.

    Besides that, your problems would be solved if we had single payer, instead of having the highest risk pool pay the least for services.

    "To recognize error, to cut losses, to alter course, is the most repugnant option in government." Historian Barbara Tuchman

    by Publius2008 on Mon Dec 31, 2012 at 02:03:22 PM PST

    •  We're all a small part of the big picture- (18+ / 0-)

      but if doctors start turning away patients because of compensation cuts, that's a big problem for a lot of people.

      •  but NOT a problem for the rich (17+ / 0-)

        or the Republicans who have supported and enabled their schemes to bilk the nation for their continuing enrichment.

        Help American return to sanity - vote the GOP OUT OF the House Majority and reduce their numbers in the Senate in 2014 elections. America requires Democratic action in order to survive!

        by dagnome on Mon Dec 31, 2012 at 02:34:35 PM PST

        [ Parent ]

      •  U.S. MD incomes are a big part of the problem. (18+ / 0-)

        They make 50-100 percent more than European, Canadian, Aussie, & N.Z. docs.  Of course, this is mostly true because of the outrageous incomes of the specialists, not the G.P.'s, family docs, general peds docs, etc.  In part, this is just a matter of supply and demand, since we have a ratio of docs to population that is much lower than in most of the wealthy West.  The American medical profession has deliberately created this situation by lobbying against the expansion of the number of places in American medical schools, so that, if it weren't for a large influx of foreign-trained docs in the last 20-30 years, we'd have an even more severe doctor shortage than we have now.  

             Obviously, it's impractical to try to make sudden drastic cuts in current doctors' incomes.  Besides motivating many of them to stop seeing Medicare patients, it's hardly fair to them to suddenly break the implicit contract under which they became doctors.  But they should be put on notice that their incomes are going to be very gradually pinched down to some sustainable level through reduction of Medicare and other insurance re-imbursement levels -- you know, part of that "shared pain" all the wealthy Villagers are always talking about.  And this can be accomplished over the long haul in a very market-based way -- double or triple the number of places in American medical schools and increase the immigration of foreign-trained doctors.  And don't listen to the A.M.A.'s screams about harming the quality of care -- it's bunk, as even a casual examination of cross-country health & longevity figures suggests, as does my 30 years of professional experience as a clinical neuropsychologists working with docs trained in a variety of different countries.  

        •  How about the ridiculous cost of medical school? (16+ / 0-)

          My friend graduated with a quarter million in debt. Until you fix that, there's no way we should be telling doctors they make too much money.

          •  I think you'll find the ridiculousness of the cost (16+ / 0-)

            is becoming the new norm for all higher ed, not just med school.

            Yet another way to separate the sheep from the wolves.

            •  Yeah, the wolves get the higher ed (9+ / 0-)

              so they can better fleece the sheep.

              If it's
              Not your body,
              Then it's
              Not your choice
              And it's
              None of your damn business!

              by TheOtherMaven on Mon Dec 31, 2012 at 08:19:39 PM PST

              [ Parent ]

            •  In other countries Higher Ed. is not nearly as (8+ / 0-)

              costly as the USA.

              "We are a Plutocracy, we ought to face it. We need, desperately, to find new ways to hear independent voices & points of view" Ramsey Clark, U.S. Attorney General.

              by Mr SeeMore on Mon Dec 31, 2012 at 11:38:23 PM PST

              [ Parent ]

            •  In countries where education is a right... (9+ / 0-)

              ... not an expensive privilege, education from kindergarten through college is free.  If they can't stay home and go to college, they get a monthly stipend for food and rent so they can devote all their time to their studies.  This is the policy in all three Scandinavian countries.

              Medical care is also considered a right for everyone in all three Scandinavian countries, from commoner to king/queen, and it's all paid for - for everyone.  Parental leave for BOTH parents is generous (can be 18 months or so) and paid (at about 80% of their salary), and their jobs are waiting for them when they go back to work.  Sick leave is paid and jobs are waiting when the person gets the doctor's okay to go back to work.

              True.  Their tax rates are high..., but NO ONE has to worry about going into debt for catastrophic illnesses, or if they have to stay home and take care of a sick relative, or when a new baby comes into the family, and no one graduates from college in debt for many years.  Furthermore, no one seems to mind the high tax rate since everyone benefits.

              It works like our Medicare Part A and Part B - NOT-FOR-PROFIT SINGLE-PAYER health insurance [which everyone pays for when they're working (except Medicare Part D which seniors and disabled pay to private corporate insurance companies for prescription coverage - we were told buy this insurance or else), just like they do with FICA/Social Security Insurance.  Social Security recipients continue to pay for Medicare after they receive SSI or SSDI and are no longer in the working world; it's deducted before the remainder is deposited in one's account.

              If we didn't have insurance, medical, and pharmaceutical corporations (along with oil, military-industrial-congressional, and mercenary corporations) standing in line to receive handouts or surgically attached to Treasury Teats so they can pay executive bonuses, shareholders, and funnel profits to offshore accounts, not to mention banks, investment banks, and Casino Wall Street waiting in the wings for our Social Security Trust Fund money, we could have educational and medical systems like the countries that always rate in the top ten in the world for best places to live or where people are listed as happiest or most contented.

              OTOH, they also don't spend huge fortunes on their military budgets.  They have a national service that most able-bodied persons have to go through for a couple of years, but they have it in perspective: it's a phase of one's life, it doesn't define their existence.  They also don't go around invading countries illegally or unconstitutionally.

              They also enforce their laws when corporations start price gouging their citizens.  [Wow!  Novel concept, eh?]

              In terms of education and medical care, the US is lagging behind even some third world countries.  [The last survey I read a couple of years ago we were at #37.]

              Boo-YA.  Yeah, we're #1..., in being the world's bullies and spending money on the military [about 50% of our national budget!] and illegally and unconstitutionally invading other countries and spending money on those same illegal and unconstitutional wars....


              That, in its essence, is fascism--ownership of government by an individual, by a group, or by any other controlling private power.
              -- Franklin D. Roosevelt

              Fascism should rightly be called Corporatism, as it is the merger of corporate and government power.
              -- Benito Mussolini

              Fascism, the more it considers and observes the future and the development of humanity, quite apart from political considerations of the moment, believes neither in the possibility nor the utility of perpetual peace.
              -- Benito Mussolini

              I'm sick of attempts to steer this nation from principles evolved in The Age of Reason to hallucinations derived from illiterate herdsmen. ~ Crashing Vor

              by NonnyO on Tue Jan 01, 2013 at 08:32:38 AM PST

              [ Parent ]

            •  Yep. My daughter-who makes about $40K per (0+ / 0-)

              year has $90K in school debt.  And she will never make anything anywhere near what an MD makes.

              We need to take a look at why all education is so expensive.

              I fall down, I get up, I keep dancing.

              by DamselleFly on Tue Jan 01, 2013 at 04:55:24 PM PST

              [ Parent ]

          •  and insurance and treating a medical practice as (0+ / 0-)

            a profitable business

      •  Total bullshit (0+ / 0-)

        What a greedy stupid system.  Yeah right I am so worried about doctors being able to drive their fucking Mercedes.  Give me a freakin break.

        "The real wealth of a nation consists of the contributions of its people and nature." -- Rianne Eisler

        by noofsh on Tue Jan 01, 2013 at 02:24:06 PM PST

        [ Parent ]

      •  I lost my gynecologist (3+ / 0-)
        Recommended by:
        Pariah Dog, Mr Robert, david78209

        I live in a Georgia city with about 100,000 population. My previous gynecologist sent out a letter saying he would no longer accept "Medicare patients." I got out the phone book and started calling other ob-gyn clinics and doctors. I found ONE doctor in this whole city who will still accept Medicare patients. I like him. He is an older man, but obviously still competent. He is board certified. But I expect this year that maybe he too will drop his Medicare patients, because of the lack of sufficient bill payments. Then I will have to go further to find a gynecologist, and I have no car. I can take the airport shuttle into Atlanta, 60 miles away, to see a doctor (if I find one there), but that round-trip on the airport shuttle will cost me $68. And Medicare won't cover my transportation expenses. So, doctors refusing Medicare payments is a HUGE problem for the patients like me who are limited in access to larger cities where more doctors may be found accepting Medicare patients. I'm grateful for my doctor here; I just hope he will continue caring for me.

        •  I'm also in a small rural community (1+ / 0-)
          Recommended by:

          and finding a doc who accepts Medicare is not easy, however, I did manage to find one that I like. Unfortunately, he's not affiliated with the local hospital so if I need to be hospitalized I'll end up depending on a hospitalist who's basically an employee of the hospital.

          The only trouble with retirement is...I never get a day off!

          by Mr Robert on Wed Jan 02, 2013 at 01:20:41 PM PST

          [ Parent ]

    •  Excuse me... (20+ / 0-)

      I don't think so...  Unless he is a specialist and/or sees patients as part of a hospital group, he is not that well paid on take home (and even then it may be a small salary).

      Most doctors (young or older) have a huge debt load to pay off (in the range of 180,000 to 250,000), then in the private practice you have to pay for:
         Office equipment (Chairs, tables)
         Computers and software (and you would be surprised how much the software for EMR costs)
         Back office staff (billers, insurance people, receptionist)
         Nursing staff
         Technical staff (if the practice is large enough and the doctor doesn't do his own software/hardware stuff)
         Exam equipment (scales, BP cuffs, exam tables, etc.)
         Lab work materials (Blood draw & tubes, swabs (cultures), collection cups, lab kits, etc)
         Office Rental/purchase

      Most who are in private practice will bring home maybe 50,000-60,000/yr in a decent practice (after 18+ months of starting).  A big practice might bring home 80-100,000/yr (a big practice is seeing patients from 8 am till 6 pm 5 days a week).

      Your comment above is about || that close to being HR'd.  How do I know these things... my partner just finished up med school and is starting a private practice.

      "Death is the winner in any war." - Nightwish/Imaginareum/Song of myself.

      by doingbusinessas on Mon Dec 31, 2012 at 05:16:26 PM PST

      [ Parent ]

      •  Ty for this comment. you are exactly right. most (8+ / 0-)

        internists, pediatricians and family practitioners are not by any means rich.

        "Say little, do much" (Pirkei Avot 1:15)

        by hester on Mon Dec 31, 2012 at 05:37:28 PM PST

        [ Parent ]

        •  Our primary care pysician works for a (8+ / 0-)

          corporation owned by a very large hospital corporation. The corporation decides whether he can see patients on Medicare, it's not up to him. In exchange, he is relieved from the responsibiity for almost all the things doingbusinessas mentioned in his comment -- billing, hiring staff, buying or leasing equipment and space, etc. In return, he probably doesn't make as much as a fully established physician does, but in the early years, he knew he could make his loan payments. We all make tradeoffs.

          “Social Security has nothing to do with balancing a budget or erasing or lowering the deficit.” -- Ronald Reagan, 1984 debate with Walter Mondale

          by RJDixon74135 on Mon Dec 31, 2012 at 06:14:06 PM PST

          [ Parent ]

      •  Oh the horror! (0+ / 0-)

        I have to laugh. But it's not funny. Reminds me of Romney talking of the 47%. Those poor impoverished docs on food stamps.

        Shorthand they are 1%ers.

        How big is your personal carbon footprint?

        by ban nock on Tue Jan 01, 2013 at 04:44:45 AM PST

        [ Parent ]

        •  now for some whining (6+ / 0-)

          Most of us aren't close to the 1%. Most aren't in the 2% either. Our salaries start with a 1. "Average" salary statistics are very misleading here, with procedural specialists skewing the numbers. Look for median instead.

          We aren't poor. This is true. And every discussion of it seems whiny. I understand that. Now for some whining:

          We aren't nearly so rich as the general perception, however.

          Also, remember that there is a long period of education previously to getting paid.

          Undergraduate prior to medical school. Then four more years of medical school. And med school isn't like some other schools. In 3rd and 4th year, you are actually working (and paying to do so). Your attendance is mandatory and you will have to repeat your rotation if you miss time. Then 3 years of residency (4 or 5 for some specialties). Then potentially another 1-3 years for fellowship. Only some of these are in the lucrative procedural specialties.

          If I just paid off student loans and didn't spend any money on anything trivial like food or shelter, then it would have taken the first 7 years of my full time work to pay off the loans. And full time for a doc is not normal full time. If you count "on call" time, then the hourly wage was less than $10 an hour during my first five years.

          I would have made considerably more money doing something else.

          I still wouldn't go back and change my choice. It ain't based on the cash though.


          The majority of docs want single payer. Shown in repeated polling. We hate dealing with multiple different insurance companies and not knowing which treatments are covered. We hate having to beg insurance companies to cover things. We hate having to figure out whether something is covered or not rather than whether or not it is the best medical option.

          The plural of anecdote is not data.

          by Skipbidder on Tue Jan 01, 2013 at 11:36:53 AM PST

          [ Parent ]

        •  No, we're not (4+ / 0-)
          Recommended by:
          Skipbidder, Alden, Mr Robert, david78209

          I'm really getting sick and tired of people assuming that I'm rich because I'm a doctor. Between time spent doing research and volunteer work and additional advanced training (absolutely choices I made, but that were involved in getting into and paying for medical school, and now getting the required training in my field), I'm closing in on 40yrs old with a new baby, lots of expenses (inc student loan debt), and a shiny $50k/yr salary in one of the most expensive areas of the country. My car is 12yrs old.

          I'm not poor, no. But a 1%-er?? Neither I nor most of the other docs I know are anywhere near that category. Someone is getting rich on health care but for the most part it isn't the practitioners: it's the insurance and pharma companies.

      •  Forgot Malpractice Insurance (1+ / 0-)
        Recommended by:

        Probably the biggest - and a dire situation that will reduce the number of licensed physicians in this county more than any other costs.

        Because incompetent doctors are protected by medical boards - raising insurance for everyone.

        If not us ... who? If not here ... where? If not now ... when?

        by RUNDOWN on Tue Jan 01, 2013 at 10:06:20 AM PST

        [ Parent ]

      •  How about if we forgive the debt of all doctors (2+ / 0-)
        Recommended by:
        my pet rock, Alden

        that spend the first 10 years of their practice on Medicare patients.  Would that help?

        •  That would be a start, except for the other (0+ / 0-)

          licensed practitioners (Nurse Practitioners, Naturopathic Doctors, Doctor Assistants, some Chiropractors) who are NOT in the medicare system.  And the AMA is fighting tooth and nail to keep them out of the medicare system, and reducing their patient load of medicare patients because it isn't worth the cost.  

          All of the ones I mentioned above are not in the medicare system and a lot of them would like to be in it.

          "Death is the winner in any war." - Nightwish/Imaginareum/Song of myself.

          by doingbusinessas on Wed Jan 02, 2013 at 11:00:33 AM PST

          [ Parent ]

      •  you don't need all that to start off (0+ / 0-)

        and a new doc can buy a practice which has the equipment and even staff. But your partner seems to want to perpetuate the old inefficient ways. The problem is that wasting money and time with excesses as you spell out does not lead to good care. It gets in the way of it.

        You can get an excellent EMR program free from the VA and the government has grants for getting it set up or even buying one and customizing it. And most doctors use the medical labs for tests; they are so automated that the cost per test  is lower than a single office can do it.

        But there are a lot of surveys and studies of doctors incomes and the average for primary care doctors runs between $180k to $220k per year. That's take home.

        And that includes doctors who take Medicare patients.

        Why on earth does he want to practice alone?

        I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

        by samddobermann on Tue Jan 08, 2013 at 03:41:39 AM PST

        [ Parent ]

  •  You might also write letters (17+ / 0-) your medical colleagues who are Republicans, who are part of the reason that Medicare has such a cost fetish.  And the Republican specialist members of Congress who make sure that primary care physicians always get the cuts and their inflated fees never do.

    Given the fact that folks on unemployment are getting their entire income at the moment taken away, physicians who complain that they can't see Medicare patients because they are not paid enough is one of the lesser issues in the cliff.  And only affect Medicare patients because the medical community uses it as political leverage to keep the US medical costs the highest per capita in the world, with poorer outcomes.

    50 states, 210 media market, 435 Congressional Districts, 3080 counties, 192,480 precincts

    by TarheelDem on Mon Dec 31, 2012 at 03:38:01 PM PST

    •  Yes. It was the opposition of the AMA (12+ / 0-)

      that prevented the US from getting a national health system when the rest of the developed world did. Doctors helped to create the US health care mess, even if in more recent times the greed of the insurance industry has become a bigger factor than the greed of the AMA.

      •  That's not accurate or fair. (2+ / 0-)
        Recommended by:
        frostbite, Lujane

        I worked for doctors in the '70's (primarily). At that time, doctor office visits were reasonable, and most people didn't fear seeing a doctor because of the cost. Doctors started raising their fees when malpractice insurance skyrocketed. Then, since it cost so much to see a doctor, people expected the doctors to never make mistakes, and sued more often. You see where this is going.

        •  lawsuits aren't the problem. (9+ / 0-)

          Stupid investments by poorly regulated insurance companies are the cause of high malpractice insurance premiums.  and next time I see a poverty-stricken doctor I'll let you know.

          •  Correct: no reduction in rates in 'tort deform' (5+ / 0-)

            states despite legislating malpractice out of effective existance in most cases.  In Texas, few lawyers will take such cases unless the victim is very young or very welathy bc they can't fund the litigation due to all non-economic (lost wages basically) being capped at amounts below the cost of preparing a case for possible trial, let alone actual trial.  Yet, malpractice rates continue to rise at roughly similar rates (adjusted for overall inflation etc.) irrc.

            One study:

        •  The AMA opposed the creation of Medicare (6+ / 0-)

          and Medicaid in the 1960s. And they opposed to anything like the British or Canadian systems in the US. Their opposition was purely about keeping up the incomes of doctors: they were against any form of government cost containment back then, because the costs of health care mostly went into their pockets.

          Eventually, corporations rebelled against paying these costs for their employees, so Ronald Reagan handed the reins of health care over to insurance companies. Now most of the cost of health care goes into the pockets of the insurance companies, and doctors, though still generally well paid, are no longer in charge of the system.

          •  just as a reminder (2+ / 0-)
            Recommended by:
            Alden, david78209

            most physicians working today are NOT members of the AMA. I'm not, and neither are most of the docs I work with.

            •  AMA doesn't represent me either (3+ / 0-)
              Recommended by:
              Alden, mudfud27, david78209

              The membership percentage is in the 15-20% range. They'd already lost much of their liberal membership. They lost some of their more conservative members recently over their support for ACA.

              Membership number is heavily inflated by the non-issue oriented memberships as well.

              The AMA very heavily recruits medical student members. They offer educational products that are valuable to medical students, and they bundle these into membership. It was considerably cheaper to get my essential anatomy textbook (Netter's Atlas) this way.

              For more established docs, they offer insurance products that are (sometimes) cheaper than you can get elsewhere as well.

              I get more junk mail from the AMA than I've ever gotten from anyone else (which is surprising for someone who has been a member of multiple lefty groups and has been a volunteer and donor).

              The AMA is a cross-specialty group, which therefore includes the very richest of doctors, who are in the procedural specialties. The salaries and trend in political outlooks tends to differ between these doctors and primary care docs and those in cognitive specialties. Neither set of doctors is monolithic in belief of course.

              I care much more about what the specialty organizations say. The largest specialty organization (the American College of Physicians, which is the group for internal medicine doctors) is on record as supporting single payer, for example.

              The plural of anecdote is not data.

              by Skipbidder on Wed Jan 02, 2013 at 09:03:05 AM PST

              [ Parent ]

              •  I've never been an AMA member, and I still get (0+ / 0-)

                a lot of junk mail from them.  They get my address from the county medical society and the state medical association, which I joined over 30 years ago.  
                I'm probably going to quit those organizations -- what they do doesn't come close to justifying the dues they charge.  The one thing that held me back for years was that I had life insurance through them.  Recently I got other (cheaper) life insurance so I'm just about out of any reason to pay almost $800 a year in combined state and county dues.

                Years ago I seriously considered telling the AMA that I'd died.  Men are (still) supposed to stay registered for the draft from ages 18 through 25, but the government wanted to keep doctors registered to age 50, so they could draft some if there were a big war.  The AMA made a deal, offering to make available its fairly comprehensive list of names and addresses of all the doctors in the country, in exchange for doctors not having to stay registered and presumably carry a draft card.  I might have tried it, but at the time I wanted to stay in the county and state organizations, so I didn't think I'd get away with it.

                We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

                by david78209 on Wed Jan 02, 2013 at 06:11:11 PM PST

                [ Parent ]

        •  They could have had sane malpractice coverage (2+ / 0-)
          Recommended by:
          Lujane, divineorder

          under a system like the British NHS, but they opposed that out of greed.

        •  Tort reform has been passed (2+ / 0-)
          Recommended by:
          radarlady, afisher

          in Texas. Not surprisingly, the cost of health care has continued to rise, at the same rate as the rest of the country.
          Even the cost of malpractice insurance has gone up, though not at the rate of previous years.
          In short, Texas removed the right to sue for pain and suffering to help insurance companies- not doctors or patients.

          In 2003, Texas voters approved Proposition 12, tort reform which capped medical malpractice payouts and made it more difficult for patients to sue hospitals. Republican politicians, led by Gov. Rick Perry (R), claimed that doctors were providing less services to patients because they feared getting sued. Republicans, joined by a “Yes on 12” campaign funded by the health insurance industry, promised that the amendment would lower health care costs and bring an influx of doctors to the state. Since 2003, Republicans nationwide have touted Texas as a model for tort reform.
          Now, a group of researchers studying Texas Medicare spending have found no decrease in doctors’ fees for senior citizens between 2002 and 2009. Medicare payments to doctors rose 1 to 2 percent faster than the rest of the country, Northwestern professor Bernard Black, a researcher on the study, said.
          In urban and high population counties, the study’s authors expected to see lower health care costs stemming from a reduction in medical tests doctors previously used to protect themselves from lawsuits. However, the researchers found no decrease in costs and a slight increase in medical tests performed. “This is not a result we expected,” said Bernard Black, a co-author and a professor at Northwestern University’s Law School and Kellogg School of Management.

          “We are not a nation that says ‘don’t ask, don’t tell.’ We are a nation that says ‘out of many, we are one.’” -Barack Obama

          by skohayes on Tue Jan 01, 2013 at 04:46:39 AM PST

          [ Parent ]

        •  No, sorry, but people are not (0+ / 0-)

          suing more often. In fact the rate of suits is way down. The malpractice insurance companies are running their own scams and charging much higher rates than needed.

          In fact the rate of law suits compared to actual incidence of malpractice (which is more than "a mistake") is shockingly low. Most people, even after horrible situations do not want to go to court.

          Different responses by doctors and hospitals are showing different and better ways to go.

          But it does come down to changing systems and getting rid of bad doctors. In most areas  studies find that a few docs cause most of the suits. In Calif among obstetricians one study showed, 93% of claims were caused by 7% of the doctors.

          I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

          by samddobermann on Tue Jan 08, 2013 at 04:17:01 AM PST

          [ Parent ]

      •  the AMA doesn't represent me (5+ / 0-)

        And the AMA is not representative of doctors in general. Their membership is inflated by the fact that they give members discounts on insurance as well as educational materials for free to medical students and residents (apprentice doctors). These are expensive, and most med students I knew joined. (It was a free Netter's Anatomy Atlas when I joined. I've since unjoined. The Netter's would run you $80 today.)

        The AMA also keeps itself relevant to the discussion based on proprietary control of the coding.

        My real professional society is the American College of Physicians. (I have two other subspecialty societies as well.) The ACP is the largest physician's group for any one specialty.

        The ACP is in favor of single payer. Here's an excerpt of their position paper on universal coverage:

        Recommendation 1a: Provide universal health insurance coverage to assure that all people within the United States have equitable access to appropriate health care without unreasonable financial barriers. Health insurance coverage and benefits should be continuous and not dependent on place of residence or employment status. The ACP further recommends that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

        Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals' freedom to make their own health care choices.
        Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.

        The American College of Physicians agrees that there are really only two options, though they are both government solutions: (1) an efficient, single payer national health program, or (2) a more expensive, administratively complex, inefficient, highly regulated and heavily subsidized fragmented system of a multitude of private plans plus public programs, with means testing and mandates to participate. It doesn't seem like a difficult choice.

        The plural of anecdote is not data.

        by Skipbidder on Tue Jan 01, 2013 at 11:46:08 AM PST

        [ Parent ]

    •  Doctors fee for service is broken. (7+ / 0-)

      Over the past few decades the costs of Doctor visits has gone up out of all reason.  Everybody has high student loans, do teachers in colleges get to pass on the cost of their loans?

      And the idea of liability insurance driving the cost up, doesn't make that much sense.

      Too many anecdotes, all I know is Canada has a working health care system, and we don't.  Insurance, fee for service breaks the system.

      Medicare for all, but the Docs on salary.  Pay off their loans like subsidize the paying off public service workers, forgive after 120 payments.

      •  My Docs are attached to a medical school so they (1+ / 0-)
        Recommended by:

        teach as well as work in their clinic. Regular Doc visit $150 specialist $300 - $500. Seriously who can afford those costs?

        The work goes on, the cause endures, the hope still lives and the dreams shall never die. ~ Edward M. (Ted) Kennedy

        by cherie clark on Tue Jan 01, 2013 at 05:43:30 AM PST

        [ Parent ]

        •  come on. (1+ / 0-)
          Recommended by:

          I also am an MD (MD/PhD) at a university center where I do research as well as work in a clinic as a specialist. We see hard cases, usually 2nd and 3rd opinions. An office visit with me is usually 1hr for a return visit, 2hrs for a new visit. We charge somewhere in the $300 range which would be $150/hr.

          Now I have nothing to do with the billing but I'm told we are actually reimbursed somewhere in the 50% range overall which would be $75/hr, thanks to the vagaries of Medicare billing and private insurance reimbursement.

          The local car mechanic labor rate (no parts) is $90-$110/hr.

          I personally have a salary determined by my department and the NIH research grant that I got for myself, which pays me about $50k/yr after everything is taken out. More senior people up to the dept head make about 2x that (he makes about 4x). Keep in mind that we live in one of the 4 most expensive cities in the country.

          I have no hope of owning a home. I drive a 12 yr old car. I still have student loan debt. I just fed my 1 month old son and I hear they're expensive. I know I'm not poor but I am far from rich here.

          I promise you this: doctor salaries are not the problem with American healthcare on the whole.

          •  You're the face of the system (1+ / 0-)
            Recommended by:

            It's hard for people to differentiate.  They see that they're paying (or someone is paying on their behalf) 10-50x their own hourly wage and they're often getting ambiguous results.  They don't recognize that you're getting at best $25.00/hr by your description while the rest goes elsewhere.  They feel, correctly, that some people in the system are making out like bandits.  They need a human face for their anger and frustration.

            My own doctor has been exceedingly generous with her time, partly because I am an interesting case and partly because I've previously been victimized elsewhere by a fateful series of careless misdiagnoses and failed super-expensive diagnostic procedures and active, unethical (at best) cover-up of those failures.

            But she's an internist and instructor in hospital-affiliated practice and for most patients in the ordinary course of things, her masters bill much more than $150/hr for her and for others in the practice like her.  This is primary care, remember...

            And actually, I can't remember the last time I visited a primary care physician whose effective billing rate was anywhere as low as $150/hr.  It makes me wonder if you work at an ideologically motivated facility that charges less than market rates.

            And of course, as you touch upon without delving into it, there is the obscenity that insurance companies pay a discounted rate even though they are much more trouble to deal with than self-pay patients, and self-pays end up paying ridiculously inflated fees as reward for being less trouble.  Most recently my insurance company (routinely) settled a hospital bill not for the 50% you mention but for less than 25% of what I would have paid if I had been self-pay.

            Ideology is when you have the answers before you know the questions.
            It is what grows into empty spaces where intelligence has died.

            by Alden on Wed Jan 02, 2013 at 10:17:17 AM PST

            [ Parent ]

          •  it isn't the pay for the time. (0+ / 0-)

            It's the number of procedures, particularly those which don't even work or work well.

            I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

            by samddobermann on Tue Jan 08, 2013 at 04:27:33 AM PST

            [ Parent ]

      •  I'd always wished we could have a non-political, (1+ / 0-)
        Recommended by:

        non-partisan audit of where each dollar spent on, say primary care in the US went, then compare it against money spent in Canada, the UK, Japan, Switzerland (which has a system similar to the one we'll have next year) and Scandinavia.  I think we'd learn a lot.

        Lots of people think lots of things.  We think that it gets eaten by insurance companies, and surely much of it does - the number of people who work in insurance is pretty large and it's not just the executives - there are an enormous numbers of claims adjustors, salespeople, phone representatives, and all sorts of other people, and they have to eat too.  Certainly, taking the insurance companies out of the picture cuts down on the number of middlemen, but in the UK, it's not that those jobs don't exist - it's that, with the exception of sales, they're done by the NHS rather than private companies.  Hell, even the NHS does outreach, even if not to the extent that our insurers do.  So, in a perfect world, I'm all for eliminating those middlemen, but I'm cautious about thinking that doing so is some sort of panacea (no pun intended ^_^).

        Of course, the GOP is convinced that it's malpractice lawsuits or insurance, and certainly insurance plays a role - all sorts of professionals have to socialize risk in order to practice their profession - although I suspect that the role of malpractice lawsuits is greatly overstated and, of course, many of those people are actually victims.

        The problem is that I don't think we could actually get that non-partisan, non-political study.  The well on this issue has been polluted for decades.  The closest we've come is some of the CBO scoring that we've gotten on various health law proposals, but that's inadequate.

        The other problem, which the massive, gut-wrenching debate over the ACA didn't really resolve, is that when we talk about medical access in the US, we really have two problems, one of access and one of cost.  I think that the ACA will solve the access issue, although inelegantly.  But I don't think we've adequately addressed the cost issue.  Still, it's a far better win than any prior president has been able to accomplish and solving the access issue is an enormous victory for disabled people; when the story of the ACA is written 50 years from now, I think more ink will be spent on the issue of disability in America then was spilled on it a couple years ago.

        "The first drawback of anger is that it destroys your inner peace; the second is that it distorts your view of reality. If you come to understand that anger is really unhelpful, you can begin to distance yourself from anger." - The Dalai Lama

        by auron renouille on Tue Jan 01, 2013 at 06:12:56 PM PST

        [ Parent ]

  •  The uncertainties & unpredictability of doc fixes (14+ / 0-)

    ...are insane and your concerns are understandable. In a recent past life I was a senior HMO mgr where a staff model was used to pay providers annual salaries, no fee for service for any patients. I can say without a doubt that Medicare was and remains a highly profitable line of business. The financial pressures on small and independent practices can't be denied but despite those hardships and because of the burden of inadequate access to health care and the overall uncontrolled cost spiral, the way most clinical care is delivered today is and must continue to change. It's tragic for all of us that our dysfunctional government is in the way but it's also the only real conduit for positive change - Medicare is the one bright horizon for heath care cost control.

  •  My hospital owns all the local doctors, and it (9+ / 0-)

    gave us a list some time ago of the Medicare Advantage Plans it WOULD accept if the doc fix did not go through and it dropped standard Medicare. I suppose that later this week, if this is not fixed, I will get another letter about that, from the relative safety of my Medicare Advantage plan. Sigh. I wonder if the Rs know about this sort of thing and use stalling on the doc fixes, and on fixing the fix so it actually works, so as to encourage free enterprise by eliminating completely in neighborhoods like mine any access by local patients to standard Medicare.

    And they are threatening to associate with a Catholic hospital group so there goes by the choice of others my rights to make my own medical decisions if inconsistent with Catholic teaching.

  •  I'm glad you treat medicare patients, I only wish (10+ / 0-)

    doctors accepted Medicaid. We should have gone to single provider long ago. You'd be paid a good salary from the government and wouldn't have to worry about running a business, because when a business comes between me and my healthcare I'm always the one who is going to lose.

    25% might seem extreme to you but from my perspective it should be about 75% or more. Medical care needs to come in line with what people pay in other countries and inline with the amount of money people make.

    How big is your personal carbon footprint?

    by ban nock on Mon Dec 31, 2012 at 04:13:41 PM PST

    •  True medical costs need to come down (12+ / 0-)

      but just cutting reimbursement rates to doctors and expecting them to magically make that happen is not a good policy. We need structural changes to our healthcare system and insurance system, to reduce costs while not damaging patient care. Those changes are complex and politically difficult, and will take time.

      •  When my pay is cut it's not magic (0+ / 0-)

        I choose to work and make money or not to work and make no money. Doctors are businesses, very very very profitable ones.

        I can fly half way around the world and get twice the quality at a quarter the cost. It's not rocket science. We got the insurance companies with the OFA, next is pharma and providers.

        How big is your personal carbon footprint?

        by ban nock on Tue Jan 01, 2013 at 04:40:52 AM PST

        [ Parent ]

        •  Many countries are doing better than we are (5+ / 0-)

          in terms of good care and low cost. Some are just cheaper because salaries and cost of living are lower across the board. But developed countries do it by things like running healthcare on a not-for-profit model (U.K. for example), regulating drug prices,, and following best practices that weed out procedures and tests that add cost without a health benefit. That is all possible but not easy in the U.S.

          •  all true (0+ / 0-)

            plus guns and butter which US has these choices

            Coriolis Effect: a plane headed from Miami (where the Earth's rotation is more pronounced) to New York would end up in the Atlantic Ocean if the pilot ignored the effects of the Earth's rotation.

            by anyname on Tue Jan 01, 2013 at 02:09:38 PM PST

            [ Parent ]

          •  Yeah, I think people understate that last issue. (1+ / 0-)
            Recommended by:

            Tell people that they can't have (x) care or (y) test because it costs too much and even progressives will scream about death panels.

            When I had unusual and, it turned out, unexplainable ear problems a few years ago, I was sent for numerous tests, probably a half-dozen non-invasive CT and electrical studies (the proper term is escaping me, but they basically hooked me up to a bunch of wires to see if things worked correctly).

            I later learned that those tests were to rule out brain cancer.  Thankfully, my PCP and the ENT specialist that my PCP sent me to did me the mercy of not telling me that the tests were not of my ear but instead of my brain stem, so thankfully I didn't spend three weeks contemplating death.

            Did I need those tests?  I'm not sure, but I harbor doubts.  But how would Americans react when their doctors told them that they couldn't be screened for brain cancer because a pencil-pusher told them that those tests for their symptoms flunked a cost-benefit analysis?  Not well.  Not well at all.  In fact, I believe that the single strongest argument against ACA was the claim (largely false) that people in single-payer nations die on waiting lists for necessary surgeries.

            Getting the kind of reasonably-priced care that is provided in Canada and the UK will require more than legislation - it'll require a real shift in how we think as patients.

            "The first drawback of anger is that it destroys your inner peace; the second is that it distorts your view of reality. If you come to understand that anger is really unhelpful, you can begin to distance yourself from anger." - The Dalai Lama

            by auron renouille on Tue Jan 01, 2013 at 06:23:18 PM PST

            [ Parent ]

            •  routine prostrate cancer screening (2+ / 0-)
              Recommended by:
              auron renouille, david78209

              is the best example: it is now considered unnecessary. First problem is, it isn't very accurate in determining if you have cancer. Second, even if you do have early stage cancer, many of the treatments for that can be more hazardous to your health than the cancer. So even if it seems counter-intuitive not to test, the studies show that it is fact a best practice.

              •  I read, probably in the NYT or somewhere, that (1+ / 0-)
                Recommended by:

                there had been pretty significant patient backlash to that change in the standard of care.  Suppose that's a microcosm of the mindsets we'll need to change to really address the cost side of the equation.

                "The first drawback of anger is that it destroys your inner peace; the second is that it distorts your view of reality. If you come to understand that anger is really unhelpful, you can begin to distance yourself from anger." - The Dalai Lama

                by auron renouille on Tue Jan 01, 2013 at 06:37:09 PM PST

                [ Parent ]

            •  right you are (1+ / 0-)
              Recommended by:

              Other countries ration care rationally.  We do it economically, those without insurance go without care.  You cannot control health care costs without rationing services.  Americans, including those bashing doctors on this thread, are very likely to be unhappy when their own wishes for services are denied because they are deemed unnecessary.  It might have to be that way, but you have to be careful what you wish for.

            •  Those tests you had, auron renouille, might well (0+ / 0-)

              have been ones that you wouldn't get in most countries.  Brain stem tumors are pretty rare, while ear problems are common if you include ringing in the ears and 'true' vertigo where you feel like you're spinning.  

              I generally tell patients over 70 who have those symptoms that the fancy tests usually don't even give us an answer you can hang your hat on, and that I've never seen an, "Oh my gosh, it's a good thing we looked and did all these tests!" situation in anyone in that age group.  So in what seem to be typical cases, I encourage the patient to take something like dramamine

              If your symptoms were not typical of ringing in the ears or vertigo, auron renouille, or if you aren't up in years, I wouldn't have the confidence to tell you that spiel.  I'd probably send you to a neurologist and/or an ENT doctor.

              We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

              by david78209 on Wed Jan 02, 2013 at 06:29:40 PM PST

              [ Parent ]

        •  no. (1+ / 0-)
          Recommended by:

          "Doctors are businesses, very very very profitable ones."

          Actually most individual practices struggle to break even, and lose money on some Medicare and most Medicaid patients. A few procedure or imaging-based specialist practices are very profitable, usually by owning the dialysis or MRI machines, etc.

          I believe one aspect of the ACA is to make Medicaid reimbursement more similar to Medicare, which should help those patients get better access.

      •  One of my coworkers (2+ / 0-)
        Recommended by:
        Cartoon Messiah, Zinman

        is in Costa Rica right now getting extensive dental work done over the holidays.

        The cost? About 1/3 the US even including the trip, hotel, food, etc he is getting the work done by a US trained dental surgeon, a few days in the recovery area they have (nice, clean, nurses, etc). The best modern equipment - all in all a very (as much as dental work can be) pleasant experience.

        Doctor trained in the US and a specialist in the procedure.

        Politics is the entertainment branch of industry. Frank Zappa

        by Da Rock on Tue Jan 01, 2013 at 09:51:22 AM PST

        [ Parent ]

    •  I think "Obamacare" will raise what Medicaid pays (3+ / 0-)
      Recommended by:
      earicicle, Lujane, ban nock

      to be the same that Medicare pays.  That will probably get many more doctors to accept Medicaid.  

      We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

      by david78209 on Mon Dec 31, 2012 at 08:23:15 PM PST

      [ Parent ]

      •  I know but long term I think it's just contributin (1+ / 0-)
        Recommended by:

        g to the problem. "providers" including doctors as small businesses, groups of doctors, small private hospitals, and large corporate hospital groups are all for profit entities, and as such they have making money as a goal. That's never going to work out well for me.

        How big is your personal carbon footprint?

        by ban nock on Tue Jan 01, 2013 at 04:37:55 AM PST

        [ Parent ]

        •  I tell you what I told my Republican (1+ / 0-)
          Recommended by:
          Cartoon Messiah

          brother that bitched about how much a teacher makes:

          You go get your medical license and set up a clinic and then get back to us.

          Expose the lies. Fight for the truth. Push progressive politics. Save our planet. Health care is a right, not a privilege.

          by lighttheway on Tue Jan 01, 2013 at 10:35:13 AM PST

          [ Parent ]

      •  Is that in all states, or only in states that (0+ / 0-)

        accept the expansion?  My state has indicated refusal of the expansion and I'm awaiting a decision from the state we seem likely to move to, although the noise coming from its government is that acceptance of the expansion is likely, although a formal decision has yet to be made.  Still, nothing is certain until it's done.

        "The first drawback of anger is that it destroys your inner peace; the second is that it distorts your view of reality. If you come to understand that anger is really unhelpful, you can begin to distance yourself from anger." - The Dalai Lama

        by auron renouille on Tue Jan 01, 2013 at 07:40:00 PM PST

        [ Parent ]

    •  In my metro area, finding providers that take (1+ / 0-)
      Recommended by:

      medicaid is not difficult, although finding a primary care provider that took medicare for my grandmother was an enormous challenge.  She did not have serious difficulties finding specialists, however.

      I have a suspicion that this issue varies greatly by geography but really have no data to back this up.  Would be interested to learn what studies, if any, have to say about this.

      "The first drawback of anger is that it destroys your inner peace; the second is that it distorts your view of reality. If you come to understand that anger is really unhelpful, you can begin to distance yourself from anger." - The Dalai Lama

      by auron renouille on Tue Jan 01, 2013 at 06:16:04 PM PST

      [ Parent ]

  •  Thank you author for the job you do (8+ / 0-)

    Indeed, our parents and grandparents as well as ourselves someday, thank you and so many others for your caring and deep sense of duty.   You take your oath seriously and it is disgusting that these idiots in the tea party cannot. Alas, this is just another brick in the wall of what has been going on for far too long.  This needs to change or how can you keep the doors open.

    Maybe, you just answered your question though.  Maybe a call to the streets by the elderly is what is needed to kick these knuckleheads in the balls to get their attention.

  •  While educating people about this (4+ / 0-)

    don't forget to mention that most large hostpitals, regardless of public or private status, get the majority of their funding from various government sources.

    I found that out when working on a financial system for one of MN's largest hospital systems.

    So these kinds of cuts can go two ways. Yes, some doctors can opt out, but a major hospital in a core city really can't afford to opt out. But with enough cuts, could they afford to opt in, either?

    I fear another decade of hospital closures if we don't figure this out.

  •  Time for a new Gray Panthers. (8+ / 0-)

    Nothing like a bunch of old people, with nothing but time to make their congresscritters crazy, to begin a revolt. I don't know what I'd do if my doctor wouldn't see me. I would absolutely attempt to drive my congresscritters crazy.

  •  I have an uncommon doctor (10+ / 0-)

    An Indian woman  in a small one doctor office, serving mostly Medicaid & Medicare patients. Her office is never packed - it only seats about ten;  one is generally seen promptly. She explains things. She's also an attending physician at the hospital (where I met her ), serves several nursing homes. She is the opposite of the Medicare/Medicare LLC mills clustered in medical office buildings around the hospital. She also clearly wants her independence & trusts herself.  I would hate to lose her.

    "There ain't no sanity clause." Chico Marx

    by DJ Rix on Mon Dec 31, 2012 at 05:44:50 PM PST

  •  I read that Medicare/Medicaid is 50% of the US (5+ / 0-)

    health care system. It's simply too big to let it fail.

  •  ideas: Single Payer Medicare 4 (6+ / 0-)

    Let CMS negotiate for lowest possible pharmaceutical drug prices. The same way the VA and other saner nations do for their constituents.

    With loser cost of care and administration, our docs, RNs and other providers can push for better compensation rates.

  •  Let me ask (10+ / 0-)

    you this, as a disabled person (who also got a college education, student loans paid off, and then became disabled) how do you think I should feel about your saying this?  The insurance company and medical system drained me of my savings $30,000.00 because I got slapped with a pre-existing and then all that was left was disability and social security.  If you think I've lived a great life your wrong, really wrong.  Part of what I have is a birth defect, but I tried and achieved getting ahead against the odds.  And when I read diaries like this I often wonder what has happened to the mentality of society let alone the compassion.  My opinion, go ahead and leave.  

    Sadly, life doesn't promise us ribbons and rainbows, and some of us get a bucket of coal, but when people complain about not making enough, it really is a slap in the face to those of us that are disabled and need social security because we are barely hanging on and keeping a roof over our heads.  Perhaps I should just hang it up because I no longer feel welcome in America because I don't make $250,000.00 or more.  Maybe anyone making under six figures should just crawl away so the wealthy don't have to see us anymore.

    I don't want to get HRd but enough is enough and if they cut Medicare and Social Security the bottom line is people will suffer and die.  And for me that is just too upsetting to think about right now.

    "During times of universal deceit, telling the truth becomes a revolution­ary act. " George Orwell

    by zaka1 on Mon Dec 31, 2012 at 08:02:34 PM PST

    •  As of right now (10:27 Central time) it looks like (6+ / 0-)

      it won't happen after all.  In that deal that Biden brokered, Medicare wouldn't get cut, and unemployment insurance continues another year.

      As a practical matter, hospitals would go bankrupt on treating Medicare patients with these cuts before doctors.  Hospitals should be screaming at Congress even more than doctors, and I imagine they are.  

      "Gee, Congressman/Congresswoman, maybe you'd better stay in Washington, near Walter Reed Hospital, because all the hospitals in your home district will be closed."

      Please write to your Congresscritter and include,

      "Enough is enough and if they cut Medicare and Social Security the bottom line is people will suffer and die."

      We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

      by david78209 on Mon Dec 31, 2012 at 08:37:23 PM PST

      [ Parent ]

      •  Please you don't have to instruct (3+ / 0-)
        Recommended by:
        Mike Taylor, Lujane, radarlady

        me, you have no idea how hard I have fought for myself and others as a social worker and with no end in sight.  I've gone right up against VP of hospitals about bills for my patients.  Medicare D was horrible for my patients on Medicaid since it killed their spend downs and being able to get their other meds.  I don't know how many of my dialysis patients died on Medicaid when they couldn't afford Medicare D.   I know of at least two.  It is a losing battle because they just will continue to chip away until there is nothing.  

        Plus all this give us is another year and that is it.  Congress and Senate listen to no one but the big guys and they could give a crap less about the people.  We'll be right back in this mess months from now.  And if you look at the permanent Bush tax break that was given it was for all of them and all of their salaries will now be taxed less than the rest of us.  All of this and they give themselves a raise.  Sorry, I'm seeing nothing but red.  I don't feel relieved at all since I've been hanging overboard by my ankles for the last month and now they've decided to wait a while before throwing me overboard.  Oh joy.

        "During times of universal deceit, telling the truth becomes a revolution­ary act. " George Orwell

        by zaka1 on Mon Dec 31, 2012 at 09:17:38 PM PST

        [ Parent ]

  •  um. no pay cut. deal made. nt (2+ / 0-)
    Recommended by:
    Lujane, david78209
    •  This was posted last night, New Year's eve (1+ / 0-)
      Recommended by:

      and I was optimistic then, just as edrie was.
      Now, early evening of New Year's Day, we're all waiting to see if the Tea Party faction of the GOP will snatch failure from the jaws of compromise (albeit, ugly compromise).

      We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

      by david78209 on Tue Jan 01, 2013 at 03:19:45 PM PST

      [ Parent ]

  •  I was on a team that developed one of (6+ / 0-)

    the first Medicare systems. This system soon became the most widely used Medicare system, and within a few years was used by various Medicare administrators to process Medicare claims in more than forty states. That same  system served as the foundation for the most widely used Medicaid system as well.

    One of my Medicare responsibilities was to devise ways to detect possible fraudulent claims. We found plenty of them. It was amazing to me how quickly utilization jumped. There were several  data bases that were available that showed utilization data by diagnosis. These data bases were regional mostly but they were significant. CA, TX, OH, and MN had solid data. Utilization went up across the board. I worked with panels of physicians to help us understand the significance of these data, and after adjustments that satisfied the objections of the most vocal defenders of Medicare practitioners we were still left with the fact that utilization had increased more than could be explained.

    Furthermore, utilization in non-Medicare also began to track Medicare utilization. This was true for Blue plans, private insurers such as Equitable, and for self-insured groups.

    Later, I developed and sold administrative systems for the many companies that materialized when HMO's burst forth. Growth in utilization was even greater than it was in the early days of Medicare. As a result I developed a small profit center to consult with Individual Practice Associations, who were suddenly under water. IPA's would negotiate contracts with various groups of potential patients. The IPA would base its premiums on the utilization of its member providers. But when they started serving patients utilization went up fast. I helped them deal with severe cash flow problems, and some of the meetings with member physicians got quite nasty as the finger-pointing exploded. It was not unusual for the IPA Physicians to agree to 30% reductions in what they had originally billed. There are many complications that arose from this predicament, but this not the place for that discussion.

    Within the last month I bought a new book written by a physician in which he exposes over utilization and competency issues that currently exist in the medical profession. It is thorough and consistent with my decades of experience in helping payers to control their medical expenses. Unfortunately I am traveling right now and I can't remember the name of the book, but the author was interviewed on BookTV within the past month.

    So, even though I have had the good fortune to be treated by wonderful physicians whenever I needed help, and even though there are great inequities in pay for our physicians, it is my opinion that they have brought it on themselves. Over decades I have watched a mixture of outstanding medical practice and medical greed and selfishness which have the damaged the profession.

    All I can say is, "Physician, heal thyself." Your profession has always had it in its power to change things for the better, but you have not. It is not Medicare's fault, it is the fault of the medical profession. If you want to stop serving Medicare patients then do it, but you get no sympathy from me.

    Might and Right are always fighting, in our youth it seems exciting. Right is always nearly winning, Might can hardly keep from grinning. -- Clarence Day

    by hestal on Mon Dec 31, 2012 at 08:46:54 PM PST

  •  You may be better suited for (3+ / 0-)
    Recommended by:
    Lujane, ban nock, divineorder

    the drug company gig. It seems like the wrong types have been attracted into the medical profession. House-calls, pro bono treatment, letting poor patients donate time/bargain for services etc. have all gone the way of the Hippocratic Oath.

    •  Yes ! Exactly (0+ / 0-)

      In my experience, physicians have fallen into two categories .... those who SUPPORTED and BENEFITED from the for-profit structure of the American medical system ... and those who were  too busy treating patients to concern themselves with politics or policy.

      Nice guys and gals ... but,  in their way, ALSO "part of the problem."

  •  I have been trying for over three years to find (1+ / 0-)
    Recommended by:

    out (approximately) how much Medicare is costing the Federal General Fund annually.  At this point in time I’m not sure if it’s costing anything.   I have sent letters to my congress people and to Social Security, but get only cryptic results that do not answer my question.  
       My question is simple. All people on Medicare pay a premium.  How much over and above the amount received as premiums is the Federal Government spending to cover the cost of Medicare?  The answer should be an easy one for officials to answer but apparently it’s not.  If you have the answer or know where I can find it, please let me know.  

  •  wow some of the posts have been not nice (4+ / 0-)

    it seems to be that however bad an individual has it (and some people really do) there is no need to bash doctors as a whole.

    Its like complaining about union workers getting decent benefits--we all need to be lifted up, not brought to the lowest level.

    •  As a person, I like the diarist, as much as one (3+ / 0-)
      Recommended by:
      david78209, Mary Mike, divineorder

      can know or appreciate another through the net or through one post. He's probably a very nice guy. I have two very old friends who are doctors who are also very nice.

      That said us normal Americans are sick, injured, and sometimes die for lack of money to get treated, and in the US doctors make many many times as much money as us normal workers. Normal is not six figures though that is the case here at DK. Median is 40K, so it's pretty normal to make 20K, poverty wages. Normal people can't afford to go to the doctor. I'm sorry if some of the time we seem not nice. We're pissed.

      How big is your personal carbon footprint?

      by ban nock on Tue Jan 01, 2013 at 05:06:42 AM PST

      [ Parent ]

  •  Thank you sir, as one who is on and depends on (3+ / 0-)
    Recommended by:
    radarlady, david78209, Mayfly

    Medicare I thank you for what you did. I think if all Doctors were to do what you did, and all patients on Medicare or soon to be on Medicare, I would hope this would help Congress get the message, but because our Congress, and esp. the House is so **ed up, I don't know if even this, would be enough, but thank you for what you did!

  •  You are wrong and cruel (2+ / 0-)
    Recommended by:
    Mayfly, david78209

    Man I was flying high, prime of my life. Making tons of $$, living large. Working for firm and we are building multi-million buildings in Chicago, all of Michigan and Florida. This was late 80's and early 90's, banking had just been deregulated, the S&L debacle was being dissolved by way of the RTC. Banks were lending. BAM, 1994, Multiple Sclerosis. 1997 left the firm and decided to start my own construction company. 2004 comes and I am now in a wheelchair and took down my shingle.

    2012, my wife works full time in retail, I receive SSDI. I went years before Medicare decided I was disabled and broke enough to qualify. I am utterly dependent on Doc's like you.

    Please protest, please encourage your patients to demand that Social Security and Medicare be left alone. But please remember that people die. You said you are doing well because of your side job. Please don't throw your patients under the bus because you feel cheated..

    "I'm mortified at the thought of anyone judging me on the state of my own toilets. But the tea masters' point is valid: Spaces that have been thoroughly and lovingly cleaned are ultimately more welcoming." - Tadao Ando

    by O Wabi Sabi on Tue Jan 01, 2013 at 12:54:49 PM PST

  •  The bullshit doc fix (1+ / 0-)
    Recommended by:

    I am fucking tired of this bullshit.  Why not change this permanently instead letting it be a yearly football!  Just sick of dc politics right noe.

    "The real wealth of a nation consists of the contributions of its people and nature." -- Rianne Eisler

    by noofsh on Tue Jan 01, 2013 at 02:22:09 PM PST

  •  I really don't think the GOP and the Tea (1+ / 0-)
    Recommended by:

    Party have any idea how our government works. They only wear their ideological binders and make their decisions accordingly without regard to the everyday workings of our government.

    “You must be the change you wish to see in the world.” --Gandhi:

    by smokey545 on Tue Jan 01, 2013 at 02:50:43 PM PST

  •  Doctor patch and depletion of trust fund (0+ / 0-)

    You should realize that the only way the part A trust fund lasts until 2024 is that the Medicare Trustees assume an immediate return to the sustainable growth rate -- ie the 26% cut referred to. The trustees have acknowledged that this is "improbable", and give an alternate depletion date of 2017. After the trust fund is depleted, Medicare will pay out only as much as current income covers - ie about a 25% immediate cut at that time. (Parts B and D are funded primarily from general tax revenues and have their own problems.)

    Sorry, there are no good solutions. The solution will involve higher medicare taxes, lower payments to providers, and lower benefits.

    Please note that the doctor patch -- aka kicking the can down the road -- has been bipartisan. The sustainable growth rate level of payments for services has been waived since 2003. The blame for the irresponsibility of Congress is in both parties.

    With all due respect to your profession, David, you and other doctors will have to take less. I agree, you are not in the top 1%. You are in the top 10% and that should be enough.

    •  The cliff deal includes additional revenue (1+ / 0-)
      Recommended by:

      in the form of an additional 0.9% Medicare tax on people with incomes over, I think, the $400,000/$450,000 level. I'm not sure if it's on earned income or all income.

      In any event, it is additional revenue to help Medicare solvency.

      I suspect we may see higher premiums for upper-income Medicare participants -- they're already a bit higher but will likely go up.

  •  nothing on the failed oil rig? (0+ / 0-)

    Oh well, guess it isn't important.

    •  why would it be in this diary? (1+ / 0-)
      Recommended by:

      This isn't an open thread...

      "When a nation goes down, or a society perishes, one condition may always be found; they forgot where they came from. They lost sight of what had brought them along." --Carl Sandburg

      by Mote Dai on Tue Jan 01, 2013 at 11:09:54 PM PST

      [ Parent ]

  •  (Congress has already screwed something ELSE (0+ / 0-)

    about MEdicare up. There is some bill the House? has not voted on that has cause Medicare to change how it funds out patient physical therapy provided by a hospital. My PT will have to discharge me with a half-rehabed injury--likely to relapse---because of this change. She said they are waiting on the passage of the bill...unitl then we have absolute yearly limit for PT. Does anyone know what this bill is--maybe a Medicaid funding bill of some kind).

    I may end up with a permanant disabilty becasue of this I am told. Sucks. Yet normal for some other insurances (absolute yearly cap on visits).

  •  A follow-up email to my Congressman (0+ / 0-)
    Congratulations on joining the majority in the House of Representatives that voted to do something sensible.

    Well, mild congratulations.  Congress managed to avoid a self-inflicted wound.  If you were aiming for your foot, congratulations on missing.

    I was mildly gratified to read that my Congressman, Lamar Smith, voted for the Senate bill even though he's a member of the Tea Party caucus.

    Kicking the can down the road is better than kicking the bucket.

    We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

    by david78209 on Wed Jan 02, 2013 at 07:12:58 AM PST

  •  The fix is part of the "fiscal cliff" bill. (0+ / 0-)
  •  Some practice medicine ... some push drugs (0+ / 0-)

    Some run for office

    Some shill for those who do.

    Why don't you figure out which you'd like to do ... then get back to us ?

  •  I see where once again today, rather than fixing (0+ / 0-)

    this ongoing problem, Congress put a temporary band aid of it until next year again. What a surpirse!

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