Saturday, March 20, 2010

Toward Black Sunday

From an anonymous question in my comments:
Dr Wes, can you explain how this house vote and recon is going to affect doctors? I note that in a MSNBC article they say they'll increase primary care reimbursments for MediCAl to that of Medicare in 2013,so are they leaving specialists, proceduralists out of this deal? where would the Primary refer the patient if speciali(s)ts don't take the MediCAL? Would this reform have impact on doctors pay? Insur, Drug companies, Hospitals all seem Ok with it's passage.
I have no idea what is going to happen on Sunday when the house bill as amended (thanks to Scott Hensley for this link) is voted on. Like many, I have a son who is a recent college graduate working part-time with no health insurance and an incredibly bleak job market before him. While I can afford insurance for him, it is incredibly expensive. I am sure others are not so fortunate. I would be foolish to say we do not have a serious problem in American health care right now.

But I find it interesting how prescient my post on Our Healthcare Hindenburg appears in retrospect now. We are in crisis, just as predicted. We must act. We have a President who has thrown down the glove to his constituents, and if nothing else, should be admired for his commitment at trying to tackle this seemingly impossible challenge. But behind the President, we also have a group with a political philosophy that thinks nothing of ripping up Mieg's field in Chicago because, well, they can. Like the pilot who tried to land there the day after the carnage, we'll be left to clean up the mess. But if the bill passes, no one will want to touch this. Not Democrats, certainly, fearing the results of the November elections, and certainly not Republicans since they didn't like the bill anyway. Who the hell wants to raise taxes and cut benefits for seniors? Are you crazy?

Doctors, despite our relationship with our patients (which will endure), are really mere pawns at this point. The bill appears to throw some money to support primary care physicians, and that's a good thing. But our "leadership" (as defined, almost comically, as the American Medical Association) has endorsed the bill, even though there is no "doctor fix" for the flawed SGR payment formula to physicians. Why? Because to do so would add $320 billion to the current CBO "scoring" of the bill and take the bill over the dreaded $1 trillion dollar amount. (Funny how $940 billion is okay, though). Thank you, AMA, for taking such a firm stand. All doctors are looking forward to the 21% pay cut and are waiting anxiously to see how the AMA will "hold Congress's feet to the fire."

Meanwhile, more predictions coming true: we have hospitals raising rates at an unprecedented rate just to cover costs, despite (at least here in Chicago) some with near record returns at a time of an unprecedented economic downturn. We have insurers, cranking their rates to new heights, crying foul that hospitals are raising theirs. (How unfair!) We have huge corporate displays from medical device, pharmaceutical, and electronic medical record companies at the American College of Cardiology meeting in Atlanta, standing to gain handsomely with the larger portion of insured coming their way. Certainly we would never want to rain on their profit parade - they're just trying to run a business, based much in part on our government-funded health entitlement programs.

Better to publish, conveniently and just before the vote, the inflated salaries of doctors as told by a recruiting company, so those filthy rich doctors can be further slapped into submission for making too much money. Politically, those salaries are easy pickin's, especially if you compare those salaries to their physician-counterparts overseas (just don't mention what it costs to train and insure those same US doctors).

This is not to say doctors have now had a part in price inflation in health care, they have. But the days of ordering an EKG, stress test, echocardiogram and nuclear scan on every patient who presents with chest pain are over. And rightly so. But in a government-developed system that rewards payments for procedure rather than the time spent with a patient, what did you expect? Wouldn't a time-based system make so much more sense? But alas, that would not be productive in the eyes of the business-savvy health care institutions. More time means fewer patients, so sorry, dear doctor, that won't work - take this lower salary instead.

So what does all this mean for doctors? First, doctors will still be seeing patients Monday after the vote. But the effects of the health care reform efforts have already been felt by today's doctors unwilling to wait until the final shoe drops. More and more doctors are selling their practices and moving to the relatively sheltered environs of a large hospital system who, at least for now, will subsidize their salaries because they generate the patient volume for these health systems. Stalwart doctors not bowing to these health systems are turning to a concierge-style pricing alternatives to compensate for the cuts to payment rates received from insurers and Medicare. For those private practice doctors, this model restores a modicum of realism to health care delivery for both the doctor and the patient and makes sense. Look for it to become the norm as these times press ahead... least until state licensure prerequisites prohibit such concierge payments. Then, if the bill passes, we'll all be government employees, one way or another.



Keith said...


When we we recognise that we are all goverment employees already. Medicare and Medicaid now account for the bulk of medical payment in this country and it is the existence of these programs that have added to the growth of medical treatment as more and more expensive, high tech procedures have been added to the rolls of covered benefits. While primary care docs can go concierge, since they do not depend on insurance to pick up the costs of high tech gadgets and operating room time, specialists are highly dependent upon this system. Just think what life would be like without the Medicare program! Millions of seniors with no insurance to pay for that pacemaker they need installed (I will bet this category is the bulkof your buisiness)

Just as Medicare came into existence year ago because we had older patients that were uninsurable by the private market, we now see the same problem developing for the middle class. Our whole economy has been influenced by the high cost of insurance. Employers try to hire employees on a part time basis to avoid the cost of health insurance, and goverments outsource more and more of their duties since they also get stuck with big health care costs that are being increasingly shed by the private sector. Indiviuals cannot leave their jobs often since their jobs are tethered to their health care coverage. Just like years ago when Medicare was created to deal with the failure of the free market to provide affordable insurance to seniors, we need to recognise that health care does not fit nicely into the Milton Friedman model of the free market and requires a buy in by all: mandates to pay into the system and cost controls to pay for the best value treatments and therapies.

I have insurance currently, but I am scared to think what happens to me and my family if I have an unexpected illness. I lose my income source and still have to pay my huge premiums. My family, including my kids might become uninsured as a result and my insurance company might either drop me, or more likely will jack my premiums to ever higher levels since my health care is costing them more. I always thought insurance meant you paid into a system when you were well so that if things go wrong, you can depend on your insurance to pay the costs. What we have for many is a system that does not meet the definition of insurance. You pay and pay when you are well, but you will likely lose your coverage once you become a significant liability with an illness. Is this insurance as most people understand it?

The time for reform is now, and although the present bill is not perfect, it deals with many of the current problems of the health care market in a realistic and sustainable way.

DrWes said...

The time for reform is now, and although the present bill is not perfect, it deals with many of the current problems of the health care market in a realistic and sustainable way.

... just like our current Medicare and Medicaid entitlements have been sustainable.

Laura said...

" least until state licensure prerequisites prohibit such concierge payments. Then, if the bill passes, we'll all be government employees, one way or another."

A friend of mine has a son in pre-med. He intends to change his major if this passes. His thinking is why incur massive debt in order to become a civil servant? He didn't want to get into medicine "just" for the money but he also doesn't view it as a sort of sacrificial religious avocation. I wonder how many other college students will make the same decision?

Anonymous said...

Thank you Dr Wes for your informative response to my question. I hope Monday will bring some peace whether this passes or not pass, can not bear any more of the rancid politics. Why are 85% doctors mute when AMA which represents 15% of them throwing them under the bus. I wish Physicians took a leadership role and figured a way to reward the efficient doctors. Lack of direction from within is why physicians are suffering and no wonder Govt,Insur are dictating whatever.

Keith said...

And why is it not sustainable? Because we keep addings new drugs, devices, and diagnostic tests, many of which do not add much to improve or sustain health. The other choice is to stick with the private insurance market which sustains itself by throwing sick people under the bus.

Andrew_M_Garland said...

ObamaCare and the Doctor

We should be frightened about the reports of medical care in England, Spain, France, and Japan. But, we don't have to wait for data from ObamaCare. The performance of Medicaid is known now, government healthcare for the poor.

Dr. Zane F. Pollard posted a frightening article describing Medicaid, and by extension ObamaCare.

Medicaid pays for medical services to the poor, and in this case to poor children who face vision impairment or blindness. Regardless, Medicaid denies and delays their care.

Consider that Medicare/caid are intentionally underpaying for the medical care that they mandate, even for the most needy children.

The government is proud of how they are negotiating lower prices for govt healthcare, but they are still going bankrupt with exploding costs.

Anonymous said...

you can get insurance for your son for just over $110 in Ilinois. I know, because I pay for my own insurance. I wish it was tax deductable, however.

Anonymous said...

Keith said...

Placing dollar figures on doctors worth to a hospital just dmonstrats the incestuous rlationship many docs can have with their hospital. What your point anyways anonymous? That doctors can order alot of high tech but often useless stuff that will generate significant income for both?

StorytellERdoc said...

One only needs to go to any ER to find that we are not in a health crisis as much as a cultural crisis. People are spending on luxuries and not necessities, and we are expected to pick up the tab for the necessity coverage. Almost every patient I treat has a nicer cell phone than me...

That being said, no elder or child should be without health care, ever...

November will be interesting.

Anonymous said...

I am a hospital employed physician. I am a family physician and I feel the pressure to generate the revenue, use the right specialists, and earn my keep. When I do my job to the best of mt ability I don't order unnecessary tests, I don't prescribe expensive drugs and I don't make unnecessary referrals. But practicing that way takes time and is a BIG LOSER. To practice medicine the right way I would have to take at least a 50% pay cut. I have two kids approaching college, still owe some on medical school. I hate my job.

D. said...

StorytellERDoc -

You said it.

I am now a cardiac nurse in Illinois. When I decided to go back to school to become a nurse, I worked part-time in an ER.

People simply do NOT believe me when I tell them what many people came in to the ER with for treatment. I am assured by these people who have NEVER provided care to anyone that these people who are coming in with small rashes, head colds, and requests for Viagra that they HAVE to come into the ER because they just can't afford to go to the doctor.

And then, their phone rings.

And out comes a cell phone or other communication device that is spanking brand new and much more costly than the 4 year old cell phone I have.

I am just so angry. Angry that I have to work and pay taxes to take care of people who treat their bodies like crap and then demand that we treat their bodies like a temple AND pay for their treatment.

Anonymous said...


Anonymous said...

Keith, the disparity between doctors' salaries and the revenue they generate for hospitals is atrocious. From a purely economic standpoint, physicians should be paid more.

Dr. Fisher, LOVE your blog--I used to work with you in the EP lab when I was a resident at ENH. Good times, I burned you a country CD for the lab, if you recall...