Is there a doctor strike in our future?
Image by Getty Images via Daylife
During the year long slugfest we like to call the healthcare ‘debate’, we’ve pretty much heard it all. Whether it was the secret deals with the pharmaceutical companies and insurance sellers or the government death panels that so desperately wanted to do in granny, it seems that every special interest in the land weighed in like the 600- pound gorilla they are.
Except for one – the doctors.
Sure, they’ve had a word here and there, but they’ve never been a major player in the process despite the fact that without them – there is no process.
Take away the doctors and there isn’t much reason to have a hospital, is there? Take away the doctor’s prescription pen and where does that leave the pharmaceutical companies?
Take away the doctors themselves and we are all in very big trouble.
Yet, as the health care ‘discussion’ devolved from ridiculous to worse, I can never once recall a politician saying, “I know…let’s ask the doctors!” Sure, there are a few ex-physicians in Congress who purport to speak for the physicians of America simply because they used to be one. But then, if these people were such dedicated physicians, why would they have given up so noble a profession for a life of comedy in the Congress
If you require proof of that statement, consider the fact that while Sen. Jim Bunning (M-Ky. – when it comes to Bunning, I believe he belongs to the ‘mashugana party’, thus the designation of “M’) led last month’s fight to block the bill that would extend unemployment benefits and continue to stave off a 21% Medicare pay cut to the nation’s physicians, this month it was Senator Tom Coburn (R-OK) – a physician – who led the effort.
Coburn was more successful than Bunning. As Congress enjoys their holiday break, the doctors who care for our elderly will be celebrating Easter knowing that when they return to their offices tomorrow, they will be paid 21% less for every Medicare patient they see.
While most docs are not yet saying no to Medicare patients as a result of the pay cut, many have re-prioritized their appointment schedules. That means that if a younger person with private health insurance wants an appointment, they will get it over the Medicare patient. With so many physician’s offices already pretty busy, Medicare patients may find themselves perpetually pushed to the bottom of the list, except for cases of emergency.
The 21% pay cut has been long coming – the result of a 1997 formula enacted to control Medicare reimbursement rates for physician care. The formula also affects Tricare, the health care program for the military.
Here’s how it works – the CMS, the government body that controls Medicare, adds up the total expenditures they make in payment to doctors each year. If the expenditures exceed a set rate, cuts are made to the Medicare reimbursement rates for the next year.
The problem is that the law lumps all doctors in together. So, if your doctor is careful about costs, avoids expensive and unnecessary tests, etc., it will do your doctor no good because she will still get the pay cut resulting from physicians who may have been less careful in their practices. Another problem is that the rates set by the CMS may be completely unrealistic.
For the past nine years, the annual expenditures have exceeded the set rate requiring a cut in physician payments the following year. However, each year Congress has voted to delay the cuts, allowing the total to run up to the 21% that has now gone into effect.
While Congress will, hopefully, restore the payments when they return from their break, this time there are some political issues that could get in the way. Permanently doing away with Medicare payment cuts means more budgetary costs to Medicare this year and in years to come. This is why the permanent fix was left out of the health care reform law. The Democrats did not want the costs picked up in the bill’s budget.
Of course, the Republicans know it. We can, therefore, expect that the coming Senate discussion required to reinstate the 21% payment will kick off cries of foul from the GOP.
Should the GOP have their way and continue to block the bill that would restore these payments to physicians, the Medicare system could go into meltdown as the doctors will have been pushed over what is a very thin edge.
How nuts could it get?
This week, a urologist in Central Florida posted a sign on his office door instructing anyone who voted for President Obama to seek care elsewhere.
While most would agree that turning away patients due to their politics does not fit the Normal Rockwell vision of the American physician we used to have, it certainly could be the sign of things to come.
In New Jersey, a group of physicians have filed their own lawsuit against the new health care legislation, claiming that they did so after learning that the majority of New Jersey physicians were strongly against the law.
This could all be adding up to trouble.
While the United States has never suffered a physicians’ strike, we may be testing the limits of how far the doctors can be pushed without beginning to push back.
In the past few months, cardiologists have suffered a 40% reduction in Medicare payment for certain services. Were the 21% payment cut to survive beyond the end of this month, many cardiology offices will cease to remain open.
Consider, for a moment, what happens to our senior citizens when their cardiologist office shuts down. If you think the emergency rooms are a problem now, you truly haven’t seen anything yet.
The physicians do, on one level, have themselves to blame as their lobbying efforts in Washington are abysmal. While the AMA remains the primary lobbying organization for doctors, the membership levels in the organization are at record lows and the clout once born by the AMA is now a shadow of what once was.
Specialties now have their own lobbying organizations, but they are small and appear ill equipped to play the game with the ‘big boys.’
Most physicians will tell you that they are doctors, not politicians- but that argument isn’t going to cut it any longer. If the doctors want to continue to do what they do, they need to get better organized and jump into the political game.
Meanwhile, the Congress may have one last chance to get things straightened out with the physicians.
Let’s hope they don’t blow it. If you thought death panels were a threat granny, wait until you see how granny fares when she can’t get in to see a doctor. You won’t like it. Trust me…I’m a …..no, I’m not. But I’ve sure spent a lot of time with them and I have every expectation I’m going to the doctors again.
I’d like of like them to be there when that moment comes.
Post Your Comment
You must be logged in to post a comment
T/S Members
Log in with your True/Slant account.
Rep. Alan Grayson (D-FL) has filed a complaint with the medical licensing board I believe in Florida over that doctor. I understand doctors may have some issues in the future, especially if we move away from private practice, but they’re also getting a lot of new customers. Doesn’t that balance it out?
By all means, doctors should volunteer to make themselves the bad guys, since the public’s generally positive perception of doctors was a major obstacle to more comprehensive health reform. Physician overbilling is one of the larger drivers of our inflated health care expenditures but the family doctor is largely untouchable, politically.
If doctors decide to line up against the American people, that’s going to make all kinds of better health care reform possible. I hope they do it.
“the family doctor is largely untouchable, politically”
In response to another comment. See in context »Thanks for another of your biting, bummer, negative comments. I continue to live for the day when you actually have something to contribute beyond exhibiting your misery as life being. You know about as much of what life is like for a family doctor as you do about…well, just about anything outside your lab walls.
Your response is incomprehensible. Surely it’s not a matter of serious contention that the American public views doctors in a much better light than they do politicians?
But, hey, you’re so smart, you tell me – in a political showdown between America’s physicians and Congress, who would you expect the American people to side with? Surely it’s not a “biting, bummer” comment to think that Americans like their family doctor more than they like their elected representative?
You’ve made a lot of very personal accusations, but I think what happened here is that you didn’t understand what I was saying and are just too proud to do anything but throw a fit instead of admit it.
In response to another comment. See in context »I will gladly admit that I probably have no idea what you are saying. The quality of your writing is so extraordinary that it rather flies right over the heads of we mere mortals.
So, let’ see if I can diagram it out, very slowly ,of course.
1. You suggest in your first note that, somehow, it was the public’s liking doctors that was a major obstacle to more comprehensive reform.
2.Despite the doctors over-billing, family doctors are, somehow, unassailable politically.
3. Disliking doctors as you do (there’s a shock since you pretty much dislike everyone), you think it is a splendid idea that they do something that will make us dislike them, thereby preventing them from being a political obstacle.
Did I get it right? Is there some shred of positive thought in there that I missed, or is your idea of a ‘positive’ the hope that physicians will self destruct?
I could spend a lot of time explaining to you just how much you’ve got it wrong – how much you completely missed the point of the piece (I’m sure its my lack of ability to communicate yet, somehow, the others seemed to get the point) but I really don’t want to.
At least you managed to get through the comment without calling me stupid – and that’s saying something. But there is still time.
In response to another comment. See in context »I don’t “dislike” doctors; I don’t, in fact, particularly dislike anybody. I don’t see how liking or disliking people is relevant to my argument.
It’s just simply a matter of fact that it would be useful to the American people to reform the American health care system in a way that would be somewhat less generous to doctors at the payment end. (On the other hand I’d be in favor of reforms to the medical education industry, particularly those that wouldn’t put doctors into such ruinous levels of debt.) But the general positive perception of doctors makes doing anything that lowers the payment of doctors politically untenable. They’re untouchable in that regard.
It has nothing to do with “disliking” doctors, though, to suggest that a massive, ideological “doctor strike” – which would last about 30 seconds before the government deployed the National Guard and nationalized all the hospitals, people need health care – would really cut the heart out of that positive perception, and remove an obstacle that prevents tens of thousands from getting the care they need.
It’s not about hating doctors, it’s about caring about my fellow Americans.
Well, naturally. To you, apparently, every political issue comes down to who you’re supposed to like or hate.
In response to another comment. See in context »My classist pov tells me that physicians net a lot of money, more than most. If they want to secure their wealth at the expense of those in need, it’s their choice. But I wouldn’t expect that would be tolerated by the majority — or by law — for very long. Besides, people who are in need can be rather inventive. Maybe we’ll develop an alternative system in which physicians are called in rarely, if at all, and only when nurses and allied health professionals have exhausted their resources.
BUT since you are so fair with most things (mashugana party??? LOL!), I have to put aside my own prejudices and stop to listen to you on this. It’s difficult though.
They make more than most but here is what they spend -
In response to another comment. See in context »4 years of pre -med, 4 years of medical school and a minimum of 2 years as basically unpaid workers in the hospital. By the time they get done with what it takes to become a doctor, most are heavily in debt. Then, it takes years before they build up enough of a practice that they can start to make any real money. And when they do, they have to pay all of these people in their office just to collect from insurance companies and the government. Further, they are the only profession I know that keeps getting a pay cut.
I’m a lawyer. Let’s face it. We could all live (and probably much happier) without lawyers. Can we say the same about doctors?
The doctors i know are very sensitive to utilizing the service of nurses and nurse practicioners in their practices. I’m a huge fan of nurse practicioners. But, they can’t do everything a doctor can, simply because they don’t have as much training.
The average family doctor is making less money than you think – especially after they pay all the costs of being a doctor today.
Yes, they make more than many other people. But (a) they put in lots more time than the rest of us, (b) incurr much more debt than the rest of us to become competent and (c) perform once of the most important services any of us can think of.
We really do need to be more mindful of them and their needs before we find they unavailable to take care of ours.
I do hear you. I respect your POV and your good will toward the medical profession, and especially to the doctors who have taken such good care of you. (I thank them for that, too.) Somehow, though, I don’t believe any of what you describe will matter if physicians really were to strike. It would be tantamount to a death sentence to how many patients? What justifies that? If one believes health care is a right, then no one should be allowed to withhold it. Yes, in the end it probably does mean a new paradigm — new ways of becoming a doctor, new responsibilities and training for allied health professionals, new definitions of how things get done properly. Maybe it’s about time.
In response to another comment. See in context »long hours
In response to another comment. See in context »no mistakes allowed
must be polite
most now work for companies so they have no job security, only average benefits
oh and if your depressed or drinking do you get rehab? no they get fired
As I have posted before, my husband and I went without any form of health insurance for more than 20 years because we couldn’t get it with our jobs, and once the rent and car payments were made (+ all the month-to-month bills that go along with living in this ‘great’ country) we most definitely did not have the $3/4/500 monthly premium health insurance companies wanted.
What changed all that was my husband getting so sick that he was even willing to go to the local VA hospital for care. After ignoring his diabetic symptoms for more than 10 years he is now living a life that is a mere shadow of what it used to be. As you brought out — if we didn’t have doctors that we could go to we would all be in the condition my husband is in — diabetes, congestive heart failure and chronic kidney failure; all because we didn’t have insurance or even a family doctor that we could go to.
There is a part of me that understands why the doctors in this country would go on strike — we all still deserve to live the ‘American Dream’ and I realize how illusory that has become even for doctors. However, the other part of me truly cannot wrap my head around the idea that the very people who are supposed to live the Hippocratic Oath would be able to shut out the very people who need them the most — the truly infirm, and the elderly. I hope there are still a few doctors out there that realize they are needed, and will do whatever they can to help those that are unable to help themselves.
The reasons you note are why doctors have never gone on strike in this country before. Let’s hope it won’t come to that.
In response to another comment. See in context »Thanks for highlighting this important issue. The 21% cut under the SGR (ironically called the Sustainable Growth Rate) is a great example of disastrous government policy. The fact that those who supported the health care bill choose to leave this out because they “didn’t want it on the tab” really exemplifies what is wrong with politicians “fixing” health care finance. The bill would have cost that much more if the fix was in there.
Physicians, by nature, are not drawn to labor union type arrangements or organizations. We are used to taking care of ourselves and working hard for our training and ultimately our livings. We see labor unions as unaligned with this mentality.
The AMA is far from being the “Union” for doctors. Kudos to you for pointing this out. Few practicing doctors are members, and the AMA has its own money generating agenda in its CPT code book sales which generate more than its members’ dues. Unfortunately, the public perception is that AMA represents physicians. Mr. Obama will have you believe this too when he states “the doctors are on board” after AMA endorses his policies. I do not think Mr. Obama is stupid or poorly informed, this leaves intentional misdirection of Americans as the only other option for this statement.
I do not foresee doctors ever being as organized in terms of lobbyists as big drug companies or the hospital associations. There are too many sub-specialties with different needs and goals to get too incredibly organized and aligned. Many of us join our own professional associations and they have Political Action Committees but this represents a school of minnows in the shark tank of Washington lobbyists. We could benefit from a lobbyist for the lobbyists that could try to get consensus when possible from the minnows and represent a larger group.
Going on strike is harsh. Seeing fewer patients whose bills don’t get paid in favor of those whose bills do get paid is simply business. Without these tough decisions, the office can close all together. We can not pretend that medicine is not business.
Physicians make relatively good incomes. There are few professions that deserve it more. How much is too much? Would love to get some of your reader’s opinions on this.
There are no residency training programs that are shorter than three years, to correct one statement in your piece (you stated 4+4+2).
I would point out that while SGR was, indeed, a mistake – because government, like private business, makes mistakes – I don’t know that I would use this mistake a reason that government should not try to better the health care system for all.
In response to another comment. See in context »I also think that you might be using ‘we’ a bit too much. From every poll i’ve seen, the physicians favor the health care reform. Indeed, their beef is not with the reform law, its with the failure to permanently repair the SGR mistake and the overall tendency of the CMS to reduce payment rates based on bad info – like what recently happened to the cardiologists based on a very faulty AMA survey.
You are certainly entitled to your political point of view – and you may or may not be right- but by politicizing the problem taking shots at Obama, this will not solve the problems facing America’s physicians and more than the doctor who wants to turn away those who voted for Obama is solving anything.
The SGR is a mistake that could be fixed tomorrow with the passage of a one page bill rectifying the problem and paying fair market rates for Medicare services. Instead, it has been patched together for too long and the politicians of the day don’t want to fix it because it is seen as politically unpopular.
“I also think that you might be using ‘we’ a bit too much. From every poll i’ve seen, the physicians favor the health care reform. Indeed, their beef is not with the reform law, its with the failure to permanently repair the SGR mistake and the overall tendency of the CMS to reduce payment rates based on bad info”-Rick
No where did I state that physicians do not support the reform bill or reform in general. Do you really read the comments or just make assumptions based on your preconceived ideas about the commentor?
Failure to fix SGR and CMS payments are HUGE errors of omission that could have easily been fixed. Too politically and fiscally expensive though. They risked toppling the bill. I haven’t met a physician yet who thinks a 21% pay cut from Medicare is a good plan. Let’s just hide the cost of that inevitable 21% fix from the real cost of reform and make the bill look better. Then we can pass it later!
I think your piece was about physicians going on strike? Given that I am a physician and work around 400 other physicians who frequently talk about this topic, I think I have a valid perspective.
Finally, I see that politicizing is only OK if the writer agrees with you (see below)but not if they don’t? How do you explain President Obama’s statement that the “doctors are on board” with reference to the AMA’s support of the health care bill? Is he uninformed, simple, or deceptive? I actually like President Obama. It is refreshing to have an intelligent and articulate president. That does not mean that I have to be in his fraternity of Democrats and support his every move. Rational criticism of irrational statements should be considered an important part of the process.
In response to another comment. See in context »gitchigummi — The “simply business” model you use as reason to abandon those in need is intrinsic to our system/culture, I know, but it has no mercy. It is a harsh and twisted kind of darwinism that imo is unconscionable. I don’t know how to make it right, I confess. But it should be made right … I believe that the need for medical care is as basic as the need for unpolluted air and water and adequate nutrition and shelter. If all of us were to accept that, then the arguments over who should or should not be cast out become moot. And we could get on with figuring out how to live in this world responsibly and as equals.
Why must you restate my comment incorrectly? I did not propose “abandoning those in need.”
The point is that if because the revenue is less than the debts for the practice the office closes. This is not a viable business model. Then no patients get seen. I wan to see as many patients as I can safely and effectively see each and every day. I have to buy my office space, supplies, accountants, billing staff, insurance, band-aids, nurses, custodians, medicines, employee benefits etc. on the open free market. You can’t expect me to survive, much less thrive, on 21% less than 80% of the fair market value payment from Medicare.
In response to another comment. See in context »So glad to have the opportunity to talk to someone else who reads Rick Ungar! So many just want to speak directly to him (I among them). But this is a nice change. == So, first, I used quotation marks to indicate which part of your post I was addressing. My interpretation of what you wrote is not in quotes. If my interpretation — no fare, no care — is incorrect, I apologize, but I don’t see how else to interpret your sentence: “Seeing fewer patients whose bills don’t get paid in favor of those whose bills do get paid is simply business.”
However, that said, I completely understand that you have to pay your bills, just like the rest of us. And as another poster remarked here, I also understand that you and I equally have a right to fight for our own American dream. The practical aspects of what Rick — and you, too — are saying, I don’t think anyone can confute. That’s the name of game in the U.S. — at least for now.
My point only is that it strikes me as both ethically and morally wrong to refuse to care. How does that work in a practical world? I’ve attempted to suggest that the current relationship between health-care professionals and patients might need to change — starting with new ways to become a physician (Rick already wrote here about an exchange, for example a free education in return for a commitment to an area in desperate need of a doc). Also, because I work with allied health professionals every day in their capacity as educators and feel deeply that there is a vast untapped potential there, one that could be applied to populations who have no access to health care at all (rural areas and inner cities). But that’s just about as far as I can go with this idea, since my knowledge is limited …
In response to another comment. See in context »Wrote “both ethically and morally wrong to refuse to care.” But meant:
In response to another comment. See in context »“both ethically and morally wrong to refuse to PROVIDE care.”
The fix for the problem of Medicare patients being deprioritized by their doctors is quite simple. It does not involve forcing doctors to see Medicare patients or meet quotas, etc. If Medicare simply paid market rates in line with what private insurers pay for the care then the disincentive to see Medicare patients goes away. It is really that simple.
In response to another comment. See in context »Doctors are not going to go on strike. I have a few freinds that became doctors and they did so for reasons relating to wanting to help people, not for money. However, when I talk to them, most will admit that they are terrible businessmen.
People go to med school to learn that someone comes into their office presenting certain symptoms, so how do you make a diagnosis. They do not go to medical school to earn an accounting degree or an MBA. They decide to hire people to do their books or to farm the work out to outsiders. They almost universally favor the use of business consultants.
The problem is that, in leaving others to handle the business aspect of it, they do not become educated in the most important aspect of their business, which is their business. They are run over by the legal and pharmacuetical industries. The pharma companies are the worst. The outside corporations, which understand the business side of things far more than the medical side of things drive up costs dramatically.
The doctors just leave it to others to handle the business. Now that the costs have risen so high, government programs must cut back. I have dealt with the CMS guidelines, and they are a nightmare. Doctors who are ill equipped to deal with business considerations are most certaintly unequipped to deal with CMS regs.
These doctors just have faith that things will work out, but are unequipped to deal with the various forces at play. They are basically a cripple in a bar fight. I think they will go out of business before they strike, merely because they are in it for their patients. I think most of them will pay the overhead out of their pocket until they are in the poor house before they go out of business.
It is not as insane here as it is in other places, but I beleive that I read from the Kaiser Institute a few years ago (you would be the one to know, so tell me if I am wrong) that in some areas of sourthern California, primary care providers were being paid less for an office visit than the prevailing cost of a large pizza delivered.
I think that medical school should expand to cover some basic business accounting and business courses. As I have previously stated on this blog, I think that the government must step in to fund education so doctors are not a quarter of a million dollars in the whole when they enter the profession. You pay now or pay later. Give the professionals the education and the knowledge they need to operate a substantial business. Otherwise, we will continue as a government and as a society to screw them into nonexistance.
Craig – I very much agree with what you say. And, yes, Medicaid rates come very close to the price of a pizza!
In response to another comment. See in context »Where I might disagree a bit is how doctors might react when they realize they are having trouble running the offices profitably. WHile they are not businessmen, they certainly understand the concept of working all day and losing money! This will breed a reaction.
While I also agree that doctors primarily choose their profession to help people, my point is that we are making it very difficult for them and, at a point, they will have to react – or we will all suffer.
most docs seem to work for hmo’s
i think they should be private, as my accountant works for me, so should my doctor
Actually, no.
In response to another comment. See in context »A lot of doctors are in an HMO network, but they are in business for themselves. The overwhelming majority of doctors in this country are private, however, if low payment persists, they will be forced into jobs as their private practices have a tougher and tougher time turning a profit.
Is all okay? Earthquake news …
I missed it. I was up in Northern California. I’m in LA now and everything is fine. The earthquake was far south in Baja – but, from what I’m told – was felt pretty big in LA. No damage or trouble.
In response to another comment. See in context »Thanks for asking, buddy!
You make a valid point about the cost of becoming a doctor and following that reasoning one can understand why following a specialist course with higher returns and respect rather than a GP makes sense.
The solution to this burden could be pay them more (not really happening under the current system) or change the structure of higher education with reforms to on the ever growing costs of education. Obama took a valuable first step with direct loans and if he can go further with loan incentives for doctors to chose to work as GP’s or to forgive loans to work where work is needed or other out of box ideas. We do need to increase nurse physicians and a program to promote just that would certainly be a big help reliving the workload on GPs but not their bottom line.
None of this helps doctors currently in practice however a more efficient way to manage their administrative costs would perhaps tax relief in doing just that could help. However if we keep private insurers the likelihood of streamlining appears remote.
A strike? The one proposed seems purely political but something else is happening here in California that is not. Lots of doctors appear to already be on strike against Medi-cal. The Venice Family clinic the largest in the country is swamped because payment to doctors have been cut some 40% so doctors are saying no to seeing the poorest with medi-cal. Here in Los Angeles County there is but a handful that are taking new patients and hundreds of practices are sending old patients to the clinics. Hopefully Congress will get the message.
But something needs to be done about payments in the future because cost control is essential.
My brother in law found himself in a hospital and his doctor came in and spent what I considered an unusual amount of time asking questions and getting to know his patient. Turns out he was trained in Norway and I asked what brought him here. He said there are great positives in our system. Namely it paid more, had less taxes then went on to say that Americans were lucky for all the opportunities…in Norway, less so…of course they did get a free education and health care. Free education and health care two out of the big three expenses for the middle class plus it puts all young citizens on equal footing to advance.
That stuck with me… a footnote to someone who is used to it but I guess doctors are paid less there but they have no student debt but instead a social responsibility. Yet the country has one of the highest standards of living in the world and one of the highest tax burdens. It makes you think about what is important in life and if health and knowledge make it to the top ten.
Agreed on all counts.
In response to another comment. See in context »I’ve been pushing for programs that aid people with medical school costs in exchange for medical services to communities in need for a long time.
You are also right about what is happening with Medi-Cal in California. The reason is doctors are now actually losing money on medi-cal patients. That certainly creates problems. This will be eased in a few years as the new healthcare law calls for paying primary care doctors the same rate for Medicaid as they are paid for Medicare. Meanwhile, it is a real crisis in California where I also live. I suspect it is the same elsewhere.
Rick-
I really don’t want to politicize this or sound like I am defending Obama. But when I read;”However, each year Congress has voted to delay the cuts, allowing the total to run up to the 21% that has now gone into effect.” I can’t help but get the impression that this guy has been given the task to clean up all the cans that have been kicked down the road for the past 2 decades.
This subject is a bit over my head, but my questions would be; Had this been dealt with annually, would it had changed anything, or would the outcome had been the same? If the 1997 formula was enacted to control Medicare reimbursement rates for physician care, is the problem that Congress didn’t address the problem?
Not much pisses me off more than people ignoring problems rather than trying to solve them; especially when they are elected or paid to do so. But, I have come to learn: That’s Politics!
Again, sorry for politicizing.
I don’t mind you politicizing because it is a political issue. I also don’t mind you defending Obama as I usually do. Besides, there is nothing about this problem that is Obama’s fault.
In response to another comment. See in context »It has been clear for about 9 years now that the formula that was put in motion in 1997 just doesn’t work. It would have been nice if it had just been done away with years ago, but that just isn’t how Congress operates. While they will probably just kick the can down the road again this year, eventually this will have to be repaired. The truth is, there is really not much Obama can do about it – its a pure Congressional issue. To fix it this year will bring great cries of phoney anger from the GOP – who all know as well as the Dems. that this has to be dealt with. Meantime, it does need to be dealt with or we are gong to have a very serious problem with our senior citizens’ health care.
Not much was said about doctors in the debate like you say, they do work! That’s all TV most of that glamorous type living they show, they put in more hours than almost anyone, those folks work their asses off. Our government likes to put things on the backs of its own, yet they never have a problem providing aid to almost every other country there is.
Pay the doctors, this is the wrong place to chince.
Using the logic of the stimulus, is it good for congress and the president to make a law that pours money into roads and bridges in the name of creating good paying jobs that produce benefits for everyone. Workers benefit. We get new roads. The law even favors US materials and union labor. Spare no expense stimulating the economy and putting people back to work. The owners of those construction companies likely benefit very handily from this stimulus as well. No one is screaming that the construction moguls are getting rich off the stimulus.
Now apply the same logic to health care. There is a huge need for it. Everyone benefits from a healthier, more productive society. Hospital employees, administrators, nurses, aides, pharmacists, custodians, etc all benefit from job security and wages. Somehow we are hung up on this because doctors will get paid more? It does not make one lick of sense.
while they simultaneously slash pay for physicians who provide health care for seniors
The gov. could hire IT types everywhere and end the medicare fraud and make money, I saw that stuff on 60 minutes, yikes.
In response to another comment. See in context »Gitchi has a pretty good point here, no?
In response to another comment. See in context »(grudgingly) Yep, he does.
In response to another comment. See in context »Maybe the federal government should pay 21% less for everything it buys including roads, bridges, tanks, fighter jets, pickup trucks, airline tickets, gasoline, air traffic controllers, prison guards, Border Patrol, ships, helicopters……….?
Could we balance the budget and kill the deficit with this policy?
In response to another comment. See in context »Rick, there are several points I just wanted to share that might be germane as to the “why” of striking. Personally, I would disagree with the idea but it has already been done for a day in WV and Pa because of the exceedingly high malpractice premiums. When they did so, they didn’t stop seeing patients all together. They stopped seeing patients electively and only saw them in urgent or emergent circumstances. This is the most likely scenario and not all docs just packing up shop and saying good luck to you.
I’ll try to organize the various pressures that impact physicians.
1) Medicare cuts are more far reaching than medicare patients and the reimbursement they provide to physicians. Inevitably, insurers will look to those reimbursement rates and often adjust accordingly. In their opinion (rightfully so), why should they pay the physician more than the Government does for the same services.
2) Medicare has only modest compensation for “cost of living”. Physicians in NYC don’t out earn physicians in Dayton, Ohio. If anything they make less. The NYC or other desirable locations like DC, Denver, San Diego, etc are already saturated markets for docs. So, physician groups higher these associates at lower rates and will have longer times to partnerships in those cities. Can you imagine a physician that makes 200k in NYC now taking a 21% cut on his/her medicare patients? This will disproportionately impact physicians in larger cities as a result of cost of living. Also those physician groups also have far more intense competition for contracts as “providers” that they will often accept a percentage of medicare reimbursements in order to be “preferred providers” for different insurance networks. That means that they undercut each other. In smaller cities this is rarely an issue since there are fewer providers and less competition.
3) This will disproportionately impact primary care and lower earning physicians. The average salary for a pediatrician that is just out of training is between 90k-120k. Internists who need to know about the most there is to know about medicine make a whopping 150-250k. One colleague of mine started his “group practice” that required by ins for his patients above and beyond their insurance coverage in order to make it work. They need approximately 1000 patients to sustain a practice and often see a patient every 10 minutes. If these cuts are implemented, you can imagine for their practice to be profitable, they would need to see more patients. The incomes are not as outrageous as some would suppose. In DC, I have several friends who are cardiothoracic surgeons who earn 200k. Keep in mind these are the guys who open your chest, stop your heart, reroute your arteries and then start your heart again. The total surgical time for a 3 vessel bypass is usually 3-3.5 hours. The specialties which do well and could sustain the cuts more readily are neurosurgery, orthopedics, ophthalmology, dermatology, radiology (depends). Oncology has already suffered substantial cuts over the last decade. Once they were making crazy money but no longer. The docs who make extremely good money often own their own equipment and or various other ancillary services that extend the revenue stream of their practice. Currently, physicians rarely make more than 500k (a lot of money to be sure), and those are the specialists who often do far more than the 4+4+3 years of training. It is more like 4+4+3+3 (most internal medicine subspecialties) or 4+4+7+2 (neurosurgery). If they do, then it is more them being owners of a physician group and is not related to their individual billing and collections. IF they are billing more than that, then they are working their asses off.
Example, an electrophysiologist (EP) is a sub-sub-specialty of cardiology. Their training requires 4 years under grad, 4 years med school, 3 years internal medicine, 3-4 years cardiology (some prestigious institutions require that trainees do a year of research – and that’s an easy way for continuous cheap labor) and EP is an additional 1-2 years. A total of 15-17 years of training after high school. If you graduate at age 18, then you’ll be at least 33 when you start your real job as an EP cardiologist.
Similarly, GI-hepatology. 4-4-3-3(4)-2.
I can see why some of those folks might be very upset if their compensation continues to drop.
6) Finally, when considering these factors, it should be important to note that it will become a disincentive for future trainees. Who’d want to go to school for up to 17 years after high school to make 200k?
My numbering was off cuz I deleted some points…..sorry for any confusion.
In response to another comment. See in context »All very good points. And I completely agree that were docs to make their point by ’striking’, they would not turn away emergency situations.
In response to another comment. See in context »Suggestions to pay for physicians training in exchange for work in areas of need are good ones, and these programs already exist. They only work for the few primary care specialties that actually practice in these smaller rural areas. The complex and highly trained sub-sub-specialists do not go work in small or even medium sized towns in rural America. They simply can not sustain a viable practice there for lack of significant numbers of patients to stay current in their fields. These doctors work in large tertiary care centers that are not in “areas of need”. Patients come to them.
Omar’s #2 is not correct. Medicare has a Geographic Conversion factor. The range of payment in my specialty is greater than a 100% difference. A physician in Minot, ND is paid less than half that of one in Miami, NY, or Phoenix per unit of care for the exact same care. Same training, same illness, same treatment, double the pay. These “cost of living factors” are politically weighted more than they are weighted toward some actual difference in cost of living. Maybe we should fly seniors from NY to Minot for their Medicare treatments.
Minnesota’s congressional delegation successfully (sort of) argued that Medicare should scrap this system for one that rewards quality and efficiency. Some congressmen actually fought this idea? Go figure.
Yes, but the sub-sub specialities make very good money, Medicare or not, so I’m not sure they are the issue at hand.
In response to another comment. See in context »Curious what your specialty is…and you are right about the geographic conversion factor. There is some language in the new law designed to deal with this a bit more effectively.
In response to another comment. See in context »I didn’t say it doesn’t exist, I said its “modest”. The conversion for small town USA vs NYC is 2.85 dollars for every dollar. I do not know of ANY such comparable compensation. It isn’t always 2:1 for the wildly different geographic locales. Keep in mind, the ND doctor faces far less competition, particularly for specialists.
Lastly, to the point of legislation about outcomes, I don’t think the resistance is inherently flawed. I am not sure of the motivating reason but I would ask you to consider the following:
Not all patient’s are created equally. If I’m a surgeon, do you think I’d start avoiding complicated cases so that I could have better outcomes? Is a 56 year old with colon cancer, diabetes and high blood pressure the same patient as a 76 year old with colon cancer and no other medical conditions?
How do you view a tertiary care center that takes on “all patients” compared with a solid but not very aggressive community hospital? A city hospital like Cook County in Ill? Why should the university program suffer its reimbursements if it has “worse” outcomes if they are starting with more complex patients? Do you add a complexity scale to adjust those scores like they do for ice skating? Who scores it? Raw, epidemiologic data of morbidity/mortality rarely tells the whole story in medicine. What about a doc providing care in a rural area with epidemic obesity compared with one in downtown Denver with a generally healthier population? Who do you think will have better outcomes? How about a predominantly lower socioeconomic geographic region compared with a higher socioeconomic region? I could go on and on.
The metrics rapidly become extremely complex. That is a reason to temper but not outright reject the idea of good outcomes, but you can bet dollars to doughnuts that physicians will game that system to have better outcomes.
In response to another comment. See in context »gitch,
One other thing, I’m not sure of your specialty either, but I think in those larger cities you face stiffer competition, different costs of living, more difficult times getting on provider lists without “discounting” your services, etc.
I agree with your first point entirely. Not really much to add to that.
Rick, the sub-sub-specialties do make good money, but in the grand scheme of things, they also represent the smallest number of physicians. For example, neurosurgery and radiation oncology are among the smallest of the physician population but make substantial incomes. There are a total of 661,400 physicians total. Internists, pediatricians, ob, psychiatry, anesthesiologists, gen surgeons, family practice and emergency medicine docs made up 67.5% of the total. Of those, anesthesia, ob and surgery are the best paid. These do NOT include the medical and surgical sub-specialties, pathology, radiology, dermatology, radiation oncology, etc. http://www.bls.gov/oco/ocos074.htm
My point is that most of that list are not the “highest” earners and they are disproportionately affected as I mentioned earlier and the “savings” from huge cuts to the specialties has less of an overall impact.
In response to another comment. See in context »[...] Im Laufe des Jahres langen Schlagabtausch wollen wir die Gesundheitsversorgung "nennen Debatte", haben wir so ziemlich alles gehört. Ob es um die heimliche Deals mit den Pharmaunternehmen und Versicherungen Verkäufer oder die Regierung den Tod Platten, die so dringend wollte in Oma zu tun war, so scheint es, dass jeder besondere Interesse für das Land in [gewogen. . . ] URL des Original-Artikel http://trueslant.com/rickungar/2010/04/04/is-there-a-doctor-strike-in-our-future/ [...]