Cut Medicare Payments for doctors, you'll have fewer doctors

Very serious business...

I don't think it will hurt the Dr's as much....
as it will Medicare recipients. At best they will just quit accepting Medicare which means that the patient has to find a new Dr or possibly file their own claims, and pay the balance Medicare consider over usual, customary and reasonable. It will affect the those on disability and retirement the hardest - and this age group has the hardest time understanding why - especially when they are use to Dr's accepting Medicare assignment. And of course it will come and bite us on the a$$ eventually - It gets so depressing. I just want to throw up my hands and walk away...where to though?

Re: I don't think it will hurt the Dr's as much....


One serious result will be the severe polaization of medical care. The rich can pick and choose, while the poor will be left with whatever is left over ( for better or worse...).

This is what is really bad...

What sort of payments do we have to cut to have fewer lawyers?

Would fewer doctors be a bad thing?

What do you call the person who graduates last in the class from medical school? "Doctor"

Only if you're sick and no one will care for your medical problem.

Lots of doctors doesn't ensure that someone will care for my medical problem.

Cold cash can solve many a problem...

For years, only the best and the brightest were even able to get in to medical school. In order to be a doctor, a young person had to study for many years, usually putting herself into heavy debt, before beginning to earn a good salary.

As Medicare cuts payments to doctors, and the HMOs control doctors to a great extent, the profession, as a result, will attract fewer and fewer top notch students. Over time, there will be more people who need excellent care, with fewer doctors to provide that care. You may see many people in medical school in the future, who would not have been admitted years ago.

Even today, I see a trend that I find disturbing. In the last decade, I have observed that many doctors are hiring nurse practitioners and physician's assistants. Many people find that instead of seeing the doctor, they get to see the nurse, or the p.a. The doctor, who is signing off on the medical forms, gets to receive the same amount of payment that he would hasve gotten had he provided the service, while paying the nurse or p.a. at a far lower rate.

Interestingly enough, I have heard many positive things about nurse practitioners, and pa.s. They have more time than the doctor to really listen to the patients. Problem is, that they are NOT as well trained as the doctor. Besides, you are paying to see a DOCTOR, not an assistant.

With 40% of MDs not taking Medicare patients, in the near future, it's obvious that new laws will be needed.

It's been suggested elsewhere, that those MDs who used Federal loan money to finance their medical education ( 8+ years ), be required to take all Medicare patients who seek them out for care.

That sounds fair enough. As they say, "The man who pays the piper, calls the tune"!

If a law like that goes into effect, I wonder how many med students will avoid the federal loan system to avoid being obliged to take in Medicare patients? Hmmm.................If it happens, there might spring up an entire new industry, private loan companies who specialize in medical school loans.

What's surprising is how many MDs try to avoid paying off their loans.

Well, that does seem to make sense. If you pay doctors more money, you will attract more people to that profession.

However, if you look at various countries, you will notice that American doctors already earn more than doctors in virtually any other country:




Now, that would suggest that the US should have more medical personnel than countries where doctors make a fraction of that. But in fact, this is a result of comparing OECD countries:





Now let's look at the situation in Germany, where doctors make only a fifth of what doctors earn in the United States:

Tuesday, July 31, 2007
Do American Doctors Make Too Much Money?

Many approaches have been advanced to lower the American health costs. These include,

•Introducing a single payer system.

•Forcing cuts in prescription drug prices

•Eliminating insurance company profits

Now American liberals, academicians, think-tank leaders, and reformers have added a new twists: Reduce American physicians incomes by not paying so much for procedures and by placing doctors on salaries.
Here are a few critics' comments, as quoted in a July 29 Sunday NYT piece (Alex Berenson, "Sending Back the Doctor's Bill").

•Dana Goldman, director of health economics, RAND Corporation, on diabetes care, "The doctor is paid to check his feet, they're paid to check his eyes, they're not paid to make sure he goes out and exercises, and really, that may be the most important thing. The whole health system is set up to pay for services that are rendered when the patient, and society is interested in health."

•Peter Bach , M.D., pulmonary specialist at Sloan Kettering and former senior adviser to Medicare and Medicaid, "The problem is the way they are paid. They have to do stuff. They have to do procedures."

•Stephen Zuckerman, MD, health economist at the Urban Institute, "There's not a lot of utilization review or prior authorization. If you're doing the work, you can expect to get paid."

•Alan Gerber, MD, director of the Center for Health Policy at Stanford University, "The United States should move toward paying doctors fixed salaries, plus bonuses based on the health of patients they care for."

In other words, if we could only place doctors on salaries, stop giving them incentives to do procedures, encourage them to provide preventive counseling, and reward them with bonuses for good outcomes, we could "significantly" reduce health costs.

Well, maybe. So far , P4P (pay-for-performance) with small bonuses for meeting quality indicators hasn't consistently produced good outcomes or lowered costs, paying doctors bonuses in the United Kingdom for meeting quality indicators has cost more than projected and has driven the National Health Service more deeply into debt, and the American people don't seem to mind American doctors being well paid, on average $200, 000 to $300, 000 a year, with about $150,000 for primary care doctors, and as much as an average of $400,000 for some specialists. According to a 2004 survey by the British government, European doctors in 2002 averaged $60,000 to $120,000.

How do academic and think tank critics, generally far removed from the clinical frontlines, know what's a fair income for American doctors? They seldom provide details or a thoughtful analysis based on life in America. Do they factor in the cost of living and housing is much greater in the U.S, the relentless 3% annual rise in practice expenses sending, the 5-6% annual rise in college tuitions now running abut $30,000 a year, the average debt of doctors entering practice, now in the neighborhood of $150,000. Besides, American doctors' malpractice rates dwarf those of their European counterparts?

And what about the American culture? Do they know that American patients "expect" to have something concrete done and quickly when they visit a doctor, as small as writing a prescription or as big as having a CT scan or MRI for their bad back or arthritic hip or knee? Are they cognizant most of those participating the American capitalistic society, outside of major corporations, which employ only about 10% of Americans, function on a fee-for-service basis without intervening third parties..

Lastly, is the critics' assertion realistic that U.S. doctors' incomes are a "significant factor" in why American health costs surpass those of Europeans by about 50% .

Let's take some rough numbers. Health costs are now $2.2 trillion in the U.S. About $500 billion of that $2.2 trillion is represented by physician incomes. Now let's say Medicare goes ahead with its 2008 plan to cut doctors' incomes by 10%, and health plans follow in lockstep as they have done in the past.. That would cut $50 billion from the $2.2 trillion, a 2.3% reduction of the total the U.S. spends on health care, a large amount but probably not significant in reducing the health care gap in national health spending.

Medicare lowering of doctors' incomes has consequences. AMA surveys indicate as many as 30% of physicians say will no longer accept Medicare patients if the 10% cut goes through, and if Congress follows through with a 40% reduction over the next five years, the number approaches 50%, and Medicare recipients will have to scramble to find care. Projected lower incomes would likely persuade talented college graduates to enter fields other than medicine and worsen the doctor shortage, estimated to be 50,000 by 2010 and $200,000 by 2020. Why would any bright young person spend 11 to 15 years preparing for a profession in which systematic fee reductions are guaranteed ?

Richard L. Reece, MD
Medinnovationblog

Idealism.

My father called it "divine calling", but our neighbours and friends in this profession certainly agree with you, oe. :wink:

Monday, August 06, 2007
It's my fault that health care is expensive? Uncle Uwe

(Reinhardt) to the rescue!

There was an editorial in last Sunday's New York Times (next to the story on discrepancies in cancer treatment I wrote about) entitled "Sending back the Doctor's bill." which argued that physician compensation was actually the culprit in US healthcare spending. That came as quite a surprise to many of the doctor's I know. Completely missed by the author is both the expense of training physicians and the "opportunity costs" invested in becoming a Doctor by highly educated people in their early twenties.
For sake of comparison I'll use myself as an example:


* Tuition and living expenses during college ~ $150,000

* Tuition and living expenses during medical school ~ $85,000

* Average wage during my intern year in 1998 ~ $5.80 /hour

* Average wage my 8th year in surgical training in 2005 ~ $9.75 /hour

* Spending ages 22-35 in the library or hospital ~ PRICELE$$


It was not rare to have contemporaries owe more then $250,000 in loans during residency that was accumulating interest at 8%+. Despite commanding salaries that sound impressive, many physicians will not be able to retire that debt until well into their 60's.

The wonderful Surgeon's Blog by Sid Schwab touched on this the other day in a post called "Times Two." which is excellent reading. Dr. Schwab is a general surgeon nearing retirement age who writes the most engaging perspective on surgery I've yet to find on the Internet. He writes,

"Working hard for its own sake, striving for excellence without any tangible recognition will be seen in some -- but hardly most-- doctors if they go on a salary. Because, unsurprisingly (or maybe surprisingly, to pundits) that's not how it works in real life. I've been in the military, and I've worked at VA hospitals. Try getting a case on after three p.m. Try getting a lab test or Xray thenabouts. Work another patient into a crowded schedule? Stay through lunch, after hours, come in early? Sorry. That's what ERs are for. If Alex Berenson (the NYT editorialist) is ok with it, so am I. Sleep, I've discovered, can be a pleasant thing."

Back to the NYT..................Princeton University economics profess, Dr. Uwe Reinhardt, pretty much the "go to guy" for health care economic theory responded with a letter that was published today:

In "Sending Back the Doctor's Bill" (Week in Review, July 29), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid.A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.

Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.


Besides, cutting doctors' take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians' practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.


This makes the physicians' collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.


As Dr. Reinhardt points out, the low lying fruit in cost-containment (ie. physician reimbursement) was strip mined by the HMO movement and Medicare over 15 years ago. There is wide-spread disenchantment and lack of job satisfaction among physicians that threatens to split wide open over further aggressive pay cuts. You don't have to be a Nobel prize winning economist to understand the inevitable brain drain and service problems you'd create.

Rob

Posted by Dr. Rob Oliver at 7:32 AM

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