Physicians

(More) Madness in Massachusetts

Lately I have been watching with complete horror the events playing out in my home state of Massachusetts. A bill currently under review by the state legislature will make participation in the state and federal Medicare/Medicaid programs a condition of medical licensure, effectively making physicians employees of the state.

This is particularly alarming because Massachusetts is essentially a leading indicator of what will happen in the rest of the country. Several years ago the state passed a series of laws mandating health coverage. Like the recently passed national health reform bill, the Massachusetts law did not address any of the well known causes of runaway costs, including tort reform, drug costs, or insurance regulation.

Although the state now has one of the highest percentages of its population insured, it is grappling with exploding healthcare costs. In response, it is imposing capitation schedules, reductions in payment rates and now mandatory participation in the health programs by physicians. What most people don’t understand is that the private insurers are also free to lower their physician payments, based on the Medicare/Medicaid benchmarks. This is all the more concerning given the fact that the Federal reimbursement rate is now scheduled to be reduced 21% on April 15.

We will no doubt see the same sequence of events play out across the country as the current versions of healthcare reform are implemented. The net effect of these laws is that it will make it close to impossible for physicians to stay in private practice. Patient access to physicians will suffer as more and more physicians retire and/or move to different states. For our academic colleagues who think this turn of events can only “help” them because they won’t have to compete with physicians in private practice, just wait. 28 states are now imposing “comparability” laws that allow nurse practitioners and other allied healthcare professionals to work without the supervision of a physicians with equal pay. Few academic departments can avoid hiring “physician extenders” if they want to stay competitive. As this gains momentum, physician payments will be pushed downwards. As the “going rate” goes lower, academic salaries will also get pushed downwards. I knew this reform effort would be bad for the practice of medicine and even worse for patient care. I just had no idea things would deteriorate this fast.

Daniel Palestrant, MD, is the CEO of Sermo.

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57 replies »

  1. Note about NPs:
    Observe carefully the fact that “Dr.” Linda, the NP, feels
    compelled to put no less than SIX (6) titles and credentials after her
    name.
    How incredibly insecure. How blatantly absurd. All the titles after
    your name DO NOT make you a REAL doctor, “Dr.” Linda!
    To be a real doctor who sees patients, go to MEDICAL SCHOOL
    and pass REAL licensing exams for a REAL medical license- the USMLE,
    or even the COMLEX. ALL THE PARTS, LINDA.
    NOT just the easiest part, Linda.
    This is for all the revolting NPs out there trying to glom onto and
    steal titles from the medical profession:
    REAL DOCTORS GO TO REAL MEDICAL SCHOOLS AND DO REAL RESIDENCIES.
    EVEN THE OSTEOPATHIC SCHOOLS ARE FAR MORE HONEST THAN THE
    FRAUD BEING PERPETRATED BY THE NPs THESE DAYS.

  2. I couldn’t agree more. Why wasn’t the point about Massachusetts being an indicator brought about with more emphasis when this national health care bill was being hammered out.
    Massachusetts is certainly not having a walk in the park with their in state health care industry. They have some of the highest insurance premiums in the nation. Why is this being done? If the providers do not want this type of legislation and the insurance companies do not want this type of legislation then who? I can only see one thing: power grab by the federal government…plus this federal government can not afford any more entitlement health care programs…they can’t even afford Medicare!

  3. Thanks for the early validation, Ms GA! You just don’t get it, because you are not a provider and your personal welfare is not at risk, at least not just yet, because your blind faith is just that, it blinds you!

  4. rbar- liked your comment on market forces. I am also very supportive of letting competition manage prices. However we need to understand that this market cannot be completely behave like market for consumers goods. One for the reason that consumer is highly scared and completely unsure about his/her judgement. Second is that seller doesn’t like to talk about price unless it gets below a threshold when the complaining starts.
    Do provider groups of insurance companies do good job of negotiating rates?
    My take around pricing has been that it doesn’t matter if competition forces you to cut price or the provider group of insurance companies or CMS. How could it happen that government induced price cut makes you lose money but competition induced doesn’t?
    The key difference for me is that when retail sellers cut price they get more volume to make up for margins loss and they hope to recoup margins later with market leadership. Unfortunately the tragedy of medical services seller is that they just don’t experience any elasticity. Quality and prices be dammed, they will still get passive patients in their catchment area no matter what.

  5. Interesting reference to flattening of world by Margarit. I looked at US deficit and spending and it was pretty obvious that current spending is untenable. So far the equilibrium was maintained by cutting off uninsured, rescinding and reducing benefits by sly.
    As a proponent of global care aka medical tourism its been my argument that caring in remote place is still humane compared to not caring at all and leaving them to elements.
    My deep psychological studies of consumer behavior 🙂 has led me to understand that there is huge fear and sloth factor. We never do research seeking good cure, best quality doctors, most effective treatments just like we do for retail goods as it is highly time consuming and medical establishment has added huge element of fear.
    Relevance to this article is that we all need to overcome huge mental blocks and do not expect status quo to continue. Patients and doctors alike. Maybe we can take heart in knowing that for a lot of time, mediocre doctors and passive patients thrived as well as quality doctors and active patients in current system.

  6. From your rec. WSJ article: “In fact, the real choice with medical care, as with any good or service, is between rationing via politics and bureaucratic lines or via a competitive market and prices.”
    Exhausted, looking at hospitals in your area with advertising for robotic prostatic surgery, cyber knife and possibly valet parking, do you think that market forces in the insurance system have any effect on prices? You probably could design a price driven competitive system, but then the whole system has to change a LOT more than the changes coming with Obamacare, and most Americans would like it even less.

  7. Dr. Linda M. MPH,MSN,ND,RN,CNC,CTN
    Clearly you illustrate my problems with NPs. Most can’t make a decision and stick to it.
    As for taking Medicaid, it is a political program and as such participating in it is a political decision, not a humanitarian decision or even an ethical decision. If a patient comes to the ED they are seen with no coverage. They are seen at my urgentcare, but they pay for it. At the urgent care we do not accept medicaid as payment, because it is an unnacceptable political program.
    If someone really needs something, I will give it to them.

  8. MD as HELL, whether flattening the world is a good thing or not is a completely different question. I have my own misgivings there. The fact is that it is happening and the currently wealthy countries will have to tighten the belt significantly. It is going to affect us all, with exception of Presidents and tycoons who are really international in nature.
    As to healthcare, anyway you look at it, whether we pay less for each service, or use less services, physicians incomes will decline. My only hope here is that the decline is not blindly across the board. Primary care doctors must be elevated and empowered to practice medicine again, instead of chasing papers and triaging referrals.
    The only reason the NP suggestion is coming up is because Primary Care has been deteriorating to the point where it is questionable if you really need a real doctor to deliver it. I am not sure how much money we will save if we do away with Primary Care as a profession that requires an MD.
    On the other hand I think we could save a bundle if Primary Care is where most medical care is provided. I also think that you will see kids wanting to go in that direction if the prestige is restored and, yes, if the reimbursement is commensurate with the responsibility.
    This NP discussion is a classic case of “penny wise and pound foolish”…

  9. You know what is both fascinating and perverse? Watching another profession, with lesser training and competency, come in and demand access to services and claim levels of skill equal to those of precedence, like the Nursing Practitioner issue discussed above. And then this cheaper substitute drives out the higher skilled provider, because, hey, why pay the higher fee for service when someone cheaper is available, says the insurer. And then, once the substitute provider is entrenched, and providing what becomes less efficient services, then they have the audacity to demand a higher pay scale!
    And physicians should be happy with this scenario?
    You supporters of this health care debacle in progress deserve the consequences that will play out! Drive out medical providers who know what is the committment and expectation to provide medical care to the community. See how efficient and effective the substitutes are.
    And don’t come bitching and moaning to us who left when all you are concerned with is focused about dollars and cents, and not responsibility and sense. Just look what social work did to mental health care these past 15 years.
    But, let’s repeat history, instead of avoiding it!
    By the way, surgeon colleagues, it may take longer to become a reality, but your specialty in medicine will be attacked sooner than you think! After all, technology requires less cutting now. See where that takes things!!!

  10. “given the high relative wages of physicians, it is rather unlikely that modest income cuts will result in a massive exodus from the field of medicine to the field of plumbing.”
    True but don’t you think there could be a mass exodus of older docs to retirement?

  11. I find it interesting that the first thing doctors do when they feel threatened is to take a cheap shot at nursing. The Physician Assistant was the answer to the growing threat and competence of Nurse Practitioners (NP). And why are NPs growing at an alarming rate? Because the NP serves a growing problem of physician vacanies in the rural communities, reservations, and other needed areas where physicians won’t go because they can’t get reimbursed for what they believe is fair medicine. It started in the early 70’s with the demise of “traditional fee-for-service,” doctors were no longer able to take a scapel to the proverbial heart of the community. The growing numbers of under and uninsured are growing by leaps and bounds. I once watched a woman get turned away from a doctor’s office because she was a medicaid patient and the doctor refused to see her. Shame on you! Since when does the “calling,” include picking and choosing which patients you will see based on ability to pay! Patients are starting to see and demand more from this country’s health care system. Alternative health modalities offered by brilliant practitioners who are circumventing the traditional medical model of “treating the disease” and instead are “finding the cause,” is leveling the playing field. Why should I continue to be “medically managed,” by a doctor who is more concerned with his bottom line than finding the cause of my illness and curing it?
    Shame on you doctors! Maybe you should leave the practice and become plummers!

  12. Margalit,
    You assume that getting through this is a good thing. What makes “flattening the world” a desirable thng? The President and his family are in the mountains of North Carolina on vacation as I write this. He is not in the flatlands. Nor did he get here by overland transportation. He flew.
    Spending more resourses on healthcare is a losing proposition, flat or not. It will not add one thing to the future of our country or our economy.
    We need to spend much less overall on all aspects of healthcare.

  13. Actually, I don’t have any problem whatsoever with the high pay of physicians, plumbers, CEOs, actors, or lawyers. Nor do I have a problem if any of these groups loses some of that income when their employers/payers are forced to aggressively cut costs.
    My point is that given the high relative wages of physicians, it is rather unlikely that modest income cuts will result in a massive exodus from the field of medicine to the field of plumbing. And by the way, the mean pay of physicians is still higher than the mean pay of actors, lawyers, and chief executives.

  14. If you want to complain about high pay why don’t we start with Hollywood, do you know what actors make? And if you want to measure value returned for that dollar, yet mainstay liberal professions never seem to get attacked like that. Why are we discussing attorney compensation? Instead it’s insurance CEOs and doctors.

  15. Doctors organizing has been illegal under various federal laws for decades. It is illegal for docs to discuss reimbursement or contracts or fees with each other. We are not to be rewarded for referrals to a particular provider, although a few weeks ago this blog had a thread advocating exactly that, if it was to the cheap provider.
    I brought up plumbing, but I said plumbing contractor, not plumber.

  16. No, rbar, if you read what Paolo wrote that started this sidebar discusssion, he claimed that doctors are the best paid profession in the US and used Vets and plumbers as examples of sizeably underpaid comparisons. And I know that is not true, while these other two are not better compensated than doctors, when you compare apples to apples per the time, expense and energy into the training and then expenses by all three once practicing, there is less the chasm Paolo tries to conclude. But, you add to my expectation of dissenters: “physicians in the US are extremely well paid,…”, well, per who’s perspective?
    People who work in business, labor, and other non-health care professions should be compensated for what they provide to the community if you want to make this claim. And, I know that there are commenters at this site who will continue to strive in nasty efforts to diminish and demean what doctors responsibly provide to the community. We’re all not subspecialty surgeons who skew the income curve. I wish primary care docs and pediatricians could comment and just shut you up!
    Because, as I also said earlier, you the collective blindly supporting this scam by government can’t attack with effectiveness insurers, patients, med tech and pharm companies, and other elements to the health care system that have created the monolith this garbage legislation claims to appropriately impact. And too many of my colleagues are the clueless doormats and thus let this exchange go unchallenged.
    Until now!

  17. What a flood of ridiculous comments … if anyone of the docs (or, bizarrely, Nate) here claims again that physicians are less well paid than a plumber, I will find he link of the recruiter database with the actual averages per specialty.
    Physicians in the US are extremely well paid, and (like anyone else) they are getting upset when working conditions and pay deteriorate, even if it is deteriorating from a very high level.

  18. Paolo how long does a doc spend in school before they can start to earn that money compared to a plumber? It’s like professional athlets, they make huge sums but it is for a very short period of time.
    A plumber can easily work 30+ years and still retire in his 50s, how many doctors can get paid that many years?
    Your biggest mistake was not asking wat they base the hours on.
    “Annual wages have been calculated by multiplying the hourly mean wage by a “year-round, full-time” hours figure of 2,080 hours;”
    How many doctors get away only working 40 hours per week? Plumbers get overtime after forty, doctors get more paperwork
    You also missed this;
    “Estimates do not include self-employed workers.”
    Who do you think the highest paid plumbers are, the guy that just finished his apprentiship or the self employed plumber charging $60+ per hour?

  19. Like that comment Nate, hookers and politicians, but aren’t politicians really hookers, they just wear nicer suits? And they screw you in ways you as the customer really do not enjoy it?
    Paolo and his collective just want to misdirect and confuse those who are looking for truths, and so they will attack doctors as the scapegoats, because ERISA has protected insureres from attack, and let’s be honest, patients won’t take responsibility for their role in some disease origins, like the smokers, poor dietary choices, sedentary lifestyles, and risky behaviors increasing trauma risks and the sequelaes that come with them.
    Congress passed a bill they did not even read, and now claim feigned surprise and confusion how to deal with the consequences. They don’t even know who is covered in federal jobs and who is exempt, but, I think they do, and they do not want us to know!
    But, it is about the party first, isn’t it, collective?
    By the way, vets make better income than what you quote, sir, if they work. I paid $75 cash for my daughter’s guinea pig seen for less than 10 minutes, and while that included some medication and special food, my bet is 70+% was for the visit, so do the math: $50 for 10 minutes, they were others with dogs and a cat there, so seeing 5 pets an hour at 50+ a visit seems to equal $250 an hour. And plumbers making $23 an hour? I don’t believe that. But, since you quote it, it must be fact?
    Displace and distract. Docs have a right to choose what plans they participate in. That is the point of this posting leading the thread. But, per this collective, doctors do not have the right to choice.
    Remember, that is the point of the dissenters, people!

  20. “The average doctor makes a lot more than the average veterinarian or the average plumber.”
    I don’t think this is true at all. If you measure compensation per hour of work over a career they don’t come anywhere close.
    “One reason is that it is the best paid profession in America”
    Hookers and Politicians off the top of my head.

  21. Congrats to Vikram for actually trying to offer solutions instead of just ranting like everyone else.

  22. I thought doctors didn’t care about money. OK, joking. It’s true that majority kmight look at doctor income and not expenses. As such I think it might be a good idea to publish doctor incomes and expenses. Larhe majority might be comfortable with docs earning 100K-300K.
    Anyway since they care about money it might be best left to doctors to come up with solution on how we can get them to compete retail style with best doctors offering lowest prices seeing most patients. How about the idea of a ‘Docmart’ chain to manage overheads? How about bidding for patient business?

  23. Unfortunately for the above clueless and inane commenters who think they can just force doctors to be doormats, you picked the wrong guy! I paid attention to my mentors and savvy supervisors who saw this power grab coming 20 years ago, and reinforced to any of us listening as students to just reject the dumbing down of medicine so anyone can act like an MD, or just dismiss what we do in our training as a monkey act. The “jd”‘s, incoherent, er, inchoate but earnest’s, and even Ms G-A, you people are really clueless or have an agenda that is just pathetic to hide behind the pontifications or insults, or both, and I am the guy who will take you on! And I appreciate sincerely and deeply those of you who are speaking as allies for me, so keep doing it!
    It is simple, and you jerks who rationalize that being underpaid for what we provide to the community is not just insulting, it is hypocrisy pure and simple. I don’t know what most of you do for a living, but if you are going to follow up saying you would accept being paid less every year, pretty much, for the hard work and sacrifice, which responsible and committed doctors do, you can read between the lines what I would like to say TU YOU if you are going to just claim being underpaid is fine!
    Yeah, I am onto you people, and your defenses are just bogus! I’ve said it before, I’ll say it again: everyone is a bleepin’ doctor until you do the work, and then you are runnin’ for the door when your skills don’t cut it! And you colleagues out there, at least practicing more than 15-20 years, you should be as outraged as I am about this mess that this current batch of bums are trying to do here through DC. I’m not surprised there is a “collective” who will preach their mantra just because it is Democrat sponsored, or the covert agendas are being realized, but what will you as doctors do if you do not fight this assault?
    Again, as simple as this, the legislation is not about helping Americans, it is both a power/money grab and trying to completely control health care interventions. And if you hated managed care, you will despise what is coming if it is not terminated and re-evaluated, so responsible and effective change can be put into motion. And watch how this perspective is just glossed over by the collective; they don’t want the average reader to hear we as doctors accept the status quo sucks. They want it their way, not the public’s way. And I just hope the unbiased and objective readers see the truth at the end of the day.
    My patients know I am the real deal; I am a staunch advocate, respect the standards of care, and champion for people to access the level of care that will impact as effectively and efficaciously as able. And to all you commenters who just deride what I say, I look forward to your moment in the sun, and I hope you get burned!!!
    The truth is coming out, and America better realize that doctors who care will not care to be involved with health care deform as being rammed down your throats as is. Learn about psychological defenses, especially the immature ones, and you will see them played out textbook by some of these commenters. And they’ll try to pin it on me! You’ll have to decide who is here to help, and who is here to hurt.

  24. what jd said.
    if any sentient creature believes the brains, the heart, the soul, of the healing professions is represented by that reliable bot ExhaustedMD, or the je ne sais quoi MD as Hell, well – I don’t quite know to which psychiatric service to refer you.

  25. Last year we wrote about the long waits for physician consultations that many Massachusetts’ newly insured residents have to deal with (http://www.john-goodman-blog.com/more-lessons-from-massachusetts/).
    The way to solve the shortage of physicians willing to see patients in health plans with low-paying reimbursements is not to force them to participate in Medicaid and Medicare. Moreover, it doesn’t appear to be something that the state could easily enforce. Most physician practices already accept Medicare or Medicaid enrollees — but limits the number they accept to a ratio of private pay patients.
    I also find the idea of forcing doctors to accept money-losing reimbursement rates as a condition of licensure to be rather coercive. In the long run it would exacerbate the problem rather than lessen it.

  26. As stupid as most of these comments are, Dan is raising an important issue and one that is likely to become more important. Many of the problems in our health care system are a consequence of bad government interventions. Please note it is not the case that government should have no role in health care or that all government interventions are bad. But you can’t blame some doctors for getting upset. After all, it’s the Medicare/RUC price-fixing process that’s been screwing primary care docs for over a decade.
    The idea that mandating Medicare and Medicaid participation will make doctors government employees is ridiculous. Nearly all doctors are effectively government employees already. Unless you’re running a cash-based practice (nothing wrong with that), the manner in which you are paid and the amounts you are paid are tightly linked to the existing Medicare fee schedule. Want to decline Medicare but take private insurance? Unless you wield market power in your region, your fees from private insurers won’t really budge from what Medicare pays. These insurers simply have to follow Medicare’s price pegs. Too high, and they’re undercut by competition. Too low, and doctors can just ramp up their Medicare business and decline their contracts. So it’s a tight window.
    The most alarming thing about linking licensure to Medicare participation is that this will stifle innovation in practice design. Want to run your practice on a subscription basis rather than the current ridiculous FFS system? You can’t, really, if you’re forced to take Medicare…unless of course you’re willing to take some substantial legal risks.
    Bottom line, this bill is incredibly unlikely to pass. NPs are not the devil. Beta blockers are surprisingly good for mild anxiety disorders. Have a nice day.

  27. Exhausted MD, I’m not an expert either, but I can tell you what I know.
    The plumber as a defendant in a construction defects case is going to be a matter of public record, available to anyone with an internet connection, for the most part. Your NPDB is not open to the public, neither is the state medical board investigation (if any), and often times the settlement or outcome isn’t, either. So I’m not sure what your complaint is, we’ll never know.
    I know you’re frustrated and angry, but if you can give me the names of ten physicians who have LOST THEIR CREDENTIALS by virtue of being named as a defendant in one frivolous lawsuit that was settled out of court I’ll eat my hat and the entire patient safety community will stop complaining.
    A plumber with a historical pattern of incompetence will eventually go out of business, credentialed (licensed) or no, again because of transparancy. People won’t hire him if his track record is really bad. If he’s being falsly accused and sued a dozen times a year, something is wrong with how he’s treating his customers and/or doing his job, I don’t think it’s any different for the physician. Contractors won’t hire him, word will get out Joe the Plumber is a lawsuit-magnet and he’ll be out of business…not to mention his cost for liability insurance would make it impossible to stay competitive.
    I’m not a doctor-basher but I don’t see it any differently for physicians.
    And finally, you’re right, he whose pockets are deepest is the one going to the mattress, right or wrong. So stop having deep pockets, drop your malpractice insurance. If you’re required by law to carry it, then maybe that’s where you should take your torches and pitchforks.

  28. Re Lisa Lindell’s comment:
    While your comment makes me have to say “I stand corrected”, does the plumber lose his credentials, go on a National Practitioner Data Bank when the lawsuit is frivilous but settled because the insurer wants to save money from full litigation, or have to fill out paperwork for future job opps the rest of his/her life for even one legal matter?
    This I doubt, but I DON’T KNOW THE SPECIFICS, but that is what happens to doctors, even when they are frivilously or falsely accused. You are guilty before innocent these days in medical malpractice lawsuits, and while there are group lawsuits involving the hospitals and various medical staff, often it is the doctor alone who is targeted. Which I would hazard to guess in your retort, the lawyers go after all and then focus on who has the deepest pockets. I doubt the plumber is usually there in the end when there is a construction firm concurrently cited in the suit.
    But, thank you for the correction.

  29. Reality, excellent comment at the end, and like your alias for this site!
    And, I would like to offer the addendum to your comment: not only expand their own sphere of influence, but diminish the sphere of ours!
    I can’t think of the best analogy or past example, but the cries of discontent and outrage WHEN, as things are going now, doctors have stepped back as advocates because of the sheer audacity of trying to dumb us down to the level of amateurs, those cries will be loud and prolonged!
    And you think all these supporters of this crap legislation and detractors of our dissent will step in and save the day? BAH!!!

  30. “Have you read about a plumber being sued lately?” I’ll chime in as a voice from the construction industry. Anytime m-o-l-d is mentioned in a construction lawsuit, every trade, supplier and subcontractor who was involved in building the structure, gets sued. Just because you “haven’t read about” the number of frivolous lawsuits in the construction industry doesn’t mean there aren’t any.

  31. Anonymous
    Docs take home salaries are less than 10% of health care spending. Also, there is no free market in care delivery. Thirds parties, not patients and doctors control the flow of dollars.
    Those who bash doctors, are only looking to expand their own sphere of influence.

  32. Personal income is always judged in relation to ego. If your income is smaller proprortionally to the size of your ego, you think you are underpaid. Other than that there is no objective threshold for what $ constitutes one person to think they are overpaid or underpaid, even when they make the same money. The only objective way to judge the fair market value is the price the market is willing to pay. Right now the market is saying that it can’t afford doctors’ salaries.

  33. “Yeah, I’m sure HandGelG would be willing to have his/her income continue to decline to point of incurring significant debt, as hey, doctors are overpaid, right?”
    The real income of the average of American has already been declining for the past decade. Every sector in the economy, except for health care, has seen significant contraction in recent years.
    Just like private companies pay their employees the minimum necessary to keep them from leaving, all governments (federal/state/local) should be paying the minimum necessary to provide required services. In the case of Medicare/Medicaid, the federal government should pay enough to ensure adequate coverage for patients on Medicare/Medicaid, and no more.
    It is normal for doctors to complain about not making enough, just like teachers and fire fighters and police officers often complain about their compensation. It is certainly their right to complain (does anybody think they get paid enough?). And it is also my right as a taxpayer and voter to insist that government pay only what’s enough to provide the service. If a few people are not happy, so be it.

  34. Like the thread so far, by in large. Glad to see colleagues are weighing in and challenging some of the less reliable rhetoric going on.
    Hey Paolo, let’s compare apples to apples, shall we? Is the veterinarian or plumber walking out of their training with a 6 figure debt to pay? Well, probably the vet could be, don’t know vet school costs, but not the plumber. Do either have call responsiblities at least 1 or more nights a week? Again, maybe the vet, but I know a good portion who don’t. Weekend calls, which are 24hr/day for 2 & 1/2 days, as Friday nights are part of it? Some vets maybe, and a very few plumbers handle emergency weekends, but again, not many and doubt the frequency docs do. Malpractice costs? Hmmm, some vets might get sued, but for a Million dollars? Have you read about a plumber being sued lately? I haven’t!
    Overhead? Vets employ staff, but what are their liabilities and clinical skill needs? Amount of office space needs? Don’t see plumbers leasing out a couple thousand sq feet of space, do you? Accessory needs? Yeah, both professions have acoutraments that are essential, maybe even Xrays for the vet, and the plumber needs his truck, the supplies for the assorted jobs, so that one is somewhat of an equivalent. How about the expenses and time needing to be affiliated with hospitals? Don’t see that one fitting the two professions. And credentialing? Vets might need CMEs and reboarding. My plumber who has been practicing for 30years? His experience is why I use him, and if he told me he didn’t take his recertification, I would think about it, but he fixes my pipes and fixtures and water conditioner systems. I would hope he keeps up with improvements in the technologies, and he does.
    Let me finish with what I read when I took the MCAT prep course with Stanley Kaplan back in the 1980’s (remember this, colleagues of tenure?), as they had an intro book that reminded customers why you were participating in this class: if you were in it for the money, they did a cost analysis of comparing a person becoming an apprentice in plumbing versus a person getting a medical education to be a doctor, and how the plumber would make conservative investments and expenditures during the time frame the doctor was in school and residency. Guess who made more money after 15 years? It wasn’t the person with the stethoscope around his neck, Paolo! So, take your generalization and flush it, and if gets stuck, when the plumber comes to literally bail you out, ask him his income stream for the hours he keeps, and you might be surprised!
    And you and your minions will then go after the plumbing industry next!?!?!?

  35. “Why would anyone want to go to medical school these days?”
    One reason is that it is the best paid profession in America and likely to remain so. The average doctor makes a lot more than the average veterinarian or the average plumber.

  36. What some may not realize is that what’s bad for physicians in this country is bad for the health of the public.
    We tend to blame doctors for everything these days even though their hard work and personal sacrifices result in lives being saved every day.
    Doctors take home less than 10% of health care dollars. Those who reflexively see cutting reimbursement to doctors as a solution to lowering health care spending either have their own interests in mind or are severely misinformed and clueless about how the health care system operates.

  37. I love it when public policy trends are defended with the “better than the worst possible outcome” argument. Related to this logic is the “see, the sky didn’t fall yet” opiate. And then there is the “cash for clunkers” type analysis, wherein the surprised journalist reports that the people who got the free money pronounced the program a stroke of genius.
    “We did this in (fad European country here) and (same) didn’t become communist.” (Parts have, and those parts are eating the rest.)
    “The same arguments were used against Medicare and Medicare worked out fine.” (Medicare is insolvent.)

  38. RE:
    “Doctors who read this should organize via internet and stage a slow down. Interesting, that is why there is political debating as to the differences between doctors and nurses. The NPs are nice and follow the cookbook, but are dangerous as all get out. They do not know what they do not know, and that is a lot.”
    Every health practitioner doesn’t know something they don’t know, same with patients! This is what makes healthcare such a unique aspect of human interchange. Don’t be so retorically immature.
    As for doctors organizing. Of course they should – every group of workers needs to work organizationally to sustain their position in our complex and exploitive world. Welcome to everyone elses’ reality!
    Primary care doctors need to become more assertive in defining their evolving roles.

  39. > A bill currently under review by the state
    > legislature will make participation in the state
    > and federal Medicare/Medicaid programs a condition
    > of medical licensure
    And I’m sure many more bills will be reviewed. I hope the judgment is that this particular bill is unconstitutional. Better if that judgment is made before it is brought to a vote.
    Read Palestrant’s post for what it is.
    > For all those docs out there with […] 5-to-1 ratio
    > of administrative staff salary & benefits overhead
    Realize that minimum efficient scale is certainly bigger than one doc and get yourselves into a well-managed practice. This is one thing under your control.
    t

  40. Let’s see how fast a serious physician shortage will arise. Let’s see nurse practitioners be responsible for the final decisions in a case. Let’s see a migration from Massachusetts like that which occurred in Tennessee.
    There is no free lunch.
    Why would anyone want to go to medical school these days? My friend the chiropracter is a happy man. So is the veteranarian. So is the dentist. So is the barber. So is the plumbing contractor. The plumbing contractor starts making a good living 10 years before the doctor does.
    Keep screwing with the doctor.

  41. Yeah, I’m sure HandGelG would be willing to have his/her income continue to decline to point of incurring significant debt, as hey, doctors are overpaid, right? It is so easy to criticize and minimize issues, until, what, they affect you?!
    And to jd, glad you won’t be back to waste your time in this thread, as we don’t need useless entanglements.
    Again, colleagues, pay attention to the naysayers. They don’t care about the quality of health care, and I’ll bet a sizeable portion of them benefit financially from this bs legislation coming. But, they won’t share that little tidbit, will they?
    Ignorance is not bliss, it is a curse. We as doctors can only hope to avoid the curse the supporters of this garbage want to pass on the population. Keep on talking and refusing to submit to enslavement. I mean, how many reasonable and realistic MDs in countries with universal health care tout it as wonderful? These supporters think one person speaks for the masses? Did Timothy McVeigh speak for the country when he did what he did 15 years ago. NO! And yet extremism gets the press and dialogue. And that is the mentality of these supporters, if it is good for the few, then it is good for the many.
    Incredulous mentality. And rigid and inflexible.

  42. Given that Daniel is the CEO of a medical forum it’s not too surprising he’s written an incendiary piece – it speaks more effectively for vested interest than it does about a bill – that’s currently ‘under review’ (ie it may not happen) by the state legislature of Massachusetts.
    All these arguments have played out in the UK almost 50 years ago… the sky didn’t fall and we didn’t become communists.
    In the words of the classic posters: Keep Calm and Carry On.

  43. Hmm … Well, my spouse & many others in specialty niches generally do not accept insurance ‘payments’ because, for the type of work they do, reimbursements are woefully inadequate. Medicare/Medicaid is even worse here. For example, if a physician spends more than a few minutes with a patient, that generally isn’t compensated. If, as my spouse often does, she spends up to an hour or more to get a very detailed history & workup, she can’t even pay the rent, much less any other overhead (malpractice insurance – even with no claims in almost 2 decades of practice; etc.) with the reimbursements based on a few minutes. As reported just today, the government accountants have calculated that — surprize, surprize — the new plan will increase the deficit, not reduce it. That is, unless they can cut somewhere — like, say, physician pay. For all those docs out there with education bills & loans to pay, and large malpractice premiums, as well as the 5-to-1 ratio of administrative staff salary & benefits overhead (largely to process claims!), good luck for this Brave New World …

  44. Thanks for the early validation, Ms GA! You just don’t get it, because you are not a provider and your personal welfare is not at risk, at least not just yet, because your blind faith is just that, it blinds you!
    Wait for it, colleagues, the mob with the pitch forks aren’t in front of you and loud enough yet to make you hold your ears and reinforce your doors. And yet, the mob is basically being stabbed in the back as the real beneficiaries stand behind them at a distance, ready to mow them down after doing the dirty work.
    I love the term “blind faith”. What an oxymoron!!!

  45. Ehm… Now that April 15 came… and went…. and the sky has not fallen, and since “deep down” everybody knows that there will never be 21% cuts across the board, and after everybody had a chance to actually read the bill and see that Medicare will be increasing payments for primary care and Medicaid will be brought up to Medicare rates, should we maybe restate the main points in this post in less alarmist terms? Or are we just having a nice little cup’o tea here?

  46. WOW, all I can say is wow. And I hope the ensuing thread that I anticipate grows from this post really shows the true colors of the participants of this site. This is what is happening out there, people, and the defenders and apologists are not providers, at least ones with souls.
    If you are a health care provider, and really believe in caring for people, this fecal impaction has to be scooped out and tossed in the toilet and flushed with passion! The people who call themselves representatives and claim they care about this country and voted for this garbage health care deform, they must be purged, like a GoLyte colonoscopy prep! And when you read or listen to those who are so passionate this legislation will save the country and make us all better, healthy, and appreciative of how Congress improved our lives, you are listening to the ultimate corruption and cluelessness that ends societies if unchallenged.
    To all you supporters of this health care legislative deform, I can only say in the fairness and respect of a public blog forum, May you experience physically impossible biological trauma to unnamed orifices below your navel. I know that is completely rude to write; so was this legislation!!!

  47. Doctors who read this should organize via internet and stage a slow down. Interesting, that is why there is political debating as to the differences between doctors and nurses. The NPs are nice and follow the cookbook, but are dangerous as all get out. They do not know what they do not know, and that is a lot.

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