Myths and Facts About Health Reform Part III

MYTH #1: In negotiations over reform, hospitals were forced to accept sharp cuts in Medicare funding.

FACT: In those negotiations, hospitals come out winners. They “were inside the tent very early on, negotiated a decrease in their Medicare updates that they figured out was acceptable” the Urban Institute’s Bob Berenson explained in a recent Health Affairs roundtable. (Berenson is in good position to analyze the changes: he was in charge of Medicare payment policy and managed care contracting at the Health Care Financing Administration – now called the Centers for Medicare and Medicaid– from 1998 to 2000 )

“And now [hospitals] are off limits until 2020 from the new board that is supposed to [make sure] Medicare hits spending targets,” Berenson added referring to the Independent Payment Advisory Board (IPAB) that will recommend ways to trim Medicare spending if it continues to grow faster than the Consumer Price Index. IPAB begins its work in 2014, but hospitals and hospices are exempt from IPAB”s proposals until 2020.

Moreover, while annual increases in Medicare payments to hospitals will be trimmed slightly, these cuts will be offset by the fact that hospitals will be seeing an influx of paying patients. Beginning in 2014, millions of formerly uninsured patients will no longer need charity care. Granted, the “Disproportionate Share Funding” (DSH) that many hospitals now receive to help defray the expense of caring for a disproportionate share of poor patients will be sliced by 75%, but a portion of the 75% cut will then be distributed back to hospitals, based on how much uncompensated care a particular hospital is still providing.

MYTH #2: Medicare already underpays hospitals; any reduction in Medicare reimbursements will threaten the financial health of the nation’s hospitals.

FACT: In its March 2009 report to Congress the Medicare Payment Advisory Commission (MedPac) pointed out that not all hospitals lose money on Medicare patients. In fact, “some hospitals are able to generate profits [while] treating Medicare patients.”

How do they do it ?

Hospitals that break even or generate profits from Medicare patients tend to fall into one of two categories, MedPac reports. First, teaching hospitals often generate profits on Medicare patients due to indirect medical education (IME) payments that exceed the indirect costs associated with teaching residents. Secondly, relatively efficient hospitals are able to cover the costs of caring for Medicare patients by keeping their costs lower than their peers’ costs.”

When MedPac examined financial outcomes for a set of hospitals that consistently perform well on cost, mortality, and readmission measures” it “found that Medicare payments, on average, roughly equaled their Medicare costs.” In other words, higher-quality, relatively efficient institutions, where doctors and nurses take more care with discharges and fewer patients “bounce back,” are far less likely to lose money on Medicare patients.

Perhaps the supposedly “inefficient” hospitals are treating poorer, sicker patients? Medicare takes this into account. As noted, when it sets payment rates for hospital services, it increase reimbursements for hospitals that see a disproportionate share of low-income patients.

Moreover, MePac observes, when a hospital needs to tighten its belt and become more efficient, it can: “MedPac research shows that hospitals under financial pressure are able to constrain their costs. By contrast, hospitals that receive rich payments from private insurers face less pressure. As a result their costs rise and their Medicare margins tend to be low.”

In other words, hospitals are like many families. The more income they have, the more they spend—and the more lax they become about sticking to a budget.

MedPac suggests that the problem is not that Medicare pays too little, but that private insurers pay certain hospitals too much. A MedPac study of private hospitals from 2001 to 2007 found that in some cases private insurers were paying 13.5% more than it cost hospitals to care for patients. As a result, these hospitals were feeling flush, and didn’t focus on efficiency. No surprise, their Medicare margin was negative, falling 11.75% short of the cost of care. By contrast, hospitals that weren’t paid as well by insurers lost 2.4% on those private patients. Under financial pressure they worked hard to avoid waste when caring for Medicare patients, and came out with a 4.2% margin.

MedPac describes how marquee hospitals squander health care dollars: “Hospitals with the greatest resources are less aggressive about containing costs and therefore have the highest Medicare ‘losses’ (the difference between Medicare rates and a hospital’s average costs). The most profitable and powerful hospitals spend more and increase their costs per unit of service. Hospitals with high profits, low financial pressure, large endowments or robust fundraising have the highest costs, and a higher cost base leads to lower Medicare margins. If Medicare were to increase payment rates, hospitals with market power would be unlikely to voluntarily cut prices charged to insurers and reduce revenue. Instead, hospitals might spend some or all of that revenue, pushing costs higher still.”

We know that, when it comes to health care, lower spending and higher quality go hand in hand. Indeed a separate MedPac study of 300 hospitals shows that more efficient hospitals have lower death rates. MedPac has concluded that “increasing Medicare payments is not a long-term solution to the problem of rising private insurance premiums and rising health care costs. In the end, affordable health care will require incentives for health care providers to reduce their rates of cost growth.” Under reform, Medicare will “encourage better care by covering the costs that reasonably efficient providers would incur in furnishing high quality care–rewarding providers whose costs fall below the payment rates and penalizing those with costs above the payment rates.”

MYTH #3: Most U.S. hospitals are efficient, and already have responded to pressure to cut waste.

FACT: MedPac reports enormous differences in the quality of care at profitable hospitals, and the latest 2009 hospital survey released by the Leapfrog Group, a nonprofit organization representing major private and public purchasers of healthcare benefits, confirms a wide disparity in hospital efficiency. For 2009, 1,244 hospitals in 45 states completed the voluntary Leapfrog Hospital Survey, and that self-reported information showed that “waste” remains a significant problem. For example, a 56% difference existed, between the highest and lowest performing hospitals in terms of resource use for heart bypass surgery.

For heart angioplasty, there was a 79% difference between the highest and lowest performers. To gauge waste, Leapfrog’s resource use measure is based on risk adjusted mean length of stay compared to readmission rates. Length of stay is a strong determinant of cost.

The variations in waste among hospitals performing the same type of surgery highlight the opportunities that exist for significantly cutting the costs of care, Leapfrog CEO Leah Binder said.

In 2009, less than half of hospitals in the survey met Leapfrog’s outcome, volume, and process standards for six other high risk procedures and conditions. Research has suggested that following nationally endorsed and evidence based guidelines for these procedures and conditions is known to save lives, Leapfrog suggested.

These procedures, with the percentage of reporting hospitals that fully meet Leapfrog’s standard in 2009, are:

Aortic valve replacement-11.8% Abdominal aortic aneurism repair-36.1% Pancreatic resection-33.5% Esophageal resection-31.5% Weight loss (bariatric) surgery-36.6% High risk deliveries-29.9%

Research indicates that a patient’s risk of dying can be reduced by approximately two to four times—depending on the high risk procedure—if care is obtained from a hospital that meets Leapfrog standards, Binder said. In particular, more than 3,000 deaths could be avoided each year if Leapfrog standards were implemented in hospitals that electively performed these procedures. Individual hospital results can be viewed and compared here.

MYTH #4: As Medicaid expands, more Medicaid patients will be showing up at hospital doors. Medicaid pays an average of 30% less than Medicare; hospitals cannot afford this drain on their resources.

FACT: Medicaid is reaching out to include patients who, in the past, were uninsured. If they became very sick, they wound up in hospitals where most could not pay their bills. Under reform, hospitals will receive some payment—which is much better than no payment.

In Part 4 of “Myths & Facts” I’ll continue to look at how reform will affect hospitals and hospital patients, focusing on concerns that because government payments are low, hospitals will continue to shift costs to private insurers, pushing premiums higher; fears that 32 million newly insured patients will crowd hospitals, leaving us all waiting on line; the belief that new regulations covering doctor-owned hospitals would leave us short of hospital beds, and the worry that reformers treated hospitals too generously, and that as a result, the cost of hospital care will continue to spiral.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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  1. Prepsoterous that health care should be amandatory.. it mandatory to balance the US budget and its never done and no ones putting the Senators in jail are they? I mean what are you going to do? you have a mortage two jobs, four kids, braces, school fees and childcare and you cant afford it on your $53,000 a year salary? whats the govt going to do ? Pull your teeth out? fine your grocery purchases? Deny you work? I mean if you dont carry auto insurance they suspend ur drivers license for failure to comply and if you dont they jail you. Are they going to jail you cause your poor and or middle class and cant manage your money well? its preposertous?
    Why dont they mandate super sports athletes cant make over $50,000 a year ? or that teaches salaries should be $100,000 a year ? Or that you have wear blue Tshirts on Wednesday? can u penetrate peoples civil freedoms any deeper to buy a product. insurance polices are a product!! like buying a bicycle or a TV set. Is there a law you have to buy a TV SET? ITS PREPOSTEROUS and shows that our senators and reps did not have people specialized in these insurance and health care fields advising them. They used lobbyests who make money by pushing thru bad bills that insurance companies and medical companies profit off of. You know most of the former PRes Bushs staff works in the medical industry cause they profited by bad legislation for the last 8 years prior?
    Eveyone wants a big salary and group benefits. I am shopping for dental insurance and cant find one single policy for NON GROUP. WHy was DENTAL Care left out of all the legislation? Because the dentists ADA lobbiest pay the senators the most! and Thus I cant afford a root canal and probably will have my tooth pulled for$50.00 instead of paying $2,000 for root canal surgery and needed crown! RELEGISTLATE AND INCLUDE DENTAL DISCOUNTS AND INDIVIDUAL COVERAGES!

  2. 76 out of 372 going to taxes and profit doesn’t sound right at all, thats 25%. If 296 is going to expenses that doesn’t leave much margin to pay taxes on. Unless the 76 includes payroll taxes and benefits?

  3. Until this year Walmart has been working with third party suppliers rather than manufacturer. What skills does Walmart have in manufacturing to help manufacturers reduce their cost? Yes they can help with packaging and transportation and they provide large, continuous volume.
    The more important benefit of size is seller/buyer power rather than economy of scale. Someone does have to pay for their ‘instant economy of scale’. Either the workers in thirld world countries or their societies or competitors if possible.
    CMS is going to exercise the buyer power for sure.
    And it does provide continuous volume that hospitals so much need with their rigid cost structure.
    Barry raised pertinent issue about hospitals cost structure being primarily salary. However I think that is not true. Here is the average breakup of hospitals in 2003 in USD billions.
    Medical labor- 100
    Operation cost and support functions- 147
    Profit, taxes-76
    I think there should be scope for applying economy of scale, aka overhead reduction. And possibly they could exercise their buyer power with their suppliers as well.

  4. Per Ms. Mahar…”Notjust primary care docs but pediatricians, geriatricians, family docs.”
    Perhaps trivial to some but the fact that Ms. Mahar is not aware of what constitutes a primary care physician pretty much sums up her lack of knowledge and credibility. LD

    So much for all the claims that the USA health care is so “terrible.” If this is LYING CHICAGO THUGS’ ‘facts,’ they’ll get theirs.
    North Korea has plenty of doctors: WHO
    By Jonathan Lynn
    Friday, April 30, 2010; 2:52 PM
    GENEVA (Reuters) – North Korea’s health system would be the envy of many developing countries because of the abundance of medical staff that it has available, the head of the World Health Organization said on Friday.
    WHO Director-General Margaret Chan, speaking a day after returning from a 2-1/2 day visit to the reclusive country, said malnutrition was a problem in North Korea but she had not seen any obvious signs of it in the capital Pyongyang.
    North Korea — which does not allow its citizens to leave the country — has no shortage of doctors and nurses, in contrast to other developing countries where skilled healthcare workers often emigrate, she said.
    This allows North Korea to provide comprehensive healthcare, with one “household doctor” looking after every 130 families, said the head of the United Nations health agency, praising North Korea’s immunization coverage and mother and child care.
    “They have something which most other developing countries would envy,” Chan told a news conference, noting that her visit was a rare sign of the communist state’s willingness to cooperate with outside agencies.
    Chan’s comments marked a significant change from the assessment of her predecessor, Gro Harlem Brundtland, who said in 2001 that North Korea’s health system was near collapse.
    Chan, who acknowledged that countries that she visits always try to look good while pointing to where they need help, met a series of North Korean officials, visited several hospitals, and also talked to Pyongyang-based diplomats, United Nations officials and representatives of the Red Cross.
    The authorities acknowledge there is a problem with malnutrition, she said, but things have become better since famine in the 1990s and a series of natural disasters in 2001.
    “Nutrition is an area that the government has to pay attention (to) and especially for pregnant women and for young children,” Chan said.
    Chan spent most of her brief visit in Pyongyang, and she said that from what she had seen there most people had the same height and weight as Asians in other countries, while there were no signs of the obesity emerging in some parts of Asia.
    But she said conditions could be different in the countryside.
    News reports said earlier this year that North Koreans were starving to death and unrest was growing as last year’s currency revaluation caused prices to soar.
    Chan, who described her visit as “technical and professional” — in other words avoiding politics — said the North Korean government’s readiness to work with international agencies, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, was encouraging.

    ” .. Aside from access to capital, there are surprisingly few economies of scale to be had in these capital intensive businesses.”
    So .. MESS-iah is a LIAR?
    Of course. All politicians — INCLUDING the ones who post “facts” here — LIE.
    Nov. 2, MESS-iah’s B.S. goes on trial. And it does not look pretty.
    So all this B.S. is for naught.

  7. To follow up on Nate’s comment, Wal-Mart also orders goods in much larger quantities than most other retailers which allows for long, efficient, lower cost production runs. It also often sends its own trucks to pick up the goods at the supplier’s plant. When you reduce the supplier’s cost to serve you, the supplier can charge less and still earn a satisfactory return on investment. Small retail competitors, by contrast, cost more to serve. That’s why they are charged more.
    None of this, by the way, has anything to do with healthcare. Aside from supplies, which account for only a small percentage of costs, large hospital groups do not have any inherent cost advantages over smaller groups or even single stand alone hospitals. Most of their costs are for salaries and benefits and everyone in a given region pays about the same for labor (per person). The same, by the way, is true for hotels, and owners of apartments, office buildings and shopping centers. Aside from access to capital, there are surprisingly few economies of scale to be had in these capital intensive businesses.

  8. “Effectively smaller chains subsidize Walmart as vendor’s cost bas remains the same.”
    This might be true in some very rare cases but so incredibly untrue in almost all. Even the slightest knmowlwdge of Wal Mart and their supply chain and you would know they invest tremendous amounts in improving their suppliers cost basis.
    When they push vendors to eliminate extra packaging it not only reduces the cost to package but also to ship. If yu look at laundry detrigent and how they pushed them to remove water and concentrate it saved millions shipping unneeded water.
    Their shipping logistics are unmatched, all of this filters down to the smaller rivals.

  9. “But the analysis also found that the law falls short of the president’s twin goal of controlling runaway costs, raising projected spending by about 1 percent over 10 years. That increase could get bigger, since Medicare cuts in the law may be unrealistic and unsustainable, the report warned.”
    Is it convenient?

  10. It all seems to be based upon MedPac’s analysis that hospitals can do same job with lesser money. Mark Spohr made interesting comment that efficiency improves quality and lowers cost.
    But how can this happen? Are hospitals and doctors practicing expensive form of medicine or are they poor at running business? Probably that’s where doctor’s input would have been so valuable in this forum.
    There are questions about one segment paying for others but that doesn’t merit too much conversation as by same yardstick we should be protesting Walmart using it’s buyer power to force it’s vendor to lower their prices. Effectively smaller chains subsidize Walmart as vendor’s cost bas remains the same. I suspect government will exercise it’s
    buyer power extensively in coming years and should there be ever the issue of doctor access the solution will be as simple as letting in more foreign doctors and hospital chains. More sellers can always be found.

    AP just reported that Greece took a bail-out from IMF (a.k.a., USA) and Euros.
    Whose going to bail-out the USA from OBAMA-BANKRUPTCY?
    Will the Chinese Commies take a sexism-card? Or a race-card?
    “.. Look at Greece and California — going BANKRUPT without an adult in sight.”

  12. “Maggie’s “analysis”, as far as it goes, blissfully ignores this variation, and the truly questionable public policy correlate- that it’s OK for one public program to pay, like two thirds of another, because it covers poor people.”
    It’s not “OK” and it’s also not OK to have Medicare pay less (or more) than what should be the proper amount. It’s disgraceful that we position patients into the healthcare system depending on what their ROI is. Hospitals should be paid ONE fee for everyone for the same work. From discussion here I think hospitals are being paid (or forcing payment) too much. We can’t control healthcare costs if we can’t reign in hospital charges.

  13. Kind of late in the process to weigh in on Maggie’s “Myth” vs. “Opinion” series, but her last point is the truly debatable one. Yes, hospitals have a long way to go to operate efficiently and Yes, 60% of Medicare is better than nothing. BUT, the fact that Medicaid is not randomly distributed and that PPACA will effectively end cost shifting places safety net institutions at risk (not just hospitals, but FQHC’s, local health departments) and they could end up being badly damaged.
    Medicaid accounts for “only” about 15% of the typical hospital’s revenues but the ones where it’s 20-40% are the one’s I worry about. (I used to work in one). Medicaid pays hospitals in most states between 60-80% of Medicare. Because PPACA requires states to maintain enrollment until 2014 “new” Medicaid program kicks in, the only way they can cope with their present fiscal crises is to SAVAGE their provider payments, which pain is not randomly distributed among hospitals.
    Health plan gross margins have been capped by the restrictions on their medical loss ratios. Hospitals that respond to the current round of Medicaid cuts will not be able to recoup their losses the traditional way- by shifting costs onto private payers- without triggering a political backlash against the plans- leading to price controls on premiums and eventually on their own charges. Since there will still be between 15-20 million uncovered folks, the people who have depended the most on cost shifting to survive will be placed at risk, a problem that we wouldn’t have had if we’d actually been able to afford universal coverage. Ed Miller, Hopkins’ CEO, said as much in a recent, largely overlooked WSJ op ed.
    Maggie’s “analysis”, as far as it goes, blissfully ignores this variation, and the truly questionable public policy correlate- that it’s OK for one public program to pay, like two thirds of another, because it covers poor people. Bloviation is not analysis. Maggie, you don’t know what you don’t know.

  14. Obama qualifications to reform health care:
    “Influential” In Univ Chicago Med Ctr hiring practices
    No birth certificate
    Can not stop smoking
    Difficulty telling the truth.
    Narcissistic personality disorder.
    Therefore, I Igor produce Obama Birth Certificate at http://www.igormarxo.org
    Compare Obama Care vs Igor Care at Obama vs Igor Care

  15. “Since I don’t reply to abusive comments, personal attacks,”
    No you just call them a misogynist and pretend to be a victim of bullies and lies.

  16. WELL … DUH!
    ” .. Seems that the President of APA shares the “liberal” opinion that this bill is not perfect, but it is a step in the right direction ..”
    Hmm .. think it MIGHT have something to do with …
    As in, spend TRILLIONS in TAXES, gimme money? Like in good old Chicago/Daley-ville?
    From the MD group that is WHERE on the MD-pay list?
    Grandma was right. Common sense is worth 50 points on the IQ test.
    Look at Greece and California — going BANKRUPT without an adult in sight.
    More than 40% of USA medical costs are tied to OVER-EATING, SMOKING, dope, booze and “extreme lifestyles.”
    What has the MESS-iah done about SMOKING and and dope? Zero. Nada. Zilch. Let the suckers pay for these preventable issues.
    So much for being a leader of adults. Nov. 2, he’s getting a wake-up call, big-time.

  17. By the way, Ms G-A, the President of the APA has a very sordid past, with his being the CEO of a pharm company and tried to get FDA approval of a medication he has a patent on that is just not realistic to pursue; just google it and you’ll read what I am saying is truth.
    And, to show how clueless and lame the APA membership has become, and frankly, is irrelevant to the majority of psychiatrists as a whole, they elected this man after this matter was public. I believe strongly in the adage, “you are judged by the company you keep.” The APA is lost, and the way they are handling the coming DSM 5, they are hammering their own nails as they proceed. Just a shame they ruin it for psychiatrists who do not share the APA’s jaded and dysfunctional agendas.

  18. Of course the articles I link and mention are not slanted to just one side alone, and that is why I hope readers will review them, but, they do raise concerns about what could be negative outcomes with this legislation. Ms Mahar, you do not come across as being even keeled, your posts are too pure a positive, and that is just plain hypocritical to basically say I am being extreme. Your posts are not realistic to what is coming, and I have the right to advise readers be aware the facts and statistics are slanted until proven otherwise. The Democrats did not handle this legislation responsibly, and the end, this will come out. And I do not look to the Republicans as an alternative. I want change to come from outside Washington. But, people have to get off their butts and participate, sacrifice, and be realistic. Does that describe politicians? No, Ma’am, it does not!

  19. Maggie,
    I replied to Bob’s thread before I saw your comment here. I suspect you are correct about the geographical aspect of the problem. A multi doc clinic would fair better in Manhattan because of everything you mention and because of the density of the population. In small town or rural America, solo practices may be a much better fit to the local needs and can be cheaper to run than a Manhattan clinic. I think we should allow the profession to evolve based on population needs and ability to meet those needs in a cost effective fashion, without imposing a particular model. The PCMH model needs to probably be revisited to allow solo docs to form virtual associations for providing a medical home. It will make a huge difference for underserved areas.

  20. Since I don’t reply to abusive comments, personal attacks, or troll-like political rants about the MESSiah etc. (repeated several times), there is not a great deal for me to reply to in this last batch of comments.
    A couple of people on this thread seem more intersted in talking about Obama than in talking about healthcare. And when they take over a thread, I notice that other people stop commenting. (This is one definition of a troll; he or she has an agenda which may have relatively little to do with the topic at hand, but neverthless he or she just pounds away on that topic until everyone else goes away.)
    Margalit– Thanks for continuing to try to keep the discussion on a rational, evidence-based track, pointing to the fact that the articles cited often contain are more even-handed that Karl or Dr. Exhusted would have us believe.
    On the question of whether the small practice remains a viable economic model–I may be exaggerating the difficutly of maintaining a small practice because I live in Manhattan. Here, both the cost of renting an office and hiring labor, paying utility bills and malpractice insurance makes it prohibitively expensive for most young doctors.
    The older doctors who I know who maintain a small practice typically own the office space–which they bought 25 to 30 years ago, before real estate sky-rocketed.
    And they still have a hard time finding a good receptioinist, and other staff.
    I suspect the situation is similar in cities on both the East Coast and the West Cost, but probably very different in other parts of the country.
    Still, I would point to Bob Wacther’s excellent new post on THCB. The doctor that he talks about is hiring a nurse to deal with the overload of information, e-mails, etc. If he were working solo, he wouldnt’ be able to afford to hire a nurse to do this and would find himself working long hours to keep up with everything.
    If he were working in a very large practice he would have a group of nurses and others refilling prescriptions, answering e-mails, fielding phone calls etc. Economies of scale would make this much less expensive.
    That said, I think primary care practices should be paid for all of the things they do in addition to seeing patients in the flesh.
    So the idea of paying doctor a lump sum per patient, adjusted for age, etc., to keep the patient well for a year seems like a good idea. (This lump sum would have to be large enough to let them pay nurses and other staff.) Or, everyone could be paid a salary. Paying them fee-for-service for each e-mail, phone call, etc. would involve too much additoinal paperwork for everyone. But they should be paid for their time, whether they are e-mailing a patient or seeing a patient.

  21. Dr. Exhausted, I have no problem with doctors not accepting insurance. I actually know several concierge docs who are very nice people. I was not implying that the two docs are money driven. Only that there is no law now, and nothing at all in the bill (I did read the whole thing), that would force a doctor to participate with any payer. So why speculate about being “allowed under the new law”? Where is that coming from? If we are going to base the conversation on facts, than let’s stick to the facts.
    And, speaking about facts, Frank, I don’t know that the President of APA has been taking bribes, so I assume he is not, and I assume that his opinion is as honest as yours.

  22. Well, Ms G-A, thank you for taking the time to read the articles I link/mention here, but, I always believe the end of an article wants the reader to focus on the main point, so I will repeat it below:
    “But Dr Beecher (President of the Minnesota Patient-Physician Alliance) also agreed with Dr Gitlow (Assoc Prof, Clinical Psychiatry, Mt Sinai Sch of Med) that psychiatrists will have a hard time meeting demand, and that more might move to cash only practices, if that is allowed under the new law. Neither Drs Beecher nor Gitlow currently accept insurance.”
    Ok, here is my interpretation of that paragraph: “meeting demand” can mean access to patients, earning a reasonable income, providing for the community, and to me, all three; “if allowed under the new law” infers that Obamacare will dictate what physicians can do as providers?–NOT ACCEPTABLE in a free country, and yes, there will STILL be a two or more tiered system, and while that sucks, it is life as we continue to allow third parties to intrude into the patient-physician relationship; and finally, “Neither Doctor accept insurance”, means they have made their choice, and note at least Dr Gitlow works for a University Hospital, so that is part of his income at least, and Beecher is involved in some patient-physician organization, so they do not strike me as private practice income focused MDs, so why did you not pick up on that and note so in your comment?
    I could infer what I have been saying already: cherry pick facts and stats to serve a purpose, not a well rounded presentation. Face it Ma’am, I learned in my life when you defend another’s position, you are guilty by association. So if this is devil’s advocate crap, I don’t practice that line of thinking. You can respect or try to repeat to your critic what you understand as their line of reasoning, but don’t give the illusion you accept it!
    It has only been six weeks since Congress passed this garbage, imagine what will be learned in 6 months!

  23. WELL … DUH!
    ” .. Seems that the President of APA shares the “liberal” opinion that this bill is not perfect, but it is a step in the right direction ..”
    hmm .. think it MIGHT have something to do with … M-O-N-E-Y????
    As in, spend TRILLIONS in TAXES, gimme money? Like in good old Chicago/Daley-ville?
    From the MD group that is WHERE on the pay list?
    Grandma was right. Common sense is worth 50 points on the IQ test.
    Look at Greece and California — going BANKRUPT without an adult in sight.
    More than 40% of USA medical costs are tied to OVER-EATING, SMOKING, dope, booze and “extreme lifestyles.”
    What has the MESS-iah done about SMOKING and and dope? Zero. Nada. Zilch. Let the suckers pay for these preventable issues.
    So much for being a leader of adults. Nov. 2, he’s getting a wake-up call, big-time.

  24. So I read the Psychiatry article as well.
    Seems that the President of APA shares the “liberal” opinion that this bill is not perfect, but it is a step in the right direction, and one of the docs quoted there actually thought the parity in coverage is basically a good thing.
    The concern about the ill effects of “mental health professionals” not being MDs is not unique to Psychiatry, as we debated here in one of Maggie’s previous posts about NPs in general. I do share that concern.
    The second concern was that IPAB will be cutting physicians fees in the future. Maybe so, but maybe they will be wise enough to cut where it needs to be cut.
    I found it very interesting that the two doctors most opposed to the bill are not taking any insurance in their practice. I guess they managed to escape slavery after all….

    “Senate Majority Leader Harry Reid is hoping to reshape the health care overhaul’s narrative in Nevada as an accomplishment for small businesses and the middle class, not the big-government tax burden his opponents have labeled it.
    “His campaign has started a “substantial” round of media touting the election-year benefits of the overhaul as he struggles to retain the seat he’s held since 1986.
    “But the ads don’t address the most controversial features of the overhaul – the mandates and the cost – that his Republican opponents are undoubtedly going to continue to talk about until Election Day. They’re also the issues, along with the controversial “deals” Reid has been attached to, that have soured voters against the plan ..”
    Nov. 2 — day of reckoning for all the Elizabeth Warren and David Himmelstein LYING about health care.

  26. I read that above exhaustive missive from the author of this posting, and just had to shake my head in disbelief. I have to sincerely wonder if you are a shadow writer for the Obama administration and just write what you are told. I can spout statistics, that are skewed to support my position, and that is absolute truth to all who read?
    http://www.clinicalpsychiatrynews.com, lead story in the April 2010 issue, “Law Fuels Debate On Specialty’s Future”, as it talks of how this legislation has a sizeable potential to devalue psychiatry as a specialty. What words of hope to you have for psychiatrists, Ms Mahar? I’m sure this legislation, which per you, will bring up the incomes for more than nots in medicine, will not affect cost choices? Gimme a break, Ma’am. And no, I am not anti-doctor, as I am one, and no, your generalizations that all physicians saw their incomes rise between 2004-08 and “these physicians all earn far more than the wealthiest 5%” are just ridiculous statements to make.
    They do vilify physicians, you just twist the wording to claim otherwise, as we all know this is an environment that wants to portray people of higher income as insensitive and cruel to the general public. But, we are not bankers, investments capitalists, and shrewd for profit businesses. But the way I read your comments, I feel I can infer this kind of rhetoric from you. And people involved in Medicare and Medicaid know this is slave labor. I know because I have worked in systems the last 15 years that are forced to take this insurance population. You can’t earn a fair income as compared to those who avoid that insurance pool. You are wrong to infer otherwise, and I will continue to say this until either you admit your mea culpa, this site bans me, or, god forbid, the US government improves reimbursement. Which do you think will happen first? I bet Jesus will have a say before the first or last choices happen!
    It is just incredible that this site allows this misinforming rhetoric to go on as legitimate with the ongoing columns that are published.
    Hey, whether you believe it is a fair analogy or not, what is going on with the oil disaster after Obama opened the East and Gulf Coasts for oil drilling is another example of act first, deny next, and then start to ask realistic questions when the damage is beyond done. I go on record that in the end, the loudest and most prolonged supporters of this health care legislative debacle will be exposed as flagrant beneficiaries, clueless party loyalists who only focus on political clout, or sincere but ignorant, naive idealists who gave up too much hope and belief in politicians who only sold them out.
    Not a group I want to hang out with, much less expect to watch out for my patients’ and my interests.
    But, we look forward to “Myths and Facts Part 4”, as manipulating and deceiving can’t be completed in a trilogy, eh?

    ” .. Karl– You continue to rant, and to lie about that article. So much hate for “Asians” “Euros” and “Obama.”
    My finance is Asian. Your comment about “Asian-hate” is just like your ability to analyze health care with any accuracy — zero-quality. You are so one-sided and biased, your bias can be seen 1,000 miles away. Good job at being biased and blind to calculator keys.
    My congratulations on getting so far with so little front-line knowledge of health care. You and MESS-iah prove that a sucker is born every minute.
    Madam, those who claim the truth are the biggest liars. And you are one of the biggest “truthers” — again, congratulations. You provide much comedy, spouting off about things you have no actual, front-line and practical knowledge of. Most would be embarrassed, but you blather on. Spectacular!
    Michael Moore has nothing on you, as a medical expert. Pity on you and those who fund your highly-questionable work.

    ” .. Karl– You continue to rant, and to lie about that article. So much hate for “Asians” “Euros” and “Obama.”
    My finance is Asian. Your comment about “Asian-hate” is just like your ability to analyze health care with any accuracy — zero-quality. You are so one-sided and biased, your bias can be seen 1,000 miles away. Good job at being biased.
    My congratulations on getting so far with so little front-line knowledge of health care. You and MESS-iah prove that a sucker born every minute.
    Madam, those who claim the truth are the biggest liars. And you are one of the biggest — again, congratulations. You provide much comedy, spouting off about things you have know actual, front-line and practical knowledge of.
    Michael Moore has nothing on you, as a medical expert. Pity on you and those who fund your highly-questionable work.

  29. “We have the classic triangle of quality, magnitude (accessibility) and costs, which in one form or another defines every project, and sooner or later every project faces the stark reality that you cannot constrain all three, and at least one of them needs to be released.”
    Margalit this comment is so dishearting. Luckily so untrue as well. It is a common failure of liberalism not an unbreakable reality.
    Education worked great when it was ran at the school and county level. Then they tried to dictate from the State level and things didn’t work quit as planned. Then the federal government thought it could do better and everything went to S#*&.
    Small well definded and focused projects can achieve all three. Its when politicians try to overreach and do things for the wrong reasons that you need to start making sacrafices.
    Every attempt at Federal and State management of healthcare has been a collosal failure. Their are thousands of examples of successful and sustainable local projects though.
    I won’t get into the politics of why liberals try to get their hands into everything and dictate from a high but don’t lose hope, it is very possible and it is done every day.

  30. Dr. Exhausted, I like you last comment, because it lends itself to honest conversation.
    I also find your perception of the liberal side being rigid, very interesting. I have the same perception regarding the conservative group. I suspect that with some glaring, and very loud exceptions, we are both wrong. For example, I disagree with Maggie on the assumption that solo practices are by definition unsustainable, and based on the rather predatory behavior of large groups with salaried physicians, I would rather compromise on efficiency than on integrity and quality.
    I also disagree with several others proposals in the bill and I do agree that there is a distinct possibility that the execution of all these lofty plans will not be as successful as we all hope, but that is true of every plan and every strategy.
    We have the classic triangle of quality, magnitude (accessibility) and costs, which in one form or another defines every project, and sooner or later every project faces the stark reality that you cannot constrain all three, and at least one of them needs to be released. I believe accessibility cannot be compromised, if we are to remain an enlightened society. The play will therefore occur between quality and cost. I just hope that whoever defines quality knows what they are doing, and honestly, I am not convinced they do, but I am hopeful that practicing docs like yourself can lend a helping hand here.

  31. My mistake, Doctor Paolo, but I am a bit baffled that if you worked to earn a doctorate degree, and you are talking with fellow doctorate colleagues, most I know do appreciate being addressed as “Doctor”, it is something that is inferred among colleagues. To each his own, I will conclude. In the future, please do address me if not just by ExhaustedMd, then Doctor E is fine. I assume by your comment you expect the same of me towards you.
    As to the rest of your above latest comment, I pay Medicare and taxes too, accept that is part of my life per income stream, and that is not the issue here. It is about further taxation, and it is without representation, as it is fact that the majority of Americans do not support this legislation as is. So, why would a healthy, educated, and aware individual be accepting and tolerant of terms that are basically punitive? I really would like to hear your answer to this perspective. Because if you have a doctorate degree, be it medicine or other educational pursuit, most people I have met who go this distance certainly possess some desire for independence and autonomy, so I would hope you afford me that perspective.
    Finally, I will say without hesitation my tone and positions are harsh and abrupt, because you cannot negotiate with those who are rigid and inflexible and putting your well being at risk. I hope my comments encourage others who, if do not completely agree with me, at least respect that when your livelihood is at risk, which this legislation is doing to doctors on a whole, kindness only goes so far in dealing with adversaries.
    The tone of the Democrats has only been “if you are not with us, then we will screw you.” The Republicans had the same tone with defense issues, so it is a basic political attitude with the current inhabitants of Congress and the White House. I think the American public deserves better, as a whole, and supporters of this crap just don’t get it. And for doctors who are, in my opinion, just blindly agreeing to this, this situation really mirrors past behaviors of equal intrusions into the livelihood of the public that history has shown have ended up disasterous.
    And we are a species who should know better, but, we seem to just let history repeat itself. Well, don’t count me in with this mindset, Doctor!

  32. Mark S., Margalit, Karl, Exhausted M.D. Admin and others who worry about docs’ salaries, Paolo, Karl
    Mark S. – Thank you. And yes, lower costs and higher quality go hand in hand. As more and more people understand this, they will realize that the Medicare “cuts” are aimed at eliminating waste that hurts patients– unnecessary care that puts them at risk, hospital errors that add to costs, and patient suffering.
    Margalit–Thanks much for your fact-filled response to
    Exhausted M.D. Responses like yours help get the facts out and counter some of the unwarranted fears.
    Many doctors will, as you say, see their incomes rise under reform–those who are at the bottom of the pay ladder. Notjust primary care docs but pediatricians, geriatricians, family docs. Those who decide to become part of pilot projects experimenting with ways to pay for good outcomes rather than volume will be eligible for bonuses.
    I know you are not anti-doctor. Nor am I.
    Many of my best sources are doctors. People I have asked to guest-post on my blog are doctors. Many doctors favor the reform legislation–or at least see it as a pretty good first step.
    Karl– You quote from an AP article that discusses the pros and cons of the reform legislation.
    What you left out, of course, are the pros
    Here’s what the article actually said.
    “The report found that the president’s law missed the mark, although not by much. The overhaul will increase national health care spending by $311 billion from 2010-2019, or nine-tenths of 1 percent. . . .
    “The report acknowledged that some of the cost-control measures in the bill — Medicare cuts, a tax on high-cost insurance and a commission to seek ongoing Medicare savings — could help reduce the rate of cost increases beyond 2020. . .
    “In a statement, HHS Secretary Kathleen Sebelius sought to highlight some positive findings for seniors. For example, the report concluded that Medicare monthly premiums would be lower than otherwise expected, due to the spending reductions.”
    The fact that you omitted these sections of the article totally undermines your credibility.
    As many commentators pointed out after looking at the pros and cons highlighted in the reprot, a 1% increase in the first 10 years to cover 35 million Americans– followed by savings after that– is a pretty good deal. In addition reform legislation reduces the deficit.
    Exhausted M.D., Admin and others who worry about doctors’ salaries:
    No one is suggesting that doctors take a vow of poverty. Before poor-mouthing, perhaps you should consider how much doctors actually earn: dermatologists earning an average of $368,000, orthopedic surgeons $476,000 , and gastroentolgoists $449,000 Moreover, it’s worth noting that this is median income; half of these specialists earn more than this, often far more.And from 2004-2008, these specialists saw their inflation-adjusted income rise. (Most American workers saw their income fall or remain flat.) (Numbers from Medical Management Association)
    Morever, the wealthiest 5% of American families take home just $250,000 a year. These physicians all earn far more than the wealthiest 5%.
    As I have mentioned, those at the lower end on the physician income ladder will see their incomes rise under reform. And it’s worth noting that even at the bottom of the ladder, median compensation for internists, family practitioners and pediatricians ranges from $186,000 to $191,000. (This is after expenses.)
    In term of income, when compared to other Americans, this puts them in the top 7%–in other words, far from poverty.
    But this is median income; admittedly some family docs, pediatricians etc earn significantly less–particularly if they are working solo or in a small practices in cities where their overhead is high.
    Give the cost of real estate, labor, utilities etc. in the 21st century, the solo or small practice just isn’t a viable economic model in many places–particularly for younger doctors.
    It also wastes health care dollars: when every solo practitioner has to hire his own receptionist/nurse, pay rent on his own office, buy his own equipment we’re looking at great redundancy that the economy just cannot afford..
    This is why more and more docs are choosing to work in large groups where they enjoy economies of scale. Also, someone else worries about running a business and they can concentrate on practicing medicine, earning a salary that is at least median in their specialty, often significantly more.
    Indeed, the sky is still blue. No one is trying to destroy physicians. And, as you say the legislaition is financed by many parties–almost none of it comes in the form of cuts to physician fees.
    From what I can tell, some physicians are taken in by the fear-mongering for political reasons. They are politically conservative –or at least conservative enough to view Obama as a “liberal” who is going to redistribute income. And so they assume he is bent on robbing physicians. Obama’s goal is to provide healthcare for everyone while simultaneously reining in health care spending.
    We’re living in a health care bubble. We’ve overbuilt the system in many ways-. In many places we have too many hospital beds, too much redundant medical equipment. There are too many drugs on the market. As a nation, we’re over medicated. We over-pay for many products and services. And, yes, we’re paying some doctors at the top of the ladder more than society can afford. Over time, we’re going to have to let the air out of the bubble.
    The health care bubble is much like the Wall Street bubble. We let growth for growth’s sake lead to expansion to a point that ultimately Wall Street was selling products that were simply pieces of paper– they didn’t benefit society or add to the wealth of the nation. Similarly, our terribly wasteful health care system has reached a point where it needs to be reined in– at least 1/3 of the health care dollars that we are spending are not adding to the health of the nation.
    The good news can be found in the very first comment on this thread: when it comes to health care, less spending is actually associated with higher quality care.
    Karl– You continue to rant, and to lie about that article. So much hate for “Asians” “Euros” and “Obama.”

    This is just a waste of time. On Nov. 2, all this changes, and MESS-iah gets a $0.01 budget for his malarkey. If not reversed, in its entirety.
    HHS’ own financial experts called Obama a financial sham. They do not want the blame, when this blows up financially.
    MESS-iah took a health care system that created medical miracles for cancer and cardio-vascular patients. And made it as MEDIOCRE as the Euros and Asians who have been FREE-LOADING off USA research for decades. What genuius!
    Nov. 2, this BS goes away. And the adults take over and cut off Junior’s credit card.

  34. Dr. Exhausted:
    1. The article you quote talks mainly about imaginary problems: A physician fee cut on April 1 that never took and never will take place and some random state proposal to force Medicare/Medicaid acceptance that has no chance of being enacted into law.
    2. The expansion of coverage in the actual new law is financed by many parties (taxes, fees, insurance companies, tanning salons, etc.). Almost none of it is financed by physician fee cuts.
    3. I already pay more than 5% of my income to finance the health care system. And while none of it helps me or my family directly, I have no problem paying for this.
    4. I have no problem with anybody making as much money as they can. I don’t want anybody to have to take vows of poverty or chastity. I said that I want the government to pay only what is necessary. In medical specialties where there is a current shortage, this means paying more than currently.
    5. I only addressed you as “Mr.” because that is how you addressed me first, and being a doctor myself, I had no idea that “Mr.” could be deemed offensive. I have no problem addressing you as “Dr.”
    6. Relax. Nobody is out to destroy physicians. There are enough problems in health care and elsewhere to worry about fake laws, imaginary proposals, and ideas that nobody espouses.
    The sky is still blue. Have a nice day.

  35. No, I do not see this man as a prophet for me or the only voice of reason, but he raises issues and facts that are too quickly dismissed by supporters of the legislative failure-to-be. I just do not see this intrusion by government as anything close to a reasonable answer to the problems at hand.
    The status quo has to change. It just is not going to be resolved responsibly by politicians. And it does not take a rocket scientist to figure this out! I just know while detractors have their agenda, so do supporters, and that seems swept under the rug so quickly and quietly by the latter, eh?
    My agenda? I want to provide health care the way I was trained, with minimal intrusions and realistic boudaries of access and opportunity that arise. Costs are part of it, but costs should not dictate all of it. I am not a wealthy person, have no intent to be wealthy, but I have the right to set my fees that reflect what is reasonable and fair per the patient response. The deceit re medicare and medicaid fees being spewed here and at other sites, it is garbage. And reasonable and fair citizens have every right to take a stand when they are being shortchanged. This pathetic argument that “everyone is having it done, that’s just the way it is”, is just the bs sold by people who aren’t impacted, or are clueless. I don’t live by the adage of “hear the lie enough…”. Look for someone else to fool!
    This legislation is only about cost. Spin as you will.

  36. What I’d like to know, Exhausted, is why you guys (I am a member of Sermo but do not use it much) allow Palestrant to fulfill his ambitions AND get paid to “speak for you.” Rest assured he has his own personal ambitions in mind, whatever they may be. Perhaps his ascent is symptomatic of a leadership vacuum in the professional colleges, but it’s scary that such bright people would follow a self-styled “leader” just because he says things you like to hear. Just give some thought to how he has gotten where he is. Are you being used?

    I’d post all the UK-NHS stories in the WSJ, but the ignorant never think.
    Like the nut-cases complaining to NPR about nothing about single-payer — MESS-iah threw that under the bus in 2007.
    Nov. 2 — this mess gets washed away, and the adults will re-assume management.
    3) There is no express legislation for changing the reimbursement model, but there is express requirements for trying various different models until a good one is found, and yes, it may take a while.

  38. OK, I read all of it.
    1) The 21% cut did not go through. It never will.
    2) Physicians are not a monolithic group – some will see pay cuts and some, like Primary Care, will see pay raises.
    3) There is no express legislation for changing the reimbursement model, but there is express requirements for trying various different models until a good one is found, and yes, it may take a while.
    4)There is express legislation to simplify administrative transactions such as billing.
    5) I would like a list of the “many states” that tie licensure to taking Medicare/Medicaid. This is just one bill introduced in one state by one misguided person.
    If you are truly independent, Dr. Exhausted, than please read both sides with equal scrutiny.
    And before you accuse me of hating docs or anything, please read my latest take on the independent doctor’s plight
    Maybe we are both independent…. in different ways…..

  39. Hey, Ms Mahar, Paolo, and the other usual suspects who support this insult to health care, read the most recent column by another writer to this blog, and readers I hope you do the same, and then let’s listen to the attack and defense by these supporters:
    I truly cannot wait if any of these people actually read the entire piece and can say something that support Obamination Care. Oh, they will, they will yet again attack doctors as being selfish greedy whores and encourage the masses to join the attack.
    Kill the doctors. Oh, who will heal you thereafter? Didn’t quite think that one through, did you, health care legislative demogogues?

    Sir, there is NOT one URL that refers to ONE spreadsheet that support the BS here. There is a saying in MHA programs to something like this: FAILURE.
    Oh, yeah — financial EXPERTS say that OBAMA CANNOT BE TRUSTED about health care.
    “WASHINGTON – President Barack Obama’s health care overhaul law is getting a mixed verdict in the first comprehensive look by neutral experts: More Americans will be covered, but costs are also going up.
    “Economic experts at the Health and Human Services Department concluded in a report issued Thursday that the health care remake will achieve Obama’s aim of expanding health insurance — adding 34 million to the coverage rolls.
    “But the analysis also found that the law falls short of the president’s twin goal of controlling runaway costs, raising projected spending by about 1 percent over 10 years. That increase could get bigger, since Medicare cuts in the law may be unrealistic and unsustainable, the report warned.
    “It’s a worrisome assessment for Democrats.
    “In particular, concerns about Medicare could become a major political liability in the midterm elections. The report projected that Medicare cuts could drive about 15 percent of hospitals and other institutional providers into the red, “possibly jeopardizing access” to care for seniors ..”
    Facts? HA, HA, HA — funny! Like Chicago being an honest town!

  41. Wow, we agree on something, the legislation is not complicated, but then that is where we diverge, as it does not logistically carry out what it contends to do, but in fact will do close to the opposite by what it will intend to do. And you do not address the risk factor of citizens not being able to carry insurance for 6 months. Interesting. Maybe because that scenario does not impact on you personally?
    Oh, my mistake, I forgot, someone else besides you will pay for it, because if you were asked to donate an extra 5% plus of your yearly income to pay for other people’s health care you were not personally involved in, that is perfectly acceptable and agreeable to do, in fact, you are writing the check as we speak, eh?
    No, you have made it clear that it is hospitals and physicians who will eat the expense, because we are all millionaires and have the extra money and time to almost literally burn to be slaves for the state.
    If it gives you pleasure to address me as “Mr”, knowing I am a doctor, I hope you are happy. Your unwavering support for legislation that will have more consequences than benefits when the facts and poor consideration for gross underestimations come to bear, will you give us a mea culpa? Or, just continue to proclaim “the color of the sky above me is what I see it to be, all the rest of you be damned!”
    Your emperor, “Mr” Obama, do you honestly think he practices what he preaches? And I don’t think George W Bush did either, so don’t make this a party issue. No, I guess, as I have written before and will again, blind loyalty must be so empowering. Until you don’t see the cliff and the jagged rocks below.
    I love the line in Harriet The Spy, when the Rosie O’Donnell character tells Harriet, “You’re independent, and that makes people uneasy.” Uncontrolled and unmanipulated thoughts and actions do drive people of power crazy. Because, it makes other people think too.
    And, that could lead to, what, healthy and responsible choices? Again, readers, read both sides and formulate your independent opinion. That I respect!

  42. Mr. Exhausted, it’s not that complicated. The federal high-risk pool program is only intended to temporarily (until 2014) help the uninsured with pre-existing conditions. It was never intended to subsidize those currently insured. The federal insurance subsidies come into effect in 2014 when the federal high-risk pool ends.

  43. To Practice Admin:
    you are witnessing yet another example of those who do not practice health care who are selling the lie that physicians should take a vow of poverty. The Mahars and Paolos of the world are stark examples of either flagrant hypocrisy, or are the most clueless, and because of this, equally dangerous people for selling a message that just enslaves people.
    Let us just hope and pray that enough people who know better continue to challenge and hound these charlatans or misguided fools for their lies or dangerous misperceptions until they either recant and be responsible, or, just shut up and move on!

  44. No, Mr Paolo, I read the article to support exactly my position, and it validates what I am reminding readers who don’t take yours and Ms Mahar’s positions as the gospel just because you throw around statistics to confuse and nauseate.
    “About 200,000 Americans whose illnesses have kept them from getting regular health insurance will not be allowed to enroll this summer in a new lower cost federal program for people like them because they already buy pricey state run plans.”
    So, the legislation is not helping lower costs, giving people choices, and you gotta love the ending of the second paragraph, which really helps people, huh, Mr Paolo: “To qualify, a person can’t have had health coverage for six months.”
    What twisted logic are you going to spew next to rationalize and defend that statement, sir!? All these politicians and crazed supporters, like you and the above columnist here, think that spewing the false facts will just be accepted as gospel, and when someone reports otherwise, they just don’t get it, do they?
    By the way, what is the color of the sky in your world, Paolo? Blood red, for all the fluid being spilled by those who will be drained by the truth now coming out!?

  45. “IPAB begins its work in 2014, but hospitals and hospices are exempt from IPAB”s proposals until 2020.”
    Unless the government needs more money then it passes a short amendment to any must pass bill eliminating this provision.
    Remember original Medicare required by law that providers by paid market rates, that lasted 5 years, I think, until the cost exploded and it was recinded. This promise isn’t worth the paper it was written on.
    “Beginning in 2014, millions of formerly uninsured patients will no longer need charity care.”
    The bill intends to do this, there is no guarantee nor is it even likly this reform will cover 32 million uninsured. Again look at the history of Medicare, Medicaid, and every other federal healthcare bill and they never achieve what they claimed they would. I don’t remember the numbers but just a few years ago Part D didn’t cover nearly the people they said it would.
    The cuts in funding are happening for sure though, so what does a hospital do if their funding drops 75% but their uninsured case load only drops 50%? Some big dollars and risk to be hoping on.
    “Medicaid is reaching out to include patients who, in the past, were uninsured.”
    This again is intent. In reality many companies will find it cheaper to pay the penalty then to insure their workers so hospitals will lose many of their highest paying customers to the lowest paying customer. Any small to medium size group with a catostrophic claim would be better off paying the penalty until the claim resolves then go back to offering insurance. Very easy to do under the new “plan”.
    “However, hospital ER departments do no have the option of refusing care to people who cannot afford to pay.”
    Actually not true Paolo, they have the option of closing as hundreds of rural hospitals have, disproving the notion that less money is better then no money. Loses are still loses, someone needs to make them up, if private plans, tax payors, or owners aren’t willing to subsidize those loses then no money is better then less.

  46. If the alternative is not getting paid at all, of course I would embrace a plan that pays me less for my work. And so would you. And so have the millions of Americans who have been accepting pay cuts in the last couple of years to keep their jobs.

  47. Paolo…….same question. Would you embrace a plan to reduce your yearly salary for doing the same or more work than you did last year?

  48. Practice Admin, your landlord has the option of evicting you if you do not pay your rent. Likewise, your staff has the option of quitting and finding work elsewhere if you pay them less.
    However, hospital ER departments do no have the option of refusing care to people who cannot afford to pay. In their case, any payment is indeed better than no payment.

  49. “Low payment beats no payment.”
    Using Maggie’s philosophy, I called our building landlord and asked if he could live with lower monthly rent because low rent was better than no rent. Weird. He didn’t share Maggie’s theory.
    I then asked our understaffed, overworked, and overwelmed staff if they would agree with Maggie that lower pay is better than no pay. Again, I couldn’t seem to convince them either.
    Interestingly enough, I got the same reaction from the electric company, phone company, and our city/county/state/federal tax offices. Every one of those organizations simply refused to agree that low payment was better than no payment.
    So, I’ll ask Maggie. Would you accept less pay today for the same work that you did last year?

  50. ExhaustedMD, thanks for the pointer to the USA Today article. I recommend you read the content, and not just the headline. It says the new federal high-risk pool is cheaper than most of the existing state-based pools.

  51. “the sky is not really blue, it is just the refraction of all the other colors make it so we can only see blue, and besides, when the sun does not shine then there is absence of color, so in the end, does the sky really have color, or is it just what the eyes misinterpret, or maybe if the sun was not shining in a yellow spectrum, then we would perhaps have a rose colored sky, and then everything would be rosey”
    Front page Right sided lead in today’s USA Today, “Health law undercuts risk pools in 35 states”. We are to believe this columnist’s positions just because that is how she sees it, and is fed alleged data by sources that only want to propagate the agenda of “accept this legislation or be punished”?
    Well, to all the Mahar’s and other false prophets of this message of how wonderful this failed legislation is showing it’s true colors, the sky in this world of Obamacare is black, very black, and not in a racial way, but in “the sun don’t shine in this place” way!!!
    You get the meaning!

  52. Maggie, thanks for putting some well-researched facts behind this argument. I have been hearing hospitals and doctors whinging about how they are losing money on Medicare and they can’t afford to see Medicare patients but I also see the tremendous waste and profiteering of these groups.
    It’s time to improve the efficiency of health care. I like the studies that show that lower spending correlates with better health care. Efficiency doesn’t just lower costs, it improves quality.

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