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Clint Eastwood’s Empty Chair Health Care Speech


Eastwood: “So, would each of you like to introduce yourself to the American Public?”

* silence *

Eastwood: “How many of you are licensed physicians?”

A few raise their hands.

Eastwood:   “Really, that’s all?  (Mumbles under his breath, “Wow.”   He continues:  “How many of you are men and how many are women?”

* silence *

Eastwood: “Given there are 50 states in the United States, could you tell us in which state each one of you live?”

* silence *  As if no one wants to admit where they live…

Eastwood: ” If one of you gets sick, are there only 14 people who vote or does someone else gets picked?”

* silence *

Eastwood: “How many of you have parents still living over 75?”

A few hands are raised.

Eastwood: “How many of you are less than 35 years of age?”

* silence *

Eastwood:  “How many of you have ever told someone they have cancer and then cared for them?”

* silence *

Eastwood:  “How many of you received grants of any kind from the US government?  Any of you stand to receive benefits from the US government of any kind?  Might one of those benefits include health care for you or your family?”

* silence *

Eastwood: “Do any of you carry the BRCA1 or BRCA2 gene for breast cancer or does anyone in your family?”

* silence *  Some appear confused by the question.

Eastwood: “Would each of you share your religious affiliation with America?  Any atheists amongst you?”

* silence *

Eastwood:  “Well, it seems we’re not getting too far.  I guess we’ll conclude there and ask the American people what they’d like to ask you…”

* Opens microphone to responsible voices… *

The Doctor Is In (And Extremely Annoyed)

It’s no secret that many doctors are unhappy about the changes to the healthcare system planned by the Obama administration.   But just how unhappy are the majority? And what will happen when the series of ambitious reforms approved by the Senate last month begin to go into effect?  It’s hard to say with any certainty.   But we have clues of what may be coming, In the days after the passage of the health reform bill,, an online community for physicians, and athenahealth, a web based healthcare IT provider, asked doctors for their reactions to the news.
The responses give a good sense of how doctors are taking the news and their likely responses.  Hundreds of doctors responded, giving a unique snap shot of a rarely polled court of public opinion. From specialists like oncologists and OBGYNS to general practicioners.  We’re reprinting the full text of their comments in these pages.

A couple of caveats. web-based polls and surveys are notoriously non-scientific. By definition they tend to attract those who are already engaged with a cause and activists who’ve already made up their minds about the issue being examined. (The well known echo chamber effect that many observers credit with reducing civilized discourse to snark. )  Another limitation: By asking people their opinion of an issue hours after , you run the risk, what could be described as the  “Oh My God!” effect.  The same kind of distrotion you’d get if you asked people what they thought about airline security the day after a plane crash or financial regulation , hours after after . something news organizations have become expersts at asking.  – or a plane crash, or a terrorist . What do they really think? Well, they’ll have to think about it. Chances are it will change.
For further background, please visit . It should go without saying, that THCB does not necessarily endorse or support the views expressed by the commenters in this thread.  We do feel however, that understanding  the evolving healthcare ,

I really think that the public needs to know how WE feel, since there still has been only a little press coverage u ntil very recently about how physicians perceive the changes that will come about. It is indeed alarming how many of us realize that private practice is dying. I do hope that we can”level the playing field” with insurers, but I also wonder if this will be a temporary fix until “Obamacare” goes into full swing.


I don’t think the public, or the government, really cares. Kind of sad. Good questions but for those of us in hospital-based practices (I’m in the ER) the last 2 questions are not even an option.  Family Medicine


Private practice is not dying. It died a while ago. Insurance types have made sure of that. The future is with groups and subsidized clinics, run by people who can deal with the parasites which are entrenched in American medicine.


Look folks, the public doesn’t give a crap how we feel and won’t until they are personally inconvenienced. The thing that could have saved us would have been a strong lobbying organization which the AMA proved conclusively they are not.


This trend will lead to more of us exiting medicine earlier than planned.

It does help to talk with patients. I have been doing that, and many of them are unaware of the impact of this legislation that has been rammed down our gullets.  Have changed a few opinions. Several have even stated that they are sorry they voted for Obama.


Who do we think we are fooling? Physicians are idiots, working on surveys like this. Nothing will be any different than it has been for the past 15 years UNLESS WE STRIKE! Then people will listen……..Then things will change.
You should have also asked how many MDs are considering retiring to escape ObamaCare. I will cast the first vote for the affirmative. I will either retire, or greatly scale back my work. I will do whatever I can to minimize my involvement with government, or insurance companies which will become tools of government control. Thanks to Congressman Dingle, we now know for certain (as if we had any doubts) that the ultimate goal of the “progressives” is to “…control the people.” –Dingle.


Many thanks Dan for staying in the fray and keeping our little voice out there. The media is not much interested yet in what physicians have to say, but this will be a good start to letting them know how physicians will begin to think in resoponse to the heavy handed government plan, the insurance company legacy and just how difficult it might be to get in to see a physician in the near future.

You are having a heart attack, stroke, in pain – call your democratic congressman/woman. Maybe he/she can help you because I will have retired.


Is it foreseeable that some physicians may very well be better off under this reform bill because cost containment will be at the forefront as opposed to just pure-click system as we currently have it? I would be curious to hear others thoughts.
Anyone who thinks the healthcare system will be benefitted by the control of those who control the (failing) post office, the (failing) social security system, the (failing) medicare structure, the (pitiful) Indian Health system…is either completely out of the loop or needs a urine drug screen. Thought the following link that was sent to me was interesting (from a doc to a senator), although I haven’t checked out the details (too busy dictating letters of medical necessity for my many special needs kids!).

This bill, while not perfect, is the most morally righteous action performed by our government in 20 years. The opposition of many of my fellow physicians to this legislation is selfish, narrow-minded, and a betrayal of the highest principles of our profession. I support this legislation whole-heartedly, regardless of whether it reduces my income.


Maybe it is time to look for a new career. Insurance companies tell us what we can order for patients from tests to drugs to home care equipment. Now the federal government is going to tell us what our services are worth. That’s a little too scary for me. I plan on voting them all out in November. If not enough Americans agree, I am sure I can find something else to do where I can earn a living that reflects my training and expertise instead of putting me on a level with a postal employee.

We need to get real here. Congress doesn’t care what we think. Ultimately, it’s insane to think attorneys should write any laws regarding the delivery of medical care. I think it would be interesting if they let us write a “reform” program for lawyers. Legal counsel would be a right not a privilege, for things less than significant criminal charges. The poor could have subsidized legal counsel. Everyone would be required to belong to a Legal Maintenance Organization or be prepared to pay a fine if they’re sued or get busted for something and they’re not covered.I could go on, to no avail. At least Tom Coburn is ragging Congress. No Viagra for sex offenders strikes me as a good idea. The attorneys general of 13 states may make some progress here.

Unfortunately I seem to be in the minority of physicians who actually went to medical school and subsequently have spent years training to help people. It is so heart-breaking to see patients with dire situations who do not have any health care coverage and are subsequently denied the treatment that they need.Yes, it is frustrating to deal with uninsured patients who do not take care of themselves and end up with potentially preventable injuries or conditions. But there are also those people who unfortunately develop unpreventable injuries or condition. And thanks to the current legislation, we will begin to be able to take care of *all* Americans, not just the privileged.

This is a major change in how our country works. It is unreasonable to expect that the first round of legislation regarding this healthcare reform will be perfect. As with any major socio-economic program, it will require multiple adaptations and improvements. How many more decades were we going to wait before embarking on this major undertaking together? Rather than bash this legislation, those that are not pleased should constructively offer their recommendations so that all can benefit.

bye bye American pie and practice-I’ll still be in business just not medicine- sad, after 26yrs of caring for others…i no longer care…. except for my family.
Silver linings in the dark cloud of Big Oh’s health care plan (O’care):

1. The coverage of the tens of millions of so-called ‘uninsured’ may somehow result in greater sympathy of (or at least empathy with) MD’s problems, most outstandingly need for medical reform.
2. The prospective need for billions/trillions more $ for O’care may impel not only recission of the much-maligned tax-cuts-for-the-rich of the Bush era but also the salutary improvements of:
2a. Implementation of much-needed taxation of lower-income Americans who now pay nothing (but get loads of gov’t benefits), e.g Nat’l Sales Tax &/or VAT (like in Europe);
2b. A rationalization & modernization of our present antiquated general tax -&-spending structure, e.g.:
>Presidential line item veto &/or impoundment of expenditures (desired by every US Prez since US Grant);
>’Sunset’ laws for phasing out of antiquated &/or ineffectual Gov’t programs (supported even by Lib-Left Democratic 1972 Prez candidate Sen George McGovern);
>Recission of the silly Constitutional prohibition against Export Taxes,
>Ending (or minimizing) the ‘double-taxation’ of dividends,
>Decreasing (or even eliminating) capital gains taxes,
>Phasing out agri-subsidies for domestic rice, sugar & tobacco growing (while buying more of same from those tropical 3rd world countries to whom we now send ‘foreign aid’ in the form of graft & armaments),
>Getting rid of all excise & other special taxes (e.g. Fed tax on gasoline) in favor of aforesaid NST &/or VAT.  I could go on but ’nuff said for now!


Listen, y’all. The only way Obama can make this scheme work is if we are complicit in his plans. Have any of you read “Atlas Shrugged?” If you haven’t, then read it; that is your IMMEDIATE asignment. In the book, the government took over productive enterprises, but soon discovered that it was the mind behind the enterprises that made business successful. John Galt led the productive people to a secret place where they could work and enjoy the fruits of their labor. Guess what happened to those left behind? The ones whose only hope of survival was to live off of the productive of society? If you know the answer to that question, you are getting close to the answer to our dilemma.
Agree with the many comments. Polls etc. are helpful, but until we start getting in there and legislating like the lawyers did, we’ll never have anything done in our favor….


Agree totally with Sermo Doc 5. The public and govt don’t care about docs- they think docs make too much money, a 21% or even higher cut will not make much of a dent in their income and they probably feel its even justified. They don’t know the expenses of practice. They will only care when they can’t find a doctor who will see them for the pittance they are willing to pay or have to wait 2 months to see one.
The main problem, is that we simply cannot afford this plan (especially with the economy and tax base where they are). Also, 85% of people are satisfied with their insurance plans and there is no reason to change the system for everybody. Why couldn’t Congress simply develop a plan to subsidize, based on need, the working un- and under-insured? The rest can go on Medicaid which is already there for them. This is simply a power grab and has nothing to do with the Dem Congress actually caring about people. Since the Democrats love unions so much, they would love it if we unionized, right?

Interesting…are those physicians who think that President Obama is this huge socialist going to accept Federal stimulus money for their Electronic health records? I smell a rat!


Well I think the general public does not want to support a system where people get benefits for not contributing back to the system. I really think that as the taxes go up and that is why some changes dont kick in for several years to make it look like nothing is different…. until all hell breaks loose. I studied in a communist country in which everything was subsidized to keep the peace until it could hold together any more…  We need a better way of paying for health care…. and how the money is spent… to provide these services…. You cant have everything… and not pay for it…
We will be broke… in 7 years… and will have to start all over… Will we be able to pick up the pieces from whats left…  Capitalism is dead… the wrong people are in control of health care… Government allowed the drug makers to charge whatever they wanted… because we had insurance… We give an 80 yo quadruple bypass to live another 4 years. We give every vaccine that comes out… We try the new flavor of the month in allergy meds… Patients demand that they are entitled to every procedure because they do not pay for it…
Its over… We all need to have a drink… and toast the good ole days…
I agree with Sermo Doc 9 that everyone should read “Atlas Shrugged” to see the ominous parallels between that novel and the current Obama/liberal socialist agenda. But for most of us, dropping out of practice is not a viable alternative at this time. We should become more politically active and campaign tirelessly to get these corrupt, power-hungry scumbag politicians thrown out in November. If the Dems could lose the Mass. senate race, they are vulnerable everywhere.
It is clear that this current Federal government cares nothing about what anyone thinks.
This may be the biggest legislation ever passed… but it is not fair by any means…
The cardiologist above better go read Robin Hood one more time…. Because he is in fantasy land…
An electrician came to my house for a repair… and handed me his card.and I quote.. “I will come any time day or night… but you might not want to pay me what I charge to come out at 2 AM” Where does this sound unreasonable? Do you as a cardiologist want to run to the hospital and put in a balloon pump… when your wife is delivering your child via c-Section.. YOU ARE A DOCTOR…. and you were trained on someone else’s expense? and you are not entitled to a life? or at least get paid to do it? You mean you are not deserving of being paid more than some Wallstreeter… who traded some stocks today?

Resign from the AMA now,
Surveys are of interest, unfortunately, only to those who care about or benefit from the results. Nowhere in the health care reform debate has any thought or attention been given to calculating, or even just estimating, the reimbursement for physician services needed to sustain the practice of medicine, in any model.Costs go up, and payments go down, the business plan of bankruptcy. Significant attention to reducing the cost of medical practice is completely lacking: Tort / liability insurance reform , billing simplification, decreasing the expense entailed in satisfying the growing, and growing more complex body of regulations that mostly have no relation to the quality of care, for a few examples.

And as for the promise of “information technology”, this is going to be just another tax on physicians activity, profitable for the database designers, but not physicians, until some breakthrough actually facilitates greater efficiency for the physician, not just the statisticians monitoring the “evidence”. I spent much of the day reviewing the proposed requirements for an electronic health record to be “certified”, so its use qualifies a physician for the government subsidy. Improved physician efficiency is not one of them.

Sorry to be such a pessimist. Perhaps if the debate now raises the real issues, the appropriate answers may become apparent.


I can understand the sentiment of the physicians in the field. We have not been treated fairly or with any knowledgeable deference. But whose fault is that?I think it is our own. We have accepted the unacceptable because it was the easy way, required not much thought and we were making money, weren’t we?

We are the physicians and we need to promote the quality of care our patients deserve and we know how to give. We can wine and grovel and push back but that is not the right thing to do because this bill provides the access to care for millions of people that could not access it before. It is a great opportunity to get it right, but, we have to take the reigns and deliver what we know is the right thing to do.

For everyone’s sake, let’s make this work. Let’s pull it away from the POLs. If we go along with the political “bull” we will get what we promote and it won’t be pleasant.

Obama and the liberals won the vote in Congress, but will lose big in November.

No one cares about docs, because they no longer value us as anything more than the puny copay they pay the front desk. Docs have done this to themselves by allowing third parties to dictate control of their practices.

Strikes will only make us even more of a villain.

If everyone would just get a backbone and opt-out of all third party plans, and deal directly with patients, we would once again be respected and valued. If not then get used to Obamacare, as it slowly and methodically crushes our profession.


The general public still thinks we’re overpaid, so if we do any bellyaching, they think we are just whining. They don’t realize that they are going to eventually feel the effects of these changes, both in their pocketbook, and in a decrease in service. Docs are going to be getting out ASAP, and there won’t be enough of them coming out of training to fill the void. Certain specialties are already seeing this. Before long, I fear it may spread to all of medicine. I’m getting to the age where things start going wrong, so I’m not real happy about this as a patient either. I may have to keep practicing to take care of my family when the wheels fall off of this thing. November is Coming.
Exactly the road Argentina traveled down from 1910 until present. Egged on by entitlements and expansion of debt spending, which accelerated though the Peronist years. Everything finally came to a head in the late 1980’s when the government and the economy collapsed. Years of 3000+% inflation reminiscent of the Weinmar Republic in 1930’s Germany. Only recently though the most austere budgets have they somewhat recovered. Just to think in 1910 they were on par with America as the two best economic powers in the western Hemisphere. Well as they say those who don’t study history are doomed to repeat it……..


What do you think the poll results would show if the dems proposed a tax on everyone to raise x-billions to cover the un-insured under Medicaid? No body likes to pay more taxes, but at the end of the day the majority of the medical community would rally behind such a proposal. But that is hardly the proposal that was rahmed down our throat. This reform is not about caring for the un-insured, it is about CONTROL. If you’ve ever lived under a dictator, you would recognize these maneuvers intended to nationalize certain industry. These maneuvers just happened to be a little craftier in order to beat the major obstacles in the way: The US Constitution and Rule of Law. Try to get it out of your head that this a “socio-economic” program. This is about power and control. This is the power and control that the Founding Fathers warned us about. They also knew how corrupt and tyrannical governments will inevitably become with more power.You must also understand that even though we took an oath, we never took an oath of misery.



I see private primary care medicine following two paths:1. Fee-for-service rendered (cash-based).

2. Subsidized care. Model where hospitals or the government owns the practice.

Reimbursement will fail to adequately compensate physician movement into primary care—it will ultimately fail as the next generation of physicians decline to pursue this tract. Extenders appear to be the government’s plan to provide this service.

As overhead continues to increase and fees are minimized by the third-party payers, the era of private practice has passed. The exception will be markets where the populace can afford private-care outside of the main-stream model.

(Presently), in the fee-for-service model, the average primary care physician provides about $2mil in down-stream revenue to a hospital system. They are the only player in the current system that can afford to pay physicians. However, the question in my mind is whether it will be in the hospital’s interest to employ the physician; or, if the government will so control the delivery of care that physicians are necessitated to work for the government directly.


Count me in with those who support the current reforms. While the proposed changes are not perfect, I think we’re headed the right way.
I anticipate forced retirement since if will likely be financially insane to practice in an area where Medicare is the HIGHEST payor. When the physician population of retirement areas is depleted, there will be a second real estate crash when people realize that they cannot retire to Florida, Arizona, etc. since they cannot get medical care there.
Might as well go to Canada….. the medicine is socialized as it will be in the US, but at least they have tort reform via the English rule (loser pays ALL costs), seems to have all but eliminated frivolous lawsuits.
the voice of Thomas Jefferson says a lot:
“Most bad government has grown out of too much government”
“Government big enough to supply everything you need is big enough to take everything you have … The course of history shows that as a government grows, liberty decreases”
I’m all for providing low cost health care to those who do not have it-especially the children, but just look to Tricare or the VA system to see that government cannot do it right.


ALL physicians who supported this bill are one or all of these:
1. Employed by another medical group or physician.
2. Works for a HMO as a low paid employee.
3. Academic physician on salary working for a University.
4. Retired physician who feels guilty about his/her success from the prior practice of medicine.
I personally will begin to phase out seeing patient’s on Medicaid and Medicare. The only way we as physicians can have an impact is if it is more difficult for patients to see physicians. This in turn will infuriate them and hopefully will have an impact on the government. Its a shame that the AMA sold physicians out, as they could have had a stronger impact. Their goal was to get the medicare reimbursement SGR formula changed. Where has that led us? No where. We are headed to a 21 percent cut in reimbursement.


Um, I don’t think the voice of the conservative Sermo crowd is at all representative of physicians at large in this country. I am ecstatic that we have the beginnings of health insurance reform here and as a citizen of a leading nation that has not yet seen healthcare as a right, I am proud to see this change and even willing to sacrifice a little of my own self interest if that is what is needed. Anybody want another option? Check out National Physicians Alliance!
I think we should accept only the insurance plans the Congress will make sure they still can choose for themselves! The only savings in this plan will be through rationing. Patients will get much less than what we think they will need. Follow the numbers (and the money)!
In my 15 years in this profession, I have yet to see someone acutally denied the care that they needed, maybe it happens more in your areas, but to this family doc, it just didn’t happen. Docs took care of the stuff, myself included, knowing we we not going to get paid. So, I don’t know if I buy all the “people left to die” stuff that the media throws out there.
I am very disappointed that the general sentiment seems to be based solely upon self interest rather than the general public health. It’s less than flattering to the profession. The reason I chose to practice medicine was to help others, not for the income (though it’s welcome) or the independence (it was clear that such an era in medicine was ending back when I graduated from medical school in 1979). As with almost any legislation, it is less than perfect; there should be more emphasis on tort reform (it would be of psychological benefit if nothing else) and better income incentives for those who practice primary care. So, keep working to improve primary care reimbursement; as for many specialists (of which I am one), we earn – and will continue to earn – a very good living. Excessively solipsistic hand wringing is unattractive. And yes, I’ve taken care of many patients that some of you refused to because they cold not pay.

Emergency Physician in (horrors) Massachusetts


Govt control will be no joking matter. I can not wait for all the performance measures and added restriction requiring enormous overhead to comply. When group insurance rates skyrocket by 300 percent next year, watch out. I am seriously considering cash only practice.
We all care. I have paid my dues, just like you did. In my 30 years as an MD, I have cared for countless souls who never paid me, or even thanked me. You entirely miss the issue. There is no question that the ill and infirm need care. There is also no question that MDs deliver enormous amounts of uncompensated care. The question being raised here is, “Who makes the decisions?” If the decisions are made between me and my patients, I am “all in.” If it is government, then count me out.
Did it ever occur to you that the Sermo docs are bright enough, not just to become docs, but to see that conservatism is the only way for the US to remain a place where everybody has the opportunity to succeed? Handouts do not help over the long term as they cannot last and are never enough and “eventually you run out of everyone else’s money” – Thatcher. Although I am not trying to speak for everyone, did you consider that perhaps Sermo docs seem to be “conservative” because as a group we value a small, non-intrusive federal government, states’ rights, personal freedom (to succeed or fail), and as docs, we value our relationship with our patients and don’t want K. Sebelius in the room with us?
Having worked almost 8 years in 2 western European countries ( Belgium and France) with socialized medicine (everybody with legal status insured), I can predict over long haul ( min 7-10 years) things would even out , expect more cost,almost certainly more deficit and consequently more taxes on higher incomers , but also more patients per physician, and consequently similar income ( lack of enough physicians per population to cover the newly insured population is practically balanced by more and more non physicians practicing medicine ( nurse practitioners, physician assistants, CRNAs, etc) in the US , a factual unfortunate event , but a remedy in this particular situation!
Hysterical FOX NEWS type comments on this matter have no substance!( like almost on everything else)

Our small, completely independent 4-doctor internal medicine/pediatrics practice in North Carolina is thriving and by all appearances will continue to do so. We have a mix of insured, self-pay, and government funded patients. We keep our overhead low, see patients 17-20 hours a week, have most appts for 30 minutes. We insist that our doctors take 4-8 weeks off a year and we both love what we do and do it in a manner that makes us proud.

We hire well, pay decently and have decent benefits for our ancillary staff of seven. We have been on an integrated practice management/EHR system for > 16 years, mostly because it took up the least amount of space in our tiny original office.

We DO NOT outsource our billing, maintain contracts with institutions that perpetually screw us, or take our reputation with our patients lightly.

What is our secret? We make all of our decisions based on whether or not we can live with ourselves while making a living, and we do not expect illness and disability to make us rich. Consequently, we enjoy the privilege of what is still the most powerful force in all of medicine, the good will of the people we serve and the staff we work with. Our patients and staff want to see us succeed so we will be around a long time to share their lives.

Call me idealistic, it’s been said before, but through ups, downs and dire predictions, I still have seen nothing that threatens any MD’s power to choose their response or to care about how they do things. It is a very hard choice, however, when everyone, including your colleagues, is telling you the sky is falling and you should run for cover. Don’t get me wrong, “The System” is an absolute mess. It rewards the wrong things and holds no one truly accountable. And the blame can be shared by all of us.

Truth is, the sky is always falling, but the essential nature of what goes on behind an exam room door never changes…unless we let it.

An observation on the “compassionate” aspect of these health care reform bills — it is not compassionate to promise something that a system is too inherently flawed to deliver, at least over the long term, in a sustainable manner. If you think that systems built on a no-visible-cost, no-accountability premise will be sustainable, must agree that you are: ignorant, naive, or on drugs. Please observe prior examples given above of entitlement-based, tax-the-“rich” economies that have collapsed multiple times in past history. Socialism & its cousins can only be sustained while you have an incentive-based capitalistic source of income to support it. This bill/law will not affect my practice immediately or for several years, but I worry about societal trends and deterioration of accountability. I see it in the families coming to my clinic, & this bill reinforces the trend.
I heard today at the hospital (and this may or may not be true) that NOT EVEN ONE person in Congress who voted FOR Obamacare has had ANY experience whatsoever in the health care industry. Not one!

What do you think of this? There are 19 doctors in the House of Reps, and several in the Senate.

Yes, I think I will accept federal stimulus money, (which was my money before it was theirs) to pay for the EHR system which the government has made it clear they will mandate us to be using within a short few years or face penalties in payment of fees for services. I smell a rat too… all the way from Washington.
Re: Whakerhill:” You are having a heart attack, stroke, in pain – call your democratic congressman/woman. Maybe he/she can help you because I will have retired.”Guess what, until this reform passed, you are now stuck in your job, if you even had one because another insurance company would refuse to cover you for preexisting conditions.
Obama is not the enemy, the insurance companies are.

Get ready for another wave of early departures from active practice. Back in the 1990s I recall seeing something about surgeon’s disability insurance risk rating being dropped to the same level as meat packing workers. Managed care made it seem better to cash-in on their disability policies than try to slog on through the aches and pains that they previously ignored.

Eliminate Private Insurance. Save 25%…..
Now that everyone is going to be insured and the government is going to take care of everyone- I suspect there is no further need for charity care. All the volunteerism of physicians, hospitals and pharma goes right out the window. Everyone will expect to be paid for everything, and the government will cover it. I have always put my faith in the most generous people in the world-Americans, from the small business man, the hourly worker, the churches, and my fellow physicians. American government has been great because it was of these people, but it is no longer. Physicians have not always been vocal and public with their charitable works, but when you see the great works that have been done you couldn’t help but be encouraged. True, everyone did not participate, but many have. Rather than pay lobbying fees and bribes to politicians, many of us have been giving to our patients. Foolish we were, but I suspect no more. The loss of this philanthropy will not only add costs to the system, but will destroy the essence of our profession. The giver gets far more than the receiver from charitable works, but even that has been robbed from us. I suspect there will be even less “professional duty and ethic” in the next generation of physicians as a result of the government take over.
I’m tired, really tired of people trying to squeeze the last drop of blood from us. I hope Athena is not trying to pitch the value of EMR stimulus to doctors! that will be the last straw…
Despite the liberal ideology expressed by a few above, many (?most) physicians entered into medical practice for mainly selfless reasons, but don’t feel we owe our souls to the government or to the public. The amount of time, dedication, sacrifice, etc. we give warrants a good reimbursement, especially considering that a good portion of our pay (or at least mine) goes to life and disability insurance. It’s not like I live in a mansion, or that I have excessive money to spend on luxury. I have hundreds of thousands in debt, I am advanced in age related to retirement, and I have to protect my family because of all that debt (i.e., life & disability). There is nothing wrong with wanting some payment for all the years of sacrifice. We, on a daily basis, give of ourselves in many ways to those who can’t pay. I don’t need the govt. shoving this crap down my throat…it makes me feel much less generous overall.
To insure all is, indeed, a noble quest. Just this morning, I was questioned by a mother of 3 (all present, the youngest one 2.5 months) with chronic low back pain, multiple prescriptions for narcotics, positive urine drug test for marijuana and cocaine, asking for more pain medications. I refused, citing the above clinical anomalies. “You just wait!! Obama will get YOU!!” I’ve got news for you, lady: he already did, thanks to the AMA.

“The Forgotten Man of Socialized Medicine, the Doctor”

This is by Leonard Peikoff and available as a recording or in printed form from the


Get it. It is very pertinent and enlightening.

This is the start of the end. I really feel sorry for physicians just finishing residency. They are know indentured servants. I wish I had a few more years end and I would retire. We have started to change from a society that rewards the productive, self discipline, delayed gratification, and those of merit to one that encourages sloth and poor choices. The economics of this law are absolutely insane an in no way sustainable. Frankly the law assumes every physician and productive member of society is a complete moron. Who will continue to invest work harder and take risks when their is absolutely no benefit. In the end everyone will be poorer, everyone will get worse care, and the deficit will grow. We are not only on the road to serfdom we are getting pretty damn close to the village. I think those that made this law no it stinks to high heaven and that is why they exempted themselves from it.
We truly took one on the chest with this stink feast. No meaningful liability reform, increased taxes, no SGR fix, and the cream de la cream the Independent payment Advisory panel. This group is appointed not elected, has almost no oversight, determines what is covered and what we can charge. To think this group has our patients or us in their best interest is naive at best. I also love how it is a true jobs creation bill 16000 new IRS auditors. Hurray I cant think of a better use of taxpayer money can you. Oh i forgot about fraud and abuse losing the portion regarding intent. as crazy as the coding process is you could have everything confiscated for coding errors with no intent involved. To praise the piece of rubbish is to not no what is in it.

All Americans except for our Sermo Doc 120s in Congress took one on the chin with this law. The real battle begins now. we must get all who run in November to work on repealing the grossly onerous portions, keep what is good, and if the president wont agree de-fund a lot of the law and wait. To the person who mentioned the VAT. I think that is certainly on its way but will just be another tax already on top of the other taxes. Lastly from meeting with members of Congress I certainly think that they believe NP and PAs can do away with the primary care physician and that we will continue to take whatever crumbs they give because we don’t have the sense to say no.

One thing that concerns me about this bill is the low cost of the fines for not buying insurance. If you calculate what the actual fine would be, a family with a $30,000 income would only pay $250 a year in fines. What’s to prevent healthy patients for opting to pay the fine instead of pay for insurance and then the minute they get sick go buy insurance? There’s no pre-existing condition exclusion now so that would be possible. That will cost the system a fortune and significantly lower the number of healthy people in the pool to offset costs. There has to be a better way to implement coverage for more Americans slowly and systematically. I can’t foresee how we won’t all be getting & giving a lower level of care in a few years. I also am concerned about how this is going to overload the emergency rooms with all of the patients that are now “insured” but can’t get in to see a doctor. And does anybody else in primary care really think it stinks to be getting hit with Medicare payment cuts (when all other insurers also base their rates on Medicare rates) and then be taxed additional Medicare and capital gains tax in addition? For a 2 doctor household like mine, that really cuts into the bottom line. And I agree with the many comments above that we didn’t just go into this profession for the money but we did delay making income for many years longer than average and then still spent years paying off debt so it takes a little momentum to get the retirement savings to where you need it. What’s wrong with finally enjoying the benefit of years of hard work? I’m getting my MBA, there will be lots of administrative jobs available.

Well now we docs can all work less and we can’t lose our health insurance either! Awesome! Way to go Obama! Come on everyone..there are huge forces at play out there that us docs cannot control anymore. It is obvious to me as the comments suggest that they think we are replaceable/substitutable for something cheaper, etc. The only thing to do is continue to be the best and when we are missed they will look back at what they had. When we can’t practice anymore and we leave or whatever, some Americans will look back with regret for the loss and others with some idealized joy that everyone in America now has health care whether it is good or bad. I surmise that the former is going to outweigh due to fact that Americans expect the best and demand the most convenient of everything. They will not be happy with the system they will be getting. In the end, we can say we told them but no one listened. So sorry…just keep on keepin on everyone and treat patients as they should and as you were trained. Let the chips fall where they may….it is not worth being miserable. Just don’t compromise your happiness or integrity over this or they will have won control completely.
Please don’t misinterpret … we must continue say what we feel is in the best interest of ourselves and our patients. We must continue to lead with our head held high. We will always have value to the patients no matter what the financial forces try to dictate… ALWAYS!
I’m thinking of charging a administrative fee for all my patients for increasing overhead and declining reimbursement. This is the only way to stay in business as cost to run a practice is rising. Has anybody done the same?
Obama did not kill medicine. Doctors allowed things to get messed up many years ago. We did not do enough to control costs, inform our patients of the realities of med. care, ensure reasonable billing practices across specialties and gen./fam. medicine, and fight for reforms long ago. The system is a mess. The reform bill will likely be a mess in many respects as well. But NO good solution will be possible in the United States where medical care is expensive and the American people demand ‘the best of everything’, and where competition (unlike in all other economic systems) increases costs, not decreases it. At least soon many more people will have access to care. I also fear the future, but I have not spent 2 minutes of my professional life fighting with medicare to provide for my patients (granted, I didn’t get paid much). But I have spent literally thousands of hours arguing with insurance companies to get appropriate studies, drugs, procedures and hospital days paid for. When there comes some absolutely cataclysmic disaster, MAYBE something reasonable will be done. But I doubt it….it’s too late…and Obama’s reform bill isn’t the reason.


I have really started to feel depressed and that I should have chosen another field. I do not mind sacraficing some income but what I fear is coming is that we will be making a ridiculously low wage for our expertise. I really dont think I would have done 14 1/2 years post high school education to make what I could have with a four year degree or less.

Too little, too late. We “greedy docs” have been demonized along with the health ins companies, drug companies, etc. Only the trial lawyers were unscathed, as they go laughing on their way to the bank.
You can pretend all you like, but you speak of drizzles, and fail to see the torrent on the horizon. The die is already cast, the torrent is coming my friend. We might have time to build a stronger dike to hold back the waters, but time is short. Those like you that hide from the truth will benefit from the heavy lifting of those willing to fight the beast if we are successful. But if you fail to engage the battle, you weaken the effort, and you deserve what you get if we fail. Good luck my friend.
My group plans on accepting no Medicaid patients (actually we don’t to begin with)- but the massive # of patients who will now be able to get on Medicaid will need to find Cardiology care elsewhere- there is no way that we can accept nearly 1/2 of what Medicare pays to care for those who tend to be sicker and more litigious. And by the way may the Chairman General Pelosi, and Dingy Harry be subjected to waterboarding (although they will have Eric Holder there to bail them out. This country is being turned into a Socialist experiment.
I believe that we as physicians can have a huge impact on deciding how the system is set up if we will only have the gumption to stand up and be counted. We need to make it clear what we want, and make it loud and clear that the AMA does not represent the average US physician. If we as a group make it clear that we will not cooperate with the system Obama and his socialists are building, we might be able to force a change. It might be too late, but the longer we wait, the tighter the stranglehold will be.
The road of American Medicine has yet to be traveled. The first major cross road will be the Public “only” Option and then the detour of licensure from a federated states licensure to a single federal license tied to the public optIon. But I”m no soothsayer.
Here’s the problem: The general public thinks that “most doctors” support this reform. Case in point: a friend of mine lobbed a ridiculous article at me when I said to him:

“Ask any physician that you know, and I guarantee that >95% of us realize that ramming a nontransparent bill down the public’s throat (against the majority’s will, I might add) is NOT the type of reform we need. Not once has there been any meaningful discussion of tort reform (which would save billions of $$ spent on unnecessary “CYA” testing) or increasing insurance competition across state lines (another simple, easily-implemented way to lower costs). The medical field is NOT happy with this bill in its current state, let me assure you.”

His reply:
“450,000 (signed) physicians completely disagree with you. See

Of course, if you read the article carefully, 450,000 docs did NOT sign this “petition” or whatever you’d like to call it; but it was a group of organizations that “REPRESENT” 450K docs. Sounds a little like the AMA chiming in with their claims that they are the voice of the US physician.

A physician’s view…As a solo practice pediatrician in a very rural, isolated, and medical shortage area, I’ve been following this bill very carefully as it will affect health care in my area, state, and the US very significantly. There are some good points such as no limits on costs of treatments,no denial due to preconditions, and a few others but the majority of the bill will not do what its intended to do. Unfortunately, this bill was crafted by politicians with very little input from doctors in the field. Yes, many from the AMA and its affiliates such as the AAP(American Academy of Pediatrics) supported this bill…but without consulting again, we doctors in the “trenches”. Those doctors in the administrative positions are often far removed from the realities of medical economics or the hassle of dealing with insurance companies and especially, government run health care.

My practice consists of mainly welfare patients on Medicaid, the government run “universal health care program”. Due to the recession, my practice now has increased up to 80% Medicaid. So I am intimately familiar with with this system. And unfortunately, it is not good. The reimbursement is poor, 40-50% less than private insurance, the amount of paper work is atrocious, the hassle factor is horrendous, and the DENIAL of care is HORRIFIC. And unfortunately, this is how the new bill will save money.

As 16 million Medicare patients get moved over to Medicaid, care will be significantly rationed. Most doctors do not participate with Medicaid and the few of us that do are presently overwhelmed. With the addition of more Medicaid enrollees, I’m convinced that they will not have any doctors to care for them. Medicaid is a joint financially shared Federal and State government program. Unfortunately, by moving Medicare (Fed only) to Medicaid, the states will be even more strained. What does this mean? Well, Medicaid doctors like myself will see reimbursements reduced even further and payments get delayed. Last I heard was 3 months. This will cause an ever greater strain as more doctors opt out of Medicaid. So, when I want to refer to a specialist, there are almost none. And if I can plead, beg, and pull strings, the wait time to see a specialist is very…very long.

I’ve not covered the impact on small rural hospitals but the effect is just as bad and many will have to close, further reducing availability of health care. So overall, I am not optimistic about this new law. I’ll try to add more comments but I just got called to an emergency….

There is a lot here, much well-said. One thing I would disagree with, though, is the concept of “increasing insurance competition” across state lines. The insurance monopolies are too big already. Instead I think they need to end the anti-trust exemption (and give it to us instead!) and to break them up like they did AT&T when they created the “Baby Bells” to increase competition. The state insurance commissioners are sometimes the last line of defense against egregious violations, even if they are generally worthless except in the most outrageous cases. But to think of trying to get justice out of some politically-connected insurance commissioner in, say Florida, calling from northern WI, fighting some national giant like Wellpoint, is, Well. Pointless. So would leave us even more powerless than we already are.

As a fourth generation physician, I have seen many changes. When the changes really became bad was in the mid 1980’s with the establishment of HBO’s which began to ration care and make obscene profits. That’s what brought the costs up. We will never see affordable healthcare without the public option. We must have this option to give competition to the insurance industry. The bill passed over the weekend will make some improvements, but costs far too much. Only when the healthcare industry is willing to help their country instead of filling their pockets will we be able to provide quality health care at a reasonable price.
I would actually think this bill had some validity were it not for 3 things
1- Obama’s refusal to take tort reform seriously.
2- Obama dropping the insurance companies’ freeze on premiums
3- Obama lengthening the the drug companies’ time on brand names

Where were the President’s principles when he cut these backroom deals? To me, this makes this law a travesty.

My biggest concern is the polarization of all facets of the American Community. Unfortunately, we do not seem to be immune. In this area, we have brought many of these changes on ourselves. I find myself passionate about both ends of the spectrum, hoping for Leadership that could bridge the middle is some reasonable fashion. The lack of addressing malpractice issues in any reasonable way, clearly shows the lack of interest of politicians in our input. I am concerned for all patients in the future– including each of us that will need physicians to take care of us. Gladly serving, yet very tired!! God bless!
I was just thinking-what would you tell a medical student, with a mountain of debt, who is looking at all of this unfolding to full bloom by the time they are ready to enter practice?

And what happens when rationing of health care occurs down the line when budgets are at their breaking point?

First of all, I’m not convinced private practice is dying, but instead is just changing from what private practice used to be. The best medicine is delivered by a doctor who really gets to know his/her patient and that happens in a private practice, not a fast paced clinic by a pressured doctor. Doctors are smart and creative. This crazy bill will provide new opportunities that maybe aren’t so obvious to us now, but give it a few years and look back. I admit this may take longer than most of us are willing to give it, but once the public realizes that the “free care” means waiting for hours in a clinic setting, those who can will be willing to pay for personalized care. Cash only, direct pay, concierge, whatever you want to call it, if you can deliver it, you’ll be in business providing excellent personalized medical care to your patients and be happy yourself. It will be an opportunity for those willing and able (already is). A well run practice won’t just need affluent patients either, but could provide this personalized care to the middle class citizens as well I think. Think outside the box. There has to be new opportunities now…
I agree, if you mean filling the pockets of the for-profit insurance execs and their shareholders, and mid-level bureaucrats that have nothing better to do than deny care all day long.

I am very unhappy to hear about the longer patents. I didn’t know that was part of the deal. There are so many psych drugs that don’t have generics and won’t for awhile yet as it is, well, in the antipsychotic class anyway. I’m pretty happy with most of the cheap antidepressants and alot of the generic antiepileptic mood stabilizers and lithium, and like haldol alot, too, actually. I treat alot of uninsured and underinsured patients, and so have to know about these things… But sometimes those medsdon’t work, or have intolerable side effects. And even the generic psych drugs often aren’t cheap, and are out of the reach of many of my patients, financially. Or the brand-name ones are Tier-3 for insured patients, which means they pay 50%, and for a $400-700/month drug, well, that isn’t going to happen. Sucks when it was covered in the past, and then at the first of the year the insurance stops paying (no longer on the formulary). But it is rather sad that they have to charge that much to begin with, though I understand that the economics of drug development sometimes justify it. You can’t exactly ask a rat if it is still hearing voices after it got the drug. Or did understand until they started intense TV advertising, now I don’t buy it, as I think that is why they have to charge so much… Anyway, big sell-out to extend the patents. I will have to protest that to my legislators. Thanks for the info.

I agree with my colleagues above that the public may be made aware of the results of the survey but I doubt if they will really care.

I looked at and read that Obama is going around the country selling his Obamacare and speeding up its acceptance hoping that the American public will forget his consitutional betrayal.

What I think will be more helpful would be suggestions and concrete recommendations and a plan on what we can do as citizens and physicians to help people not forget, and to make sure our voices are heard in the elections and to help prepare for the future Aside from reading Ayn Rand ,praying and buying gold(someone suggested this in another post before our triple A rating goes down) what can and what should we do in the meantime? I hope the D4PC can give us the leadership and guidelines we need. Praying for their successful trip and mission.

Nobody cares how physicians feel. We will be rapidly replaced in primary care by physician’s assistants ( though I do not know who they will be assisting) and nurse practitioners. Only when patients realize ther are less available doctors with even less time to spend with patients may this country wake up and start to recognize that what doctors think really does matter…too late…the insurance companies and trial lawyers are laughing all the way to the bank!
I see a real problem for many of my patients. Many of their employers may find it advantageous to just pay the fine and not get insurance coverage. So then they go to the exchange, but can only get a policy from a lowpaying insurer that pays Medicaid scale rates. We cannot accept those policies in private practice, not because we want to drive a Mercedes (my car is 11 yrs old) but because we lose money on each patient at these rates. (Recall the joke about the doctor who was losing money on each patient, but was going to make it up with volume!) Therefore, these patients who like their doctors WILL NOT get to keep their doctors Mr. President, and will have to wait for appointments at the clinics or the few privates willing to take the loss who will be inundated (and whose patients with better paying plans won’t be able to see them). I think it is a brilliantly devious plan to get a significant number of patients out of private practice care, and to get them to eventually accept not just a Public Option, but a National Health Service. Pardon my pessimism, but this administration know what it’s doing.
There would be probably more unhappy physicians if people would be aware that the presidential family and all congressmen are excempt from the health care bill they approved!

As socialism is very good…for others, right?

Not only will this bill reduce your income, it will also bankrupt your country.

The only word of caution I would add here is to physicians who fantasize that they can leave medicine and change to another career or occupation. Be prepared for a shock. If you can retire, that is one thing, but if you think you can walk out of medicine and quickly get another job in the corporate world making as much money, you will be sadly disappointed.

For one thing, no one wants ex-doctors! You will be considered over-qualified or under-experienced. You will probably have to start at an entry-level position, low-paying. And, your skill set and way of thinking does not necessarily translate well into the corporate-business way of doing things.

Sales, however, is a natural fit for physicians, who are used to interviewing people. However, selling is hard work, and requires considerable effort at prospecting (something foreign to doctors) and a very thick skin (rejection happens every day, and one must be able to deal with it–no ego strokes).

people MAY NOTcare how physicians feel, but i don’t think they really understand what is going on behind the scene……the majority think that doctors make too much money, “so who really gives a shit if their reimbursements are cut”!!! but they don’t understand the reality and gravity of the sacrafice and suffering we do for this profession. so PEOPLE MUST UNDERSTAND. and the only way that will happen is if we walk out for a day and then see what happends. people don’t really care about trash collectors until they walk off the job and then everyone gets desparate and really cares to find out how they feel and what are the real issues. WE REALLY NEED TO STICK TOGETHER AS A PROFESSION, NOW MORE THAN EVER BEFORE. my astute colleague pointed out that physicians are not trained to work together as a whole. our residency training teaches us how to work independently and to be extremely competitive with one another. but this is not residency anymore…..this is real life. SO WE NEED TO GET WITH THE PROGRAM. afterall we are regarded as a profession that comprises of the most intelligent people of society….so let’s start acting like it! we need to stop being passive and more of the “offense”.
I’d say the same thing I have said on other posts..
There are over 800,000 docs in the US. You have polled what, 1,000 on a mostly very conservative site?


The employed docs are doing just fine right now… I am private practice and I am doing just fine.. There will be accommodations in the current system to cope with the new laws.. and when things don’t work, the laws will be modified… while we all wish the current bill was different in many ways, guess what, it isn’t…

We should all be working to get more economically conservative legistlators in the Congress and then try to incrementally improve this puppy.

It is not going to be overturned… the lawsuits are a waste of time… The Supreme Court does not involve itself except in rare cases with these kind of public laws… There is nothing in the Constitution about a mandatory income tax.. but guess what.. don’t pay yours and you will end up in a cell next to Wesley Snipes!!

I am so disheartened that it hurts.
Back door deals, bribery, blackmail….apparently that is what makes todays world go around.The passage has ushered in a virus that will never be killed. I do appreciate Dan’s work and all of those of you who cared enough to post on sermo. It does give some comfort that I am not the only one willing to fight.


Obama and friends do not want to help medicine or help our patients, they want control over the lives of Americans, they want to destroy liberty, look at the people in power! Many of them admit to loving Marxist ideas, admit to wanting to destroy America. They don’t even know what private enterprise is, they would not know how to run a small business for one day. They are all career politicians and their politics is Godless marxism, Obama wants to “CHANGE” America into a marxist country where there is no liberty and freedom, where everyone is the same, where there is no incentive to do anything but depend on the government. I visited East Germany when Russia was in control. It was like a black and white country in a color world. No one worked, the food was pitiful, everyone walked around East Berlin with a scowl on his or her face, they had no hope. Do you want a country with no hope, let Obama stay in control with all his cronies. If you want hope, if you want freedom, if you want the freedom to practice your religion, then do not vote another Democrat into office. The worst Republican is light years ahead of the best Democrat. Look how Representative Stupak (Stupid) folded! Does he have any principles at all? Remember what happened this week next November and vote every Democrat out of office. Let Obama see what the outcome will be when he tries to take away liberty from Americans. Wake up! Look at history! Has socialism ever worked? It never has! When you take away incentive and liberty and true hope, nothing good comes from it. What I don’t get is that a lot of supposedly smart doctors and nurses just flock to Obama like moths to the light. Doctors wake up! Take our country back. Remember what happened in 1776. If you want socialism or marxism move to Cuba or Venezuela. America is the last best place on earth and they are ruining it. My only hope is that God is in control, and no matter what they do to destroy our liberty they will never take that away from me.
I think one of our biggest problems is that if they asked 1000 of us in primary care to answer “what does it cost you to see one patient? (please provide some data to back your number) that over 90% of us would not be able to answer.

We may have the info here and there but we haven’t asked ourselves that simple question and figured out the answer. If we figure that one out, we could have some idea of whether any contract makes sense or not.

My multispecialty group looks at what it costs us to see patients for each contract (based on time to reimbursement, administrative costs to meet information requirements of the plan [do they ask for patient past records on every claim to see if they can get out of paying it or is their formulary so restrictive that we have to prior auth anything not on the Wal-Mart $4.00 list] and do they have a lot of patients in the area [such that we can batch our billing to them and generate economy of scale or are they a little fish that we have to assign a specific billing specialist to so that we can get it right when we bill them.])

We also look at how often do they pay us correctly, because we have found that many of the plans “do not have the correct fee schedule loaded” for us, and that for some reason, it usually underpays us a couple of bucks. The ones that seem to know what they agreed to pay us and pay us accordingly do not require as much effort to get correctly paid so their contract rate does not have to be as high as ones that seem to stack the deck in their own favor.

Bottom line on the new healthcare bill… they havent even finished it yet, so neither they nor us know fully what is in it. We need to read it, dissect it and wrangle the intent out of each section to know what helps, what hurts and what it will do to medicine. Back in school we divided the work up in study groups to help cover the massive amount of material, and we need to do the same here. As my mom told me many times, “It’s just like eating an elephant, you have to do it a bite at a time”

To close, I will pull from the great philosophers Lilo and Stitch. “Aliens are all about rules” which means, if we learn the provisions and figure out how to put them to work for us, (or change them if they cannot work by exerting appropriate pressure for specific points rather than just “throw it all out and start over”) the powers that be will have no choice but to live up to the specifics.

To: Daniel Palestrant, MD
I couldn’t find an email address for a personal note to you. I will have to share this note to you with the entire SERMO community. Come to think about it, perhaps it may not be such a bad idea sharing my comment with the whole community there may be at least one other other physician in the USA who finds a bit of truth in my comments.First, I’m probably one of the few physicians in America who thinks that you should stop having Rush Limbaugh, Randy Neugebauer, Glen Beck, and Gerry Callahan construct your survey questions. A move to someone a little more balanced such as Karl Rove would probably be a step forward. But let me get to the the point of this comment.

From January to June of 1965 I found myself in the bluegrass of Kentucky finishing my internship. The King-Armstrong bill was moving through congress. Most of the medical community across the country was up in arms predicting that the private practice of medicine would no longer be possible after July 1, 1965, if the bill passed. The sky was falling in and and physicians would become paupers or low level government employees. It was a scary time but fortunately President Johnson sent me a letter of greetings inviting me to take a vacation in Vietnam, wherever that was. I accepted and spent 2 eyeopening years waiting to see what would happen. After my trip to Disneyland East and and a re-entry stay at Fort Devens, I accept an honorable discharge and returned to the land of tobacco. Much to my surprise the sky was still blue and it hadn’t fallen in yet.

Over the next 40 odd years I observed physician’s earning a living wage in an interesting profession that was making progress in treating illness. I was happy to see that most of my physician colleagues were able to live in nice communities and could afford to educate their children in good schools. But I also observed some not so happy situations. Unfortunately, we were 32nd in health status. However, we did spend twice as much on medical care than other developed countries.

Then in November of 2008, I again heard that the sky was going to fall in. After spending four decades in the silver age of medicine, I was too old to take a vacation in Iraq, Iran, or Afghanistan. I didn’t know what to do. Then on March 21, 2010 the sky fell in 219 to 212. On March 24, 2010 your survey arrived and forced me to face reality and make a decision. Confronted by the poll, I decided to take a gamble and vote for history repeating itself. So, I am now looking forward to a golden age in medicine where physicians will live long and prosper and their patients will have an improved health status.

You ought to look at the old clips from 1965 they may give you a different perspective on what might happen in a rational system that makes healthcare a right for all not just a perk for the wealthy and powerful. You could even take a look at Ignatius and his emphasis social justice. When people are suffering hardship and oppression, their business is our business. Social justice calls us to open up our eyes to the needs of others who may be suffering due to the way we conduct business.

So I voted in the poll. I believe that we have taken the first step toward considering the community’s stake in health care. I am convinced that this will lead to a truly fulfilling and rewarding career for physicians in the future. We certainly can’t stay on the path we are currently taking.


You are making the logical error that many make, which is the assumption that because some of us are opposed to the complexities and totality of THIS bill, that we are opposed to any sort of reform.

We are not. Most of us would welcome rational reform. What we are opposed to is sweeping reform that threatens the economy because cost controls are not addressed.

You see, the world is not as simple as A or B; up or down; black or white–it’s actually a thousand shades of gray, and all the colors in the rainbow. Which means that if we don’t want “x” it doesn’t mean we want “the opposite of x.” There may be many other options.

I’m afraid this bill will provide lower quality care for all. I suspect we will all have a better idea of the ramifications of this bill in a year after we have spent some time living with it. I wonder who will replace those who go out of business?
Let’s incorporate. All of us. To hell with their anti-trust laws. They’re making up their own laws as they go along. They have broken every covenant with the American people. What are they going to do?
This is so much more than just a Healthcare Reform. I hope that is not a revelation. They couldn’t care less about the uninsured. It is about control. Well, let’s turn it on its head.
Notwithstanding the “poll results” as presented here, my guess is that many physicians will end up behaving very differently than they purport in all the angry rants and bluster shown above. It happened after Medicare passed in 1965 and it will happen again. Additionally, as predicted by a number of us who appear to be grounded more in reality than in polemics, already the American public appears to support (49% vs 40%) the reform bill that was passed. My guess is that the support will continue to grow as the actual elements of the bill become evident as opposed to the general BS and frank lies that were perpetrated by the Republicans (eg. death panels, government take-over, etc.).
The Bill is flawed, no doubt. The insurance companies make out like like the bandits they are and the pharmaceutical industry still doesn’t have to negotiate prices for meds. That will change as good sense starts to percolate to the top.
Perhaps even some measure of tort reform will evolve which would be a good thing. That being said, malpractice claims never contributed more than 2-3% to the total cost of medical care. Still, it’s nonsensical and we’re the only society in the developed world that tolerates it (kind of like being the only society that doesn’t have a single payor system). Last week, I had dinner with an Irish attorney who tries an occasional malpractice case. Contingency fees are illegal in Ireland and most (if not all) of the rest of Europe. Anyone interested in adopting the whole ball of wax as exercised by the remainder of the developed world? Their approach seems to be much less expensive and delivers better results according to most actuaries.
I find it interesting that everyone likes to blame the (recently passed) healthcare reform bill for the decline of medicine. Anyone who actually feels that this is actually going to change anything is foolish. Truthfully, nobody really knows WHAT impact this will have in our profession. There is a great deal of prophesying and fearmongering about what the future will hold. Most of these predictions are based on “facts” that the opponents of the bill put into the media frenzy, and were further propagated by an uninformed public. I think most people who have been physicians for a while SHOULD be able to clearly see that the decline we see today has been YEARS in the making. Obama didn’t cause it, the democratic congress didn’t cause it. People use the term “Obamacare”, and imply that the system was great before we elected him. I am sick of party politics and the resentments it creates. Had a republican been elected president and came up with the SAME bill, the democrats would have been calling foul.


I just wrote a few well thought out paragraphs for the past hour—and hit add comment and they didn’t get posted and are now lost!
boiled down: Do away with accepting reduced fees via contracts: The Insurance fraud law needs to be changed to eliminate penalizing i=the uninsured with the Full Price! Wall Street Journal front page editorial approx 3years ago “The 20,000$ Appendectomy. And another editorial a week or two later “The Pricing of Generic Drugs”!
Have a national insurance clearinghouse for insurance applications, and claims.
There is no rational reason that an individual is charged premiums higher than the “Group Rate” from an insurer! The Actuarial risk of the individual is unchanged by being an employee! The Group Rate doesn’t apply—the N should be 300,000,000 ! The premium should be the same for all. A national clearing house eliminates the excuse that it costs more to administer the paperwork to an individual!
Eliminate the expectation that the employer is responsible for providing insurance! Make it portable and increase the N to 300,000,000! But still use Private insurers!(Is this what is done in the German Health Plan?)
Have a National professional regulatory board which meets at regular intervals and which negotiates fees and rules, which includes medical and insurance & gov. participants.
Nationally regulate the health insurance industry/ take that away from States! With an agency sorta like that of the Banking Industry(but better :)…to get uniformity of rules and solvency!

It’s very interesting to see the split between family medicine docs and specialists- only the former seem to have a significant percentage supporting the current “reform” package. This shows that we really ARE, in some way, just greedy bastards. Family docs truly are underpaid, but are for this package, at least to some degree, because they think they’ll get more reimbursement in the new climate, while specialists KNOW they’ll get less, so they’re against it.

The times are definitely changing, whether we like it or not. I think the change provided by the current legislation is misdirected, in terms of achieving best patient care, but medicine is NOT going to stay the way it’s been up to this point, regardless. In my own specialty of diagnostic radiology, our greed for avoiding night call by using tele-radiology is now progressing to the point where most small hospitals that cannot a full staff of specialized radiologists are going to the model of having one generalist on site to perform fluoro and other basic procedures, and farming everything else out by tele-radiology. Is this good for patients? YES! The problem cases can now be read by sub-specialists or sub-sub-specialist who will be far more conversant with the problems presented than the generalist ever could be. Is this good for the individual radiologist? NO! Unless you’re an interventionist, and can still pick & choose where you want to practice, you’ll either be a non-procedural specialist sitting in front of a PACS screen as an employee, or a generalist practicing in an area where you wouldn’t even consider bringing your family to live 5 years ago. or working as an employee in a major urban health care center. I myself am a generalist who just saw a hospital in a small mountain town with no amenities and an hour from even a middling-size city fill a permanent slot with a radiologist who came from all the amenities of the DC area, because that’s the best he could find in this situation! I myself am such a generalist, but too close to retirement, and too happy with where I’m located, to move. I’d hoped to do locums for 2 more years before retiring fully, but in the limited market for my type, this will probably not be an option. My penalty will be having to dig into savings earlier than planned, and having a slightly-lower quality of life in retirement than I’d hoped, so I don’t get off quite scott-free, but I’m glad I’m not in this specialty, 40 years of age, and facing another 25 years in the current market. NEVERTHELESS, if we truly believe that the patient comes first, it’s probably a better way of practice for the patient’s benefit.

For other docs, the greed is in signing on NP’s and PA’s to bring in extra revenue while taking off a large portion of what they earn for our own profit. Where do you think the manpower to take care of the newly-insured will come from? Do you really thing you’ll be able to limit scope of practice for these people in the future? Primary care docs better be preparing to see their practice opportunities and income go down, as well- you’re likely to lose most, if not all or more, of what you think you may gain under Obamacare.

For all of us, we’d better prepare for being gov’t. or employee “slaves”, or setting up insurance-free practices, and trade some of the patient base and income we’ll lose to maintain control over our lives and practices. in almost ALL cases, prepare for a drop in income and lifestyle, and I pray that you weren’t living up to your last dollar of income, but chose a lesser lifestyle, and to save some money, before all this hit the fan.

The point is that the LACK of a health care system is not an option if patient care, and not self-interest, is truly our aim. Obamacare is an abomination, too, being a profit guarantee for the insurance companies, dropping the majority of the new people covered into the unsustainable Medicaid system, etc. We need a system that does not pay from dollar one for patient care, but where the patient is responsible for day-to-day medical care. Do we have business suit insurance that pays you for a new suit, when your old one wears out, except for a $25 deductible? Then why should we have health insurance that does so. Insurance should cover catastrophic costs only- the type that would pull your child out of school, force you into bankruptcy, etc. What “catastrophic” is should be determined by your income level, and all should have the option of a tax-free HSA, should they so choose, to cover the rest. Don’t make it mandatory, but don’t bleed for the people who fail to cover themselves and suffer the consequences if they develop a serious illness, either. We DO need a program to cover the truly needy- or an obligation to provide them free care. If we do opt for a gov’t. program, let’s be honest and say it WILL require a tax increase, rather than trying to hide it in an unfunded mandate (Medicaid), tax only the “wealthy”, etc. Let’s see if the American people truly have any compassion, or if greed and selfishness triumph here, as well.

thanks Dan. Just about every poll says 60-40 against just like the overall polls in the country 40% conservative, 35% indi (who split 60/40), 25% libtard. And its the latter with the power right now so shame on the other 75%.

I get a laugh at the MDs who post that the survey is biased, its underpowered, its written by Rush Limbaugh. Have heard the same crap for years at credentials, peer and quality committees from physicians confronted with facts. . . And to the PCPs and ED docs who think this is a zero sum game and when the specialists lose you win – think again – the independent NP is going to replace you at 75% of the cost – and guess who gets to do primary care for everyone Mr. ED doc – just like Mass. now.


From the study
<<Only 16% say they are basing their clinical decisions on what they think is
best for the patient rather than what payers are willing to cover>>

Anyone thinks we dont have covert rationing going on right now???

With all due respect, attacking the survey doesn’t make much sense. First, the demographics of the survey are very representative of practicing physicians, and most questions, when you lump the Likert scores into broader categories (ie, yes/no, agree/disagree) , the numbers are pretty close, suggesting little bias. Second, 1000 respondents for a physician survey is pretty good-again, as long as its representative (see above). If the demos at the end of the survey are correct, I am hard pressed to think of another physician organization which is more representative of US docs. Can you? Third, the results are consistent with other physician satisfaction surveys over time, in that ~50% of doctors are ambivalent about the future.

It sounds like you are in the ~50% that are optimistic-and that’s great. (As an employed, salaried doc I am fairly optimistic about my personal security, I just don’t know why we are letting our profession get raked over the coals in this bill while everyone else gets plate after plate of pork shoveled their way.)

BTW, if you don’t like this survey’s methodology, you must have hated the AMA physician practice survey, which was based on 36 responses, concluded that most cardiology offices did not use paid staff, that practice expenses decreased by >30%, that equipment was in use 100% of the time, and was in direct opposition to three other validated and current practice surveys out there. CMS chose the AMA’s survey. Go figure.

Pay-for-performance will NEVER work. It’s just one more way for the government bureaucrats to gum up the works. It is incompatible with free-market economics and human psychology. Fee-for-service worked just fine until the government began its incremental takeover several decades ago. There is noting wrong with fee-for-service. It works just fine for accountants, attorneys, plumbers, auto-mechanics, and everyone else in our economy. And it worked just fine for doctors until abuse of insurance became widespread. Fixing that issue would have resolved the problem. Instead, Medicare introduced price controls and central bureaucratic management, and things have been deteriorating every since. It’s time we doctors stopped taking blame for this; and it’s time we stopped letting people bad-mouth fee-for-service, the standard way professionals get paid in a free-market economy. Medicare and the federal government policies ARE THE PROBLEM, not doctors or fee-for-service.
The 21% pay cut from Medicare scares me, however it has been taking months for me to get paid at ALL. Always an excuse not the correct number, a computer glitch, the case manager is out, call back next week. It makes me think they don’t have the money.
But, many of the predictions about Medicare DID happen. Government meddling did create the current mess. The folks in 1965 were right. Things just didn’t completely deteriorate as quickly as expected.
This time the sky is falling. The bureaucrats are even more incompetent and determined to control US! As for social justice: I don’t know anyone more concerned about this than physicians. But, if you’ll notice, they didn’t even ask for our opinion. I don’t believe that this has anything to do with social justice. I believe it is a power grab. And yes, the system definitely needs fixing. We ALL agree on that. But, WE are the ones who should fix it.

Please note my post above. None of the legislators with ANY health care experience voted for this bill. Zero. What does that say?

Now is a good time to correct the facts on the advent of Medicare and the physicians in 1965. Johnson faced a nationwide rebellion from the docs in this country after Medicare was passed. He overcame this by (1) promising to pay the docs for their work by paying their fees in full, and in typical LBJ fashion, threatening to bring the full force of the government down on the AMA, state medical societies, and county medical societies under the antitrust provisions of the law if the doctors really refused to accept Medicare patients en masse. Over the past 40 years, in spite of the pie-in-the-sky attitudes of the frontal lobotomized docs who love government intrusion, we have lost many, many of the freedoms we had in 1965. We now have the government, the joint commission, the hospitals, and the intermediaries watching our every move. We now have the pseudo-science of evidence based medicine declaring the ONE right way to treat any disease. We now have the total loss of the mental health system (compared to 1965). And the list goes on and on, et cetera, ad infinitum.

Now Obama and the dimwitcrats have passed another vast entitlement, so large that we none of us (and certainly none of them) can know what is written in the bill. Passing a law, and entitling the bureaucrats to make rules and regulations is an invitation to further physician abuse and harassment. When the extra 30 million have Medicaid, they will flock to the ER’s because the private guys won’t see them, just like now! The government will respond eventually by forcing docs to see ’em. To follow will be determinations of what specialty training and how much is allowed, as well where the young doc will practice. Witness the reports of recent federal actions against a group of docs who refused to sign new Medicare contracts in the midwest. Unprecedented, but emboldened and desperate bureaucrats feel safe in doing this in our times.

The Arabs have a saying: don’t let the camel get its nose under the tent; he will soon be in your bed!

Thomas Jefferson was right about government. It will (has) become the danger. DeTocqueville thought so, and looks like he was right also.

Did any Democrat physicians vote for the bill? The most noteworthy and vocal physicians are all arch conservative Republicans who have received substantial sums of money from insurance, pharmaceutical companies, etc. Alternatively, the are radical, right wing conservative religionists who claim to be responding to “a higher authority” (my apologies to Hebrew National).
For the first time, we have parity for mental health coverage. Do you not think that is an improvement? The existence of Medicare has taken on a large percentage of coverage for emergency services which previously were un-reimbursed. Surely, as an ED doc you knew this. The “freedoms” we have lost are largely a reflection on the billing games that many docs play in order to support fees for their lucrative, procedure-based practices. If you think the current sorry state of health care is solely a reflection on Obama, you have your head stuck someplace where the historical sun doesn’t shine. I note that your comments only relate to the blow to your financial bottom line. Any concerns about the increased availability of adequate routine and preventive care for an additional 32 million people such that you and some of your colleagues will no longer be able to bad mouth the “crocks” and “gomers” who show up inappropriately on your doorstep?

The question asking if we’ll be refusing insurance compensation and going to a type of cash-only business will be moot. I bet that, like Massachusetts, medical licensure will be contingent on accepting the government and private insurance payments for service.
It relates to the systematic dismantlng of the private/public state by state system of mental health care. He knows as an ER doc and I know as a PCP, hospital specialist, admin for a large (>300 MD practice including pyschiatry), and hospital CMO that the present bastardized system of “managed psychiatric care” has created a system where the truly psychotic either constantly in transit between jail, hospital ER, and if lucky state hospital, with MSWs and PhDs delivering “managed care” while the remaining private psych MDs push pills and order labs for offices full of private pay OCD, depression and old fashioned neurotics (fee for service of course, cash at time of service, medicare, medicaid and most insurance not accepted).

Great survey. It’s clear that physicians can expect further deterioration in their autonomy over the next 2-5 years. This is specially true for primary care physicians who would have to comply with the greatest number of quality metrics and have the largest burden of reporting requirements.Specialist too will see declining revenues. Some can partially buffer this by restructuring their practices and redesigning workflows to increase efficiency.

In many cases, high malpractice and increasing administrative costs associated with the growing reporting requirements and P4P pressures will make it very difficult to maintain a private practice. In this new reality, physicians must be business savvy and learn very quickly how to play the survival game.

I don’t know if you can say that the sky is falling for physicians but the fact that we are being squeezed from every direction is very clear. Lack of transparent leadership has been a major historical problem. I think our best bet is to figure out a way to direct the flow of the changes on the horizon in our favor in order to optimize how we care for our patients. We need to do this through innovation and strong leadership.

This may be too late. I am sure many of the docs have read works by Dr.Peikoff. For those not yet familiar…this was copied and pasted from www.capmag.comHealth Care Is Not A Right
by Leonard Peikoff (January 23, 1998)

Delivered at a Town Hall Meeting on the Clinton Health Plan
Red Lion Hotel, Costa Mesa CA
December 11, 1993
Good morning, ladies and gentlemen:

Most people who oppose socialized medicine do so on the grounds that it is moral and well-intentioned, but impractical; i.e., it is a noble idea — which just somehow does not work. I do not agree that socialized medicine is moral and well-intentioned, but impractical. Of course, it is impractical — it does not work — but I hold that it is impractical because it is immoral. This is not a case of noble in theory but a failure in practice; it is a case of vicious in theory and therefore a disaster in practice. So I’m going to leave it to other speakers to concentrate on the practical flaws in the Clinton health plan. I want to focus on the moral issue at stake. So long as people believe that socialized medicine is a noble plan, there is no way to fight it. You cannot stop a noble plan — not if it really is noble. The only way you can defeat it is to unmask it — to show that it is the very opposite of noble. Then at least you have a fighting chance.

What is morality in this context? The American concept of it is officially stated in the Declaration of Independence. It upholds man’s unalienable, individual rights. The term “rights,” note, is a moral (not just a political) term; it tells us that a certain course of behavior is right, sanctioned, proper, a prerogative to be respected by others, not interfered with — and that anyone who violates a man’s rights is: wrong, morally wrong, unsanctioned, evil.

Now our only rights, the American viewpoint continues, are the rights to life, liberty, property, and the pursuit of happiness. That’s all. According to the Founding Fathers, we are not born with a right to a trip to Disneyland, or a meal at Mcdonald’s, or a kidney dialysis (nor with the 18th-century equivalent of these things). We have certain specific rights — and only these.

Why only these? Observe that all legitimate rights have one thing in common: they are rights to action, not to rewards from other people. The American rights impose no obligations on other people, merely the negative obligation to leave you alone. The system guarantees you the chance to work for what you want — not to be given it without effort by somebody else.

The right to life, e.g., does not mean that your neighbors have to feed and clothe you; it means you have the right to earn your food and clothes yourself, if necessary by a hard struggle, and that no one can forcibly stop your struggle for these things or steal them from you if and when you have achieved them. In other words: you have the right to act, and to keep the results of your actions, the products you make, to keep them or to trade them with others, if you wish. But you have no right to the actions or products of others, except on terms to which they voluntarily agree.

For the rest of the article…


Decreasing specialist income to level the playing field is not the same as an increase in primary care docs’ incomes. I’m not sure what makes primary care docs think they will somehow get more money without changing anything on their end. And those who feel somehow protected with fixed salaries at universities will also see a decline in payments once the hospital realizes what they are now worth. This could present itself as fewer employer paid benefits initially but you will essentially earn less also. It’s a business no matter where you are working. Time to stop saying “I don’t care about the business side of things, I just want to see patients.” I always hated hearing that.And, while I am hopeful for the best, getting physicians to unite would require a miracle from God because all of us have such different goals. I’m sure the only way opting out would work for most physicians is if EVERY competing physician in their area opted out. Or if things get so bad for patients that they are willing to pay the fee so they don’t have to wait. A lot of patients can afford a doctor visit – they just don’t want to pay if they don’t have to, but this is normal human behavior if you are given that option. What they cant afford is expensive medications and big procedures and hospital visits, etc. This is what insurance should primarily be for.

This is a win for patients. And in the long run us doctors will be ok. Some people will find their cheese has been moved, get over it. It is not the poor who have been getting the free lunch to this point. I hear a lot more entitlement in these posts then I do from my patients on Medicare or Medicaid. And please stop all the talk of “Doctors coming together.” We are not all the same and never will be, for better or for worse, that is the way it is.
According to their website, Doctors for America has 16,000 members. However, they are politcally well connected and work closely with other progressive groups. Although they are officially non partisan, they were formerly Doctors for Obama prior to the election, and changed their name afterwards-you can follow their Facebook history as well as track the board members. So it’s hard to say you’re non partisan when every member joined a group dedicated to electing a single public official :)Not surprisingly, they tend to be more progressive and skew a little younger demographically; most board members are within 3-5 years of residency and work in employed positions in large academic institutions.


Remember that docs are expected to help patients in all facets of their lives, not just their physical health, and becoming dependent on the government for handouts will not benefit any of them. Don’t just supply the fish – teach them to fish! Self reliance, liberty, and encouragement go much farther that creating more entitlements which is Obama’s goal – so that he controls all of us.

The current reform bill has merits but also a lot of deficiencies. It does provide relief esp to the middle class but does nothing in improving access which may well be diminished from the increased demand. It provides no remedy on the Medicare reimbursement formula or TORT reform. It is mainly a cost-shifting scheme even though it is deceptively labeled as cost-savings which cannot be achieved in an aging and adiposity-accumulating population. It will be supported by both an increase in taxation on most and a shifting of expenses to the states.
It is probably well-intentioned but nonetheless deceptive in presentation.

You’re right-except the bill doesn’t really even provide relief to the middle class; most analysts, and even the economics pundits at the NYT who pushed for the bill, concede that any increased cost borne by insurers will be passed on to policy holders, which will in turn result in increased premiums, or in the case of employer supplied insurance, decreased or flattened wages.The entire bill is a cost shift exercise in which only two groups-patients and physicians-will be left holding the bag. And it’s not like we have friends on the GOP side, either. Their main complaint is that, in effect, this bill doesn’t hurt us enough. I have come to realize that, given the ties both sides have to insurers and industry, any and all talk of “cost control “is code for shifting costs onto physicians, decreasing physician reimbursment, and limiting physician autonomy. Witness the payment advisory board and the prohibition of physician owed hospitals. We need a serious lobby in Washington. Unfortunately its the only way to push back.

The bill does nothing for us as physicians with regard to the Medicare formula, access is unchanged or worse with more patients to cover, and TORT reform which in my opinion is VERY BIG problem is not at all addressed in the bill. What we need is to eliminate the third party payer system, which in essence is broken.

“Unfortunately it is the only way to push back”.I ask:Is it?This should be a purely professional issue for us.The political process IS the political process.It feels like we have yet to be pushed far enough;there will be no rhetoric once our collective threshold is breached.Doctors who defend the bill may stand to gain from it.


What I meant above is that until we unite to fight this mess as a profession,with one voice,in a non-partisan manner,we will continue to take it up that highway named after the town in Pennsylvania.
Our voice as physicians has been deliberately ignored.
It can be attributed to self-serving economic forces (the evil empire of the insurance sector and their friends in corporate America) and to our completely ineffectual national leadership (which has consistently sold physician interests down the river for decades).
Also we must never underestimate the unsympathetic attitude toward the medical profession in the aggregate by the general public. It’s completely different from the one on one doctor-patient relationship.

Pushing back as a united profession is essentially pushing back as a lobby. The reality is that if you don’t have an office on K street you are invisible to our elected leaders.

What we need is a company with dollars to represent us. To serve our interests and to move/promote legislation that represents us as a community. We need lobbyists that are supported by a company that sponsors us.

The key is Congress . . . that is far more important than the Presidency.
We need majorities in the both houses of true citizen conservatives, not party loyalist on either side.

I have read “Atlas Shrugged.” and will reread it.This is a horrible , horrible plan, and the start of more and more and more government control

This little Independent plans to vote for every Republican that I can.
and I pray that Palin does not have the arrogance to run in 2012

Health care dollars in America have been grossly misappropriated for the past 30 years. While we docs have taken an 85-95% cut in pay, the price of healthcare has zoomed up due to OVERPAYMENTS to 3 big industries: (1) pharmaceutical companies (Why should an ophth.steroid drop that cost $0.79 in 1985 cost $75.00 in 2010?), (2) medical device companies (Why should an Orthopedist get ~$800 to fix a shattered ankle, including 90 days of post-op care, while the company that made the 6 titanium screws get $60,000?), and (3) health insurance administrators (Why should the CEO of BCBSNC get a $300,000,000.00 Christmas bonus?) I have never read an article that referenced a study that proved EHR can improve the quality of healthcare—have you?
We will all be stuck with all pts being on a national health plan. Eventually we will all be employees working set hours (ALL DAY LONG) like when we were residents. Glad I will retire in the near future but fell sorry for my younger colleagues. Or will the govt open up clinics with NPs and Foreign docs only. Sad, very sad. Sounds like our only hope is D4PC.

ehr’s are a joke. why can’t somebody invent a chart that has all the data on paper right in front of you. no logging in, no timing out, no down time for updates. oh that is what we did have.


We will all be stuck with all pts being on a national health plan. Eventually we will all be employees working set hours (ALL DAY LONG) like when we were residents. Glad I will retire in the near future but fell sorry for my younger colleagues. Or will the govt open up clinics with NPs and Foreign docs only. Sad, very sad. Sounds like our only hope is D4PC.
do you really believe that there is ANY chance that the “law” will be changed to any significant degree, or as Hannity and Rush say, repealled after November?There is no chance for any of the above. Even with a majority, the poison is introduced. Like HIV, once infected there is little that can be done to prevent progression, only slow it or stall it.

I have been as adament as anyone, but the facts are, we DONT MATTER. We are now pawns to be used. the next step is Hospital envelopement of docs, employment at ridiculous wages, more regulation. Private practice is dead, and so is independent practice. BO is very arrogant, and for a reason, he can be. He all but dared the House/Senate to try to repeal the law, and is it not likley he would be so bold if he didn’t know something we don’t.

Docs4Patientcare sounds great but the fact is that this and any other physician move is good natured and in the patients best interest. Both factors that mean nothing to congress or most obama supportors who want something for nothing.

I am very disheartened and feel little hope for my let alone my childrens future, in what used to be the greatest country on earth. Proof of the depths of our depravity…..Fidel Castro has formally endorsed Obamacare…..Has it really come to that?

Here is something not mentioned ANYWHERE in the media. See HR 3590, Chapter 48, Sec. 5000A. Requirement to maintain minimum essential coverage.”In the case of any failure by a taxpayer to timely pay any penalty imposed by this section, such taxpayer shall not be subject to any criminal prosecution or penalty with respect to such failure.”

So, people can *still* refuse to obtain insurance, refuse to pay the fines, and face no prosecution or penalty. Who in their right minds would pay for insurance, or pay the fine for NOT having it, knowing that there is no fear of prosecution or penalty, and they can *still* obtain insurance at any time, with guaranteed acceptance and limited lifetime benefits?

There is much to say – oddly I didn’t give a shit. Things are screwed up now, and it’ll likely be worse. The public thinks we make too, much, and will continue to do so as many of us go out of business.Investing emotion is a waste of time. We can thank Obama for vainly stirring the coals, with things in motion there is chance for both conservative and progressive to battle the status quo. This could be good.

In the end there will be a finished product. Be it a sculpture of manure or a fine Sermo Doc 120piece remains to be seen.

I see a lot of people who are losing their insurance, and I care about them.

I see rude partisan statements here, particularly from the left. I don’t care – you can judge a tree by it’s fruit.

I will close my doors when I must. 21% might just do that.

For primary care doctors the choices remain: (and have been for a while now)
1. Chicken sh**
2. Bullsh**
3. or suicide….1. You work for the chicken feed the insurance companies and medicare want to pay you. (chicken sh**)

2. You as a doctor start selling vitamins and doing facials or dispensing dope..(bullsh**)

3. You work your butt off trying to game the system and die early…

I gonna be selling real estate guys and gals, I’d love to have your referrals and list your homes that you can’t afford any more. I can sell them to insurance execs and dope dealers, politicians and other criminals who can afford them!

No matter what flowery wishful thoughts our colleagues have imagined about this new era of American socialism, the details in obamacare will wash away these delusions soon enough. If you don’t think that lowered reimbursement rates will force you to consider dropping that insurance, you are delusional. If you believe that a group of new patients clinging onto a piece of paper that signify their right to your time and energy, and that all expenses in this paper are to be paid by you, will give you pause – you are delusional. The looters can only accomplish one task – to loot.

In the name of the people.

I suspect that medicine will now evolve to operate under the VA model. I anticipate more clinics and little longterm relationship between a single physician and patient. Patients will get a new doctor every year or two and consistency in health care will diminish.There will be many programs to educate patients on preventative health but like most vets the population will largely ignore recommendations and be as healthy as the average vet.

I am really tired of the ones who say this bill was a good thing for America and all of those who are uninsured as now they have access to health care. If you are a physician and were so concerned about their access before, you could have seen them for free. I have. The problem with insurance that covers everything is the patients do not “have a dog in the fight”. They must be responsible for their health. Look at the biggest abusers of the system….Medicaid…they don’t have to pay a dime, so they show up at the emergency room whenever they have a hangnail or a sniffle. Another issue is that everyone will have to buy a certain kind of health insurance-this is just wrong. I know what is best for me and my family, the government doesn’t. I want a plan that covers only the catastrophic which is what I have now. I am healthy and take care of myself as does my wife, so we don’t need or want some comprehensive BS plan that covers everthing and that we will be paying thousands a month for. As far as a moral obligation? What about a moral obligation not to kill a fetus? Or a moral obligation to feed everyone? Is that what is next?…the government will now provide food and shelter for all…Health care is not a right people. You cannot say it is a right as it is a service that is provided by others. One thing about liberals is that they are good at spending other people’s money…
Great presence,presentation and delivery Dan.You were able to emphasize the tort reform issue,the primary problem we face in day to day practice which rated no mention in the current bill.We virtually practice with guns to our heads since the entire environment forces primary care physicians to accelerate their pace,use ancilliary practitioners etc. just to make ends meet,all of which increase the risk of errors(omission and commision).
As an anesthesiologist in private practice, I am a service provider. I have contracts with surgeons. If our surgeons decide to drop Medicaid or Medicare patients then clearly we would not be disappointed. We also have contractual obligations with hospitals to cover call. Due to this obligation we don’t have a say interms of dropping Medicare and Medicaid patients. Ultimately this HC bill will destroy private practice. As anesthesiologists we will likely be hospital employees in the future paid by the hospital which will be receiving state and federal subsidies.

The CNBC report presented the results of this survey in an inaccurate manner, which is an unfortunate sign of the obvious bias promoted by SERMO as an organization.It was stated on the air that 66% of physicians are planning to drop Medicare and Medicaid because of reform. Repeated for emphasis by President Palestrant. Not true.

That was not the question asked. The question asked was more like: Will the health reform changes lead you to “consider” dropping Medicare and Medicaid? And in a frustrating moment, doctors are much more willing to say Yes, as a vote of anger. But realistically, they are not going to drop Medicare. Perhaps metropolitan elite practices have the option to do so, but middle America lives off Medicare. It will never happen.

It is disappointing that this open forum (just like our congressmen) cannot present results that are meaningful, accurate, and not skewed by biased question structure. Who is lobbying Sermo?

I would ask that each physician take a moment to create a mental snapshot of healthcare practice right at this minute…or actually one week ago.
Be honest with yourselves- you believe the current state of affairs is pretty terrible. Please admit to yourselves that your statements about where we are NOW on this board, to colleagues, family, and anyone who will listen have been overwhelmingly negative. Abuses of the insurance industry, intrusion into our practices and our interactions with patients, declining reimbursements, the malpractice situation…these just scratch the surface of our discontent. Please acknowledge how bad things are now-don’t take my word for it…YOU have been saying so.
Take a “snapshot” of where we are now, and realize it has NOTHING to do with the bill that was signed 72 hours ago. I ask that you do that so you can honestly assess the effects of the bill. A day, a week, a year from now, many of you will be blaming “Obamacare” for screwing up healthcare. If you can remember how terrible you thought things were on March 21, 2010, a day before it passed, you will be able to more accurately assess the impact of the bill. Unfortunately, many are already blaming the bill, when in fact it hasn’t even been implemented yet.
We want some legislation which will actually FIX some of these problems. This doesn’t. It pretends to, but it doesn’t. Physicians deal with facts and truth. Problems don’t go away because we (or anyone else) wave a magic wand. That is the way that politicians think.

Actually, today, Fidel, very much still alive, called ObamaCare “a Miracle”!! That tell you anything?

My income has dramatically increased since I opted-out 12 years ago. The free market works just fine, and will get better as more clueless doctors close their doors. The demand for doctors is increasing as the supply shrinks daily.

My fees are going up. The Laws of Economics are as sound as the Law of Gravity.

The 21% cut happens April 1. There is no money for a Doc-Fix, and no one in Washington will add 280 billion to the deficit for us. Tom Coburn M.D. himself blocked a one month extension. Good for him, and our country.


Here is another thought:

Making money and caring about patients are not incongruent.

There is no reason to feel guilty for wanting to earn a great income.

My training and experience are worth a great deal.

For those above who feel guilty – that is fine – kindly leave the rest of us out of it.


For cash MD 🙂

Cannot wait to go for cash.
Meanwhile, charging a 35 dollar annual administrative fee. Have patient sign a short letter designed by our healthcare attorney. This was done about two years ago. Have not rechecked to see if it is Ok.


A couple of thoughts…….Physicians need to realize this fight is not over, it is just beginning. In Massachusetts, there is already a bill in front of the state legislature to make participation in Medicare/Medicaid a condition of licensure. This is important for number of reasons, not the least of which is that the MA universal healthcare reform, enacted several years ago is extremely similar to the one we just implemented on a national level. Tying your medical license to participation in these programs is simply the next step towards socializing medicine. As best as I can tell the Mass Medical Society are completely MIA on this….

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.


Direct cost of healthcare is >18% of GDP.
Real effect is more eg do they count effect of job losses which are in healthcare segment?
The fact that they have not agreed to participate in the same plan they are mandating for the public says it all !!
They won’t even discuss tort reform,how they can possibly keep things defecit neutral,how patients can keep their present physician and insurance plan when they are hell bent on destroying both,etc.,etc…….
How can they expect anyone with half a brain to accept their non-answers and arrogance??Or are there more surprises coming?
The founders of our country warned that the people should never allow congress to pass laws that didn’t also directly apply to those serving in congress. It is now the solemn duty of the people in this nation to stand up for what is right.
Sadly the doctors who support OB are CLUELESS.. they did NOT pay attention to the Indian woman interviewing OB leading up to Nov Presidential Election.. She complained that The Reservations HAD NO DOCS< NO CLINICS< NO HOSPITALS…

What did she expect after YEARS OF GOV MEDICINE??

the Irony here is that this evolution has no other plan to STEAL FROM..

GOVERNMENT MEDICINE IS FEAST or FAMINE and anyone who has actually worked in GOV spots KNOWS THIS.

ok , so Medicaid ran out of money, STEAL from Medicare

VA ran out of money STEAL From Medicare.. Indian reservations out of gov medicine money .. just run down..

It is great to be altuistic and want best for all, but reality is WHO WILL PAY.. certainly NOT the GOV who gave themselves EXEMPTION from this CARE.. so ROYALTY WHO PASSED THIS will be in one CLASS of HEALTH CARE and the rest of us in the Famine GOVERNMENT health care.. btw.. those of you who are happy, I will be so happy when you get your cont pay cuts below cost of providing services…. but then only so many of you can go work in the Presidents CASTLE.. and since your character will be in line with His.. ,, well , a patient in his 80s taught me that those patients who go to docs just like themselves.. get exactly that.

PS WORK TO KEEP further american students OUT OF MEDICINE>. they are NOT going to the MISSION FIELDS with DEBT…

Chuck SHumer had the audacity to say today that this reform is going to further decrease the deficit. !!
He is NOT telling Property owners in NY state that the Medicaid increase which is 90% linked to property will tax homeowners out of their homes.!!i am amazed at the ability to lie with a straight face by Pelosi and Shumer and Reid and OB

to those of you who are optimistic of this and blaming past docs charging too much, I must inform you that it was

President Johnson who CUT the copay and premium to 1/5 th of what they KNEW Medicare would cost in 1965 and so it was predicted by the Insurance Commission in 1965 that Medicare would run out of money in 1990.. In 1990 medicare started PRICE fixing and CLAIMING that the docs were charging too much and technology cost too much INSTEAD of taking any personal responsiblity.. DO NOT ask ME to take Responsibility.. In my field i was taking asthmatics who were repeatedly hositalized and stabilizing them and improving quality of life and decreasing their costs… THE GOV LIES AND BLAMES YOU and NEVER THEMSELVES… do NOT be so IGNORANT anymore.. WAKE UP .. or try to as eventually you will learn the hard way…………..

we are already seeing people show up in our ER with non-emergent issues saying. “Now that health care is free I want to get checked out” If you combine this with EMR which is being insisted upon by Obama et al (which has proven to be less efficient than more) we should anticipate national ER wait times to explode across the board. This does not even take into account the number of docs who will choose to opt out from obamacare/medicare and medicaid….this will drive these patients to the ER in record numbers.

add 30 million patients AND lower cost AND increase quality? What are they smoking?
The reality is: Insurance premiums will go up across the board. See it from the perspective of an insurance company: No lifetime limits, disregard preexisting conditions, no ability to kick people out once they became too expensive….All three measures I do not agree with and that people rightfully were very upset about, but that kept costs down for the insurances. So, much less means to save money. What are insurance companies going to do? Pay out less, meaning cut reimbursements. Second, increase premiums.

I cannot say that this new business is driving me to retire because I already planned to retire at the end of this year (I will be between my 69th and 70th birthdays at that point). But it is reinforcing me that I have made the right decision. It also is notable how all the people interviewed on national TV – both the politicians and the “experts” the networks bring in to discuss things – really do not know what they are talking about. Somebody gives them talking points and they say them
as much as I disagree with Howard Dean, he is at least apparently honest and stated this is the first of a planned redistribution of wealth from the upper and middle class to the poorIve said it many times, this aint about healthcare, its about POWER

we are just the patsies to get them their power

30 million patients are being added to the system. OK so what happened to them before?

My guess is that they did not get care until they got really , really sick and then put a bigger stress on the system–on the emergency services, intensive care units, etc. I think alot of them had to get emergency medicaid anyway, which requires a big beauracracy itself. I don’t think they stayed out of the system by staying healthy and then dying.

“what are the ins co going to do”?Give me a break ….just look to the salaries of the leaders of these ins cos.Do you really believe 85% of premiums go to patient care ?If you added up the cumulative salaries and benefits packages of the top 10 inscos ….mindboggling.But you are correct thats exactly what they will do.They wont be regulated.
The PATIENTS? We complain about the reimbursement bureaucracy and torts but we are lucky if they are sympathetic when we are mugged burgled or Killed! OK the case in CT was “there but for the grace of God”..and the Gun Nuts. (Petit family.) They figure we are rich and we DO have recession proof profession and live comfortably. The PAPERWORK is what gets me. Yesterday I spent half an hour on the phone trying to get oxycontin re-approved for a patient answereing stupid questions. If it was approved let it STAY approved! I am Sooo SICK of CMN and prior authorizations.Medicine stifles my Creative Mojo

Unfortunately here in NJ, we’re being crushed. All major commercial insurers pay less than Medicare – the big A pays an OV at 65% of regional rate. Just got an offer from another payer – 53% of MCR. And here there is reg/law/contract that prevents any balance billing,even when reimbursement is below cost. So my question is how do you give high quality care, work so few hours (I’m solo, work 6 days/60 hours) and still make a decent income, without burning out? BTW, many of my patients think doctors (me included) make too much $. ALL of them make more than I do.

I have a private practice and teach part-time at the VA. I think most Americans need to experience what our veterans have for years.(long waits for surgery and being bounced from one doctor to another) Alot of the veterans see a PA first and then maybe a MD or resident! The point I am making is that the VA is the model for our future health care! I wonder if our congressmen or Mr. obama would go to the VA for their healthcare! Let’s vote them all out in November! They have too many benefits and are worthless.

Like it or not YOU must get actively involved in politics if medical care in these United States is to maintain the quality it has acheived. The recent revelation of a proposal to produce 3 year medical wonders (primary care physicians) is just the beginning. Your politicians can at will make physicians. The educational institutions will fall all over themselves to get at the moneys offered. They will prostitute themselves.
So, if we are to save medicine as we know it; YOU must get involved. That means contributing time and money on an individual basis. It is only at the ballot box that this usurpation can be stopped and controlled. Don’t give these so called socialist credit for just trying to help people. They are trying to help themselves to hierarchy within the new order. And since they have no moral compass, they move by any means available or necessary.


For all of you who feel strongly about overturning ObamaCare, I suggest that you leave the AMA, hopefully you have left long ago as they only care about protecting their coding money $70 million per year which the government allows( which is why the AMA supported ObamaCare) and join the Association of American Physicians who just filed suit to stop ObamaCare ( ), and the AAPS had actually filed suit against Hillary Care and won in the past.
Obama! How about you stop giving warmongers American taxpayer money and start taking care of Americans instead.How about treating the Physicians with some respect and dignity? We could’ve been scum lawyers like Sebelius, or yourself, or Wall Street 401k robbers like your major political contributors, but we chose to care for life instead- to keep alive fathers who support their families, kids, mothers!

You will be punished in hell, and we probably will too, but you (all politicians currently serving, with Bush and Cheney included) will be punished longer! It’s my curse anyway and I hope it comes true!

Pay for Performance? How is this determined? Does this mean that a Radiologist will get paid more if the imaging is read as normal vs abnormal. So should the CV physician only operate on the 50 or younger non smoker without hyperlipidemia at or below ideal weight who is a performance triathelete without a family history of Cardiac disease, depression,or diabetes living on the Ornish vegetarian diet, wealthy, intellectual, living in a Buddhist monastery?
Obamacare is, as we all know, destroying the patient-physician relationship. I do not know of a physician that does not care about the well being of the patient. If a person is in need of medical care they receive it. We all became physicians to help people. Financially, we all charge fees, I believe, appropriate to the level of our skills. As insurance companies and the government continue to reduce those fees and essentially tell us how to practice medicine, our independence will be gone. The vast majority of physicians appreciate the freedom and independence of the practice of medicine. That is just about gone. It is the same feeling that all Americans feel and enjoy by living in this great country. When our freedom is gone the thrill will also be gone.
Obama is not to blame.The present system is a mess and reform is definitely needed.The healthcare bill is a starting point and with time changes will be made to improve it.
I have lived and worked in the system projected by these reforms. The downside goes further than lower pay. Both physician and patient lose power. Patient anger turns to regret and then apathy. Physician anger changes to frustration and then resignation. I hope there will be a middle way.
The reforms have the potential to remove the proprietary interest physicians have in their business and will not be able to practice in a way that is fair and ethical to themselves and very bad for the patients who will lose a champion.
The present system has to be changed. It has the character of a Greek tragedy. Do you want the Devil or The Deep Blue Sea?
We know the Devil and I’m glad that will go but what will come in it’s place. The battle has just begun. Those who quit or threaten to should go. Most are ‘blowhards ‘anyway.
This is the chance for physicians to reclaim medicine for themselves. Quit whining and act positively.
I read one post above said: “There are some good points such as no limits on costs of treatments,no denial due to preconditions…”
This makes it impossibly expensive. “no limits” does not exist in the real world and something is going to have to give and that something will be the hard work of doctors not getting appropriately compensated and taxes going sky high and of course extremely high premiums for commercial insurances thus forcing many who don’t want to to go to government insurance…. thus creating the universal (and totalitarian) system the left wants. Money has to come from somewhere people; it does not fall from the sky. Let the people hold the money and they themselves can ration it as they see fit. This will cause price shopping and will then reduce costs eventually.
I am not happy about this situation! My patients are predominately insured by Medicare.
We are so worried about what this 21% Medicare cut will do to us! Our situation is not the same as other physicians. We have the added expense of 24/7 care for a severely disabled child in our home, which we elected not to place in residential care.
I suppose I don’t have to add that there is little $ left over with the outrageous taxes I pay! And I understand they will only go higher! Makes me wonder why I stay in such a stressful field for such little reward…
Thanks AMA… you A…holes!!!!

I hate to say it but we deserve what we get as a profession. Being on this site for a while, I have heard many complaints about the way the system works. Being in business for the last three years I’ve learned that I was nothing but a fool to think that as a doctor I was going to save the work and people should respect us for that in itself. I used to think business was a bit slimy and that my profession was better than that. I tried to change the system by doing something I thought was good – I found it was impossible to do without turning to the business world. It has been said time and again but doctors need to smarten up about business and pay better attention to what is going on in our own profession. There was a recent post on PA’s wanting more respect and there were so many negative comments – but the point is, at least they are standing up and fighting for themselves. What are we doing?

I’m a Doctor. And This Stuff Even Confuses Me!!!

Extremely irate on the East Coast writes:

I’m a doctor. I have an MBA from a prestigious business school. I understand medical billing. Here’s a story for you that sums it all up.

After many years as an independent, my OBGYN recently joined a large physician group affiliated with a nationally known academic medical center.

(I’ll keep the name of the institution out of this since I like my OBGYN and several of my friends work at the medical center.)

Late last year I had a minor procedure at the academic medical center. My OBGYN handled the surgery. Everything went smoothly.

When the bill came I was charged a reasonable $600. This year I had to have a repeat of the same procedure. My OBGYN again performed the procedure. Same outcome. Same nurses. Same specialist. Same room. When my bill came in the mail I got the shock of my life. The total was four times as much as it had been a year earlier!!!! I had no idea.

My OBGYN’s office told me there is nothing they can do. Prices are set by the new academic medical center supergroup. As far as I can tell, the only thing that has changed is the sign over my doctor’s door.

What recourse do I have? What consumer protections does the ACA contain designed to prevent this kind of behavior?

I’m a doctor. I understand the issues involved. If I’m confused, how is the average consumer supposed to deal with this? This is extremely bad.

Lost in the health care maze? Having trouble with your health Insurance? Confused about your treatment options? Email your questions to THCB’s editors. We’ll run the good ones as posts.

Wal-Mart Could Transform Care–But Does It Want To?

“Why is Wal-Mart speaking at a health care summit?” the company’s vice president for health and wellness, Marcus Osborne, rhetorically offered up at a conference back in January.

“Wal-Mart’s in retail, we’re not in health care.”

But as analysts, researchers, and other experts who spoke with me. took care to point out, Wal-Mart is in health care, and getting further entrenched by the year. In the past six months alone, Wal-Mart launched a major contracting initiative with half-a-dozen major hospitals, and dropped hints — since retracted — that the company is exploring new services like a health insurance exchange.

Notably, Osborne teased a broader health care strategy for Wal-Mart that would include “full primary care services over the next five to seven years,” in a Q&A at that January conference captured by the Orlando Business Journal.

Wal-Mart has since denied Osborne’s comments — the second time in about 18 months that the company has had to walk back stories about its planned primary care services — and Osborne subsequently stopped talking to the press. (Wal-Mart declined to comment, and Osborne did not respond to an interview request for this story.)
But Osborne’s remarks from that January conference, and his other archived speeches, are still readily accessible. And they paint a vivid picture of a company that’s not just a potential market-mover and disruptive innovator, but an organization that could do a lot to positively reform health care.

Background: Wal-Mart’s Growing Role in U.S. Health Care System

In many ways, this isn’t a new story. Back in 2007, Princeton University’s Uwe Reinhardt suggested to NPR that Wal-Mart could be “taking aim at the entire health care system” by expanding its new discount drug program.

“I think it’s a really fascinating way to come out of the corner and really slug the system,” Reinhardt said at the time. “At the moment, the body blows don’t hurt. But they add up. I’m watching this with great fascination, and expect more from them.”

And in subsequent years, Wal-Mart did grow its health care footprint, from launching retail clinics based within its stores to advocating for national health reform. Considering its history — as recently as 2005, Wal-Mart had little involvement in the health care market and was being pilloried for skimping on its own employees’ benefits — it’s been a significant turnaround for the firm, and has positioned Wal-Mart as one of the leading disruptive innovators in health care.Continue reading…

Thank You, Angelina

Dear Ms. Jolie,

Thank you for your bravery and leadership in the battle against breast cancer. In a small way, through my patients, I understand the challenge and pain it took not only to undergo prophylactic mastectomies, because you carry the BRCA1 cancer gene, but also to reveal this deeply personal part of your life to the world (NYT, 5/14/13; My Medical Choice). You had no obligation to open your soul; your selfless act leaves those of us that treat the dread disease, in awe.

Your action will save more lives than all the patients I could help, even if I were to practice oncology for hundreds of years. By opening up the conversation, by educating and by boldly stating that beauty, strength and health are possible, even when radical choices are made, you open up life saving opportunities for many. Mastectomies may not be the answer for all women, but the very idea that cancer can be prevented, instead of simply waiting in fear, is earth shattering.

Women and men will now better understand the genetic risks for cancer, be exposed to the different options which are available in the prevention of cancer and know that it is possible, whatever path is taken, to continue with full lives. You have made it easier for patients, their families and physicians to have vital discussions.

The announcement of your surgery coincides with a critical legal battle, the deliberations of the United States Supreme Court regarding BRCA genetic testing. You have put pressure on the Court to find against Myriad Genetics Corporation in the company’s attempt to protect their expensive monopoly of the breast cancer genetic assay. Thus, the Court will have the opportunity to reduce the cost of testing, which as you note, can run thousands of dollars per patient.

Your action changes the war against breast cancer. You have prevented the suffering of thousands and given them the opportunity to go on with life and be part of what is truly important, families and communities.

Thank you for your remarkable sacrifice.


James C. Salwitz, MD

James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.

Did Angelina Do the Wrong Thing?

A woman’s mother dies at age 56. A blood test is done. The woman finds out she has a genetic pre-disposition to cancer. She takes what action she thinks she needs to take. A familiar story repeated over and over again every day. I’ve met many women who have made this choice. While not “normal”, it is a familiar situation. These women’s difficult choices go unheralded. But not Angelina. She has a voice and she’s not afraid to use it.

I am of two minds about Ms. Jolie’s announcement. Unlike double mastectomies for ductal carcinoma in situ (DCIS), which isn’t necessarily a cancer and can be treated with a lumpectomy, BRCA1 gene mutations can’t be treated any other way. Unless I hear differently from my breast surgeon friends, I’d say she probably did the right thing. Her decision to talk about it is probably encouraging to women who have or will have to make that choice. It raises awareness of the gene mutation. It puts breast cancer on the front page of the New York Times. Again.

Here’s my problem: double mastectomy is not a benign procedure. Ms. Jolie seems to have had a remarkably easy time of it. Yes, she says she was right back to her normal life soon after, but since Jolie’s life is not normal that’s hard to generalize. The truth is there is significant pain involved, a long period of waiting while the tissue expanders do their work, then there’s further procedures for the implants, which can develop capsules around them, or rupture, or get infected. If Angelina had chosen breast reconstructive surgery there would be the risk of the flap losing blood flow, multiple drains, overnight stays in recovery rooms or ICUs, and many many surgeries for revision, nipple creation, etc. And the results are not always beautiful. I understand that it is not Ms. Jolie’s role to scare people, but to encourage them. I would just warn against falsely rosy expectations.

I am not trying to discourage double mastectomy. Sometimes it is necessary. I do think that people who have extraordinary access to public attention must pay extraordinary attention to what they say. I wish Angelina all the best for a complete, and beautiful, recovery.

Shirie Leng, MD is a practicing anesthesiologist at Beth Israel Deaconess Medical Center in Boston. She blogs regularly at medicine for real.

Into the Extrapolation Machine

The Kaiser Family Foundation (KFF) recently released a study that showed that 42% of Americans are unaware that Obamacare (the Affordable Care Act) remains the “law of the land.” News like this seems to us, to act as a Rorschach test on how observers feel about the law. Considering 50% of Americans can’t identify New York on a map we tend not to read too much into these polls. However, according to the logic of extrapolation, since we know that the ACA remains law, we are in the elite 58% (it’s about time we made it into the elite of something).

In almost parallel to the KFF news, the New England Journal of Medicine published a follow-up study of the “Oregon experiment.” For those who haven’t been following closely, the study found that previously uninsured people who were enrolled in Medicaid did not see an improvement in clinical measures when compared to those who remained uninsured. The study did seem to show a reduction in the amount of financial distress for the insured however.

Another contentious study, another Rorschach test (example, example). The problem we see with the polarity of views is that both sides seem to be cranking up the extrapolation machine and use single studies/data points to draw broad conclusions to gin up opinions about ACA’s success or lack thereof. In light of the fact that for most practical matters ACA doesn’t really get going until 2014, use of the extrapolation noise generator approach smacks of a lack of analytical rigor in our view. We will know soon enough how the program is doing… exchanges start enrolling on 10/1.

As investors, we should state upfront that we tend to give more weight to financial returns than what the philosopher-kings might call the political context. So what caught our eye in the Oregon study was that Medicaid recipients had higher healthcare utilization rates (and associated costs) than the uninsured. The connection between gaining insured status and healthcare utilization should not come as a surprise since there is a very extensive literature elucidating this connection.

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The ACO Failure Hypothesis: Likely But Not Inevitable

We recently participated in a program at Columbia Business School’s Healthcare Program on whether ACOs (Accountable Care Organizations) will fail. For those of you that don’t know, ACOs are one of the structures promulgated by PPACA (aka Obamacare) designed to encourage better cost control and quality improvement in the healthcare system.

The current zeitgeist among the commentariat is that ACOs will fail (examples: here and here). We think the reason for the one-sided nature of the question is that those of us who lived through the healthcare upheaval in the early and mid “90s” saw first hand the failure of PHOs, PPMs and IDNs (and all of the other acronyms now relegated to the dustbin of history). When ACOs are touted as a saving grace for the system, you can almost hear the collective groan of the industry veterans.

Ever the contrarian, however, we took the side of the debate that said ACOs will NOT fail. The premise of our argument was that since we already have a good idea of why the structure will fail, we can, a priori, fix the shortcomings, and though likely, ACO failure is not inevitable.

There is an extensive list of why list of why ACOs will fail. We put them into four general buckets.

Infrastructure: The system has mis-allocated resources so we have too many of some things and not enough of others leading to inefficiencies.

Technological/telecommunication: For a number reasons the healthcare system has not adopted technology as fast as other industries.

Cultural: Providers are habituated to fee-for-service payment mechanisms and patients aren’t likely to change their own healthcare behaviors.

Inertia: The well known system problems (e.g. asymmetry of information, the Pareto nature of patient demand, unexplained variation of care, counterproductive incentives) have been around forever and are difficult to overcome.

Because we spend most of our time identifying private healthcare companies with investment potential, we often get a view into what is happening in the entrepreneurial space under the punditry radar.

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Why You Probably Have a Lot Less to Fear From the Latest Superbug Than You Think

Infectious disease is the most hyperbolic of all medical fields, at least when the media gets ahold of such.

Right now we are to fear a new avian influenza virus. Previously there was another avian influenza strain whose outbreak threatened the world and of course SARS and, more distantly, the ebola virus and the threat of bioterrorism. And on the periphery, as these acute threats come and go, is the persistent threat of super bugs; bacteria resistant to multiple antibiotics. Sometimes all antibiotics.

I remember my pharmacology professor in medical school claiming that within our practice lives we would reach the useful end of antibiotics. A claim, literally, that physicians would no longer have any use for antibiotics by the time I reached the end of my career.

Scary stuff but evidence that such outrageousness sells pharmacology in a classroom as much as it does magazines on a news stand. Time magazine a post called “The End of Antibiotics?” referencing a Guardian article along the same lines. This followed a similar 2009 scare article in Time.

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Is Patient Engagement the Solution…or a Healthcare Urban Legend?

The following statistic from the Centers for Disease Control and Prevention (CDC) never fails to shock: the 133-million adults – or “nearly 1 in 2” — with chronic disease account for 75% of spending.   Engaging those high utilizers, the story continues, will help bring healthcare spending under control.

This storyline is a classic healthcare urban legend.  Essentially nothing in that paragraph makes sense as a matter of policy, or even arithmetic.

Yes, the CDC got their arithmetic wrong.  133-million Americans comprise about 60% of adults, not “nearly 1 in 2.”   Second, their definition of “chronic disease” specifically includes stroke, which is a medical event, not a chronic disease, and cancer, many of which would not fit that definition either.    (Sloppy editing and arithmetic is a CDC trademark.  They also observe that ”almost 1 in 5 youth…has a BMI in or above the 95th percentile” on their growth chart, which of course is mathematically impossible as written.)

Third, speaking of definitions, how are they defining “chronic disease” so broadly that 60% of us have at least one?   Are they counting tooth decay?  Dandruff?  Ring around the collar?

Corrected or Not, The Statistic Itself Makes No Sense

The statistic is intended to demonstrate that a concentration of costs among people with out-of-control chronic disease but actually shows the opposite.  It shows a diffusion of costs, not a concentration.   60% of adults accounting for 75% of spending – or even the incorrect 50% of adults accounting for 75% of spending — is about as far from a 20-80 rule as one can get.    Basically costs are not concentrated in ongoing day-to-day chronic disease.

Second, that 75% covers all expenses of that 60%, not just being out of control and needing to go to the hospital, which seems to be the underlying assumption behind the flurry of activity designed to engage these people and control their conditions.  Quite the contrary: in many conditions (rare diseases, high blood pressure and asthma come to mind) preventive drugs already overwhelm medical events as a expense category.  In a typical commercial or even TANF Medicaid population, only about 10% of hospitalizations are for the five “common chronics” of asthma, diabetes (and its complications), CAD, COPD and heart failure.    (In Medicare this percentage and absolute number are much higher – that is indeed a population where control of chronic disease matters.)

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