The end of medicine as we know it ...

[DCJenn]

I think it's too early to start panicking too much- the bills are so divergent right now that what ends up in the final version will be very different than what's there now.

Things are definitely going to be different but like all change, it's the devil you know vs. the devil you don't.

I'm sure every single physician out there would like to see changes to the medical reimbursement system and I'll bet that every one of them wants something different. Add to that the hospitals, clinics, insurers, Pharma, medical equipment suppliers and manufacturers, the nurses, the staff and all of the medical administrative people and if you ask them THEY'LL all have different answers to what is the right way to get people covered and try to contain costs.

I don't think that this Bill is the END of medicine, but I do think it's the BEGINNING of a drastic and arguably drastically needed systems change. It's not going to be perfect, or even all that good at first. However, historically most of our important social change legislation has started at X and as things have worked or not worked, they've been tweaked over time. I was listening to a commentator on NPR the other day who was saying that when Social Security first passed it was a terrible bill that everyone hated.

It's not going to be an easy process but I'd argue that the current system is already on life support.

Jenn

[Flynn]

I'm sure every single physician out there would like to see changes to the medical reimbursement system and I'll bet that every one of them wants something different. Add to that the hospitals, clinics, insurers, Pharma, medical equipment suppliers and manufacturers, the nurses, the staff and all of the medical administrative people and if you ask them THEY'LL all have different answers to what is the right way to get people covered and try to contain costs.

.................

It's not going to be an easy process but I'd argue that the current system is already on life support.

Jenn

Ditto to the above.

I'd also like to point out that docs are indeed PART of the problem in addition to all the other layers. They do a HORRIBLE job keeping track of outcomes and data based medicine with respect to each individual doctor. There is no checks and balance system in place and lets face it, SOME docs have been abusing the system for YEARS.

Medicine has gotten increasingly more expensive with technology. Some docs really keep that in mind and only order tests where it's medically necessary. I can name 10 docs off the top of my head at DH's hospital where it's COMMON knowledge that as soon as X and Y symptom shows up they order about 5 tests that cost over 5 grand. Two are medically necessary and DH along with many other docs agree on this. These docs have been doing this for over 5 years. Nobody says anything to them. Clinical medicine is fast becoming extinct and so far that's BEEN OKAY.

Granted many docs feel they NEED to order fancy tests due to the fear of being sued and I'm not minmizing this. That definitely plays a roll here.

The point is this is so layered and Obama is a small player here.

DH feels that non procedure docs will just find another way to bill to compensate for consults and other things that are cut.

[medpedspouse]

Me too...

We've stopped talking about it because I just hate seeing the defeat in DH's face when I know he's thinking that he won't be able to provide for us in the way he thought when he chose medicine. No doctor goes into it just for the money, but it's a huge gamble that is no longer paying off in financial terms or in terms of personal satisfaction.

They really have doctors right where they want them - they're not allowed to strike, and they have too many loans or are too far behind on retirement to quit.

Same here...including the defeat. We never went in it for the money BUT hoped that it would at least pay off the student loan debt.... in less than a lifetime.

The really sad thing is that our spouses don't have much in retirement because they do not make anything while in med school and not much at the GME level. So, you pretty much spend a buttload of money for an education, for a career that is not going to pay you much - to cover your educational "investment", and you will be 8-10+ years behind your peers in putting money away for retirement. Not much of an investment huh?

[PrincessFiona]

Re: The end of medicine as we know it ...

Jenn this is NOT in the bill. It is separate and started Jan 1. It is a done deal.

Done. Deal. The new pay scale for Medicare is out and includes no more consultation codes for specialists as well as major cuts. This is unrelated to the possible 21.2% cuts on hold.

These payment changes are in effect. Every physician in the system is affected in some way.

So we punish all for the misakes of a few?


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[Flynn]

So we punish all for the misakes of a few?


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I have no way of looking this up (part of the problem with docs and medicine in general) but I would say it's NOT a few. So...yes, we all suffer.

[DCJenn]

Well, if it's a done deal then it will have to be undone or changed or whatever. It sounds like its a way to force people to back in to the health care reforms as there will be no other option.

This is just one more symptom of the very sick system so yes, apparently everyone has to pay for the way the system forces lots of people to work. As Flynn said, there are abusers of the system - some have legit reasons, some don't. The whys don't matter and nor does it matter that there are docs who don't abuse the system.

That's why the whole HMO debacle didn't work out either- there were physicians who responded to the financial incentive of not ordering tests by not ordering any tests or enough tests or appropriate tests/services.

and of course, the political will of the country is not to tackle any of the elephants in the living room. The biggest elephant is the baby boomer generation who will completely change our medical system, our social security system and will continue to expect top of the line services. No one wants to figure out how and who is going to pay for these millions of aging people.

There should be a better way to pay for the drastic increases in Medicare costs other than scaling back services but I don't know what that might be. Seriously, how do we pay for the aging Boomers? Even if they scrapped the entire system as it currently exists, I'm not sure how we adequately cover the ever expanding 65+ crowd. If Americans agree that providing health care for our senior and disabled population is one of the things we want to do, then we have to suck it up and someone has to pay for it. The boomers have already paid into the system and rightly believe that it's their turn. There aren't enough people paying in to the system through our current taxes to support the current population, let alone the expanding one.

Medicine is expensive and speciality medicine is REALLY expensive. There aren't that many people who can afford fee for service payments for specialty services- or even the out of pocket costs of general medicine.

I hope it doesn't force physicians out of medicine because we're already facing a physician shortage.

What are the answers?

Jenn

[SoonerTexan]

This sort of makes me want to run before we start dumping out $$$ for tuition...then again, we have 8-10 years for people to fight it out before we get there.

Do a good job for me--please?

[Sheherezade]

I think that the Medicare cuts are inevitable -- because Medicare can NOT continue paying out like it has in the past with all the new enrollees. Sure, this may mean that docs get paid less ----- but it might also mean that Medicare OFFERS less or is accepted less. I'm not sure that the cuts in Medicare will equal the end of medicine as we know it unless medicine is defined by Medicare.

I'm not sure what the alternate solution would be to stop the bleeding in the Medicare program. Higher taxes? (I wouldn't want more Medicare tax withheld.) Less covered? (Fine with me now - but I'm sure the AARP is against that option.) Lower fees for the same service? (That's what they are starting with this.) Limit enrollment to later ages? Push more people in to private plans? Reduce fraud? (They've been investigating this as well.) What other options reduce Medicare costs?

I'm thinking that they will reduce payments and let the medical system be the "bad guy" when/if they stop accepting Medicare. Maybe that's the best political move. Looks like you are pinching those nasty doctors when you are really cutting off Medicare services for seniors.

Anyway....I think that Medicare is a somewhat separate issue from the medical system as a whole. Medicare is a government program in trouble because of increased life expectancy and advances in health care. And honestly, the medical system/private health insurance industry issues are similar -- but at least that system isn't made up entirely of people over 65 and thus more likely to have health issues and end of life care.

ETA: cross post with Jenn and Sooner

[Flynn]

What Jenn said.



Kris -- I meant to put more in my post but my 19 month old bumped me and I hit "send" and then I had to pick up my 5 year old from school. I hope I didn't sound like an ass towards you -- but I'm sure I did and I'm sorry about that. It wasn't my intention.



Food for thought: My DH saw a patient three weeks ago. Here are the facts as I (we) know them:

white male 52 years old
at least 70 pounds over weight

a type 2 diabetic

he had 7 stents put in, in the last 18 months -- due in part to genes and lifestyle

He now needs surgery to fix the problem that wasn't fixed with the stents.




This man spent 6 months with an FP getting tons of tests. The pricetag was likely just under 5 grand -- probably higher. The cardiologist did over 5 grand of work on this person -- only for him to need surgery less than two years out.

Surgery would have helped this patient and CUT costs by at least 7500 -- but it took forever for the docs to get him to one. This happens in DH's day, everyday and he's not that busy of a surgeon. Non procedure docs don't make money unless they "do stuff." Some procedure docs can bandaid the problem and get paid -- when surgery might be the better option for the patient. Some surgeons get most of their referals from non-surgeons which makes NO sense. The system is broken on so many levels.

This is just one example of IMO poor, very expensive medicine. Nobody will talk to the FP or the Cardiologist. They will keep on practicing medicine they way they do and if someone DID talk to them they likely would get all defensive and give the "I've been doing this for years and it's worked just fine so far..." argument.

[PrincessFiona]

Re: The end of medicine as we know it ...

Angie, historically private insurance ties payments to Medicare.

Cost cuttingbin Medicare? Yes. I agree that it needs to be done. Downgrading specialists and backdoor paycuts to physicians across the board without addressing tuition and litigation as well as corporate hospital incomes? Hmmmm.

This is a poorly thought out bill and who will change it? The dens who supported it? The country who blames physicians for the high cost of healthcare when they aren't the root cause?

When a surgeon calls Thomas after a pt develops a post-surgical problem it is because they don't know any farther. Thomas goes through the chart, evaluates the medical history, examines the patient, reviews the chart and any tests, may order more tests and comes up with a plan. For a new level patient visit this might take 1-1.5 hours depending on complexity and other comorbidities.

He now can't even bill for this patient as a new patient if his partner has seen them for any reason over the last 3 years. Consult codes have been completely eliminated. It is now possible to bill a lower visit code. For all specialists. Cuts also include reimbursement for echos, eeg's, and imaging.

The consequence is that docs AND hospitals will take in lesscand hospitals will not be able to fund programs that are in the red.


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[DCJenn]

So very true, Angie-

As soon as you segregate populations you create very distinct cost centers- seniors and old people, the poor and working poor, etc.

The reason for the so-called "public option" was to spread costs across populations- of course, I would cost less to care for than my dad AND my kid. I don't need annual physicals, and I don't (currently) have any pressing health needs. I've had my vaccinations!

The reason why the government is responsible for Medicare is that by design it loses money. It can't possibly pay for itself. There's no self-respecting Health Insurance Provider that would take that on- or Medicaid for that matter. Those people are sick! No one else would do it. So, how do we pay for it?

(and I still have no answers but it's far more interesting to discuss this than to audit medical records... ironically, medical billing for that matter!)

Jenn

[PrincessFiona]

Re: The end of medicine as we know it ...

Flynn, he also needs stents like you said due to lifestyle issues. Now I'll sound nasty, but what part if this on him too? If we are cutting payments to docs are we upping copays for self induced illness? Devils advocate question.


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[Pollyanna]

Angie, historically private insurance ties payments to Medicare.

Cost cuttingbin Medicare? Yes. I agree that it needs to be done. Downgrading specialists and backdoor paycuts to physicians across the board without addressing tuition and litigation as well as corporate hospital incomes? Hmmmm.

This is a poorly thought out bill and who will change it? The dens who supported it? The country who blames physicians for the high cost of healthcare when they aren't the root cause?

When a surgeon calls Thomas after a pt develops a post-surgical problem it is because they don't know any farther. Thomas goes through the chart, evaluates the medical history, examines the patient, reviews the chart and any tests, may order more tests and comes up with a plan. For a new level patient visit this might take 1-1.5 hours depending on complexity and other comorbidities.

He now can't even bill for this patient as a new patient if his partner has seen them for any reason over the last 3 years. Consult codes have been completely eliminated. It is now possible to bill a lower visit code. For all specialists. Cuts also include reimbursement for echos, eeg's, and imaging.

The consequence is that docs AND hospitals will take in lesscand hospitals will not be able to fund programs that are in the red.


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Yep! This is not only bad for physicians but a HUGE nightmare for patients. I like how Dr. Walton-Shirley compares these cuts to the death penalty (one of the articles posted by Kris):

The same criticisms about the death penalty for criminals holds true for the death penalty for American cardiology:
1. It will discriminate against the poor, who in many practices will be turned away. I've made the statement that I'd rather be dead than turn away someone with inability to pay. I might as well make the funeral arrangements now.
2. It condemns the innocent to die; not only can patients die, which is the worst scenario, practices will as well. Cardiologists who work hard, pay their bills, pay their taxes, adhere to rigid guidelines for billing, and do an honest day's work will be at the same risk of reducing their practice size and seeing fewer patients right along with the criminals who have regularly cheated on billing.
3. The death penalty is not a deterrent to crime; changing reimbursement is not going to keeping cheaters from cheating. It will just encourage them to cheat more so they can make up the difference. It also won't drive any personal responsibility into the mix, a glaring omission in every single attempt at healthcare reform of any type.
4. The death penalty is biased. Well, I need another paragraph for that one.

[Flynn]

Flynn, he also needs stents like you said due to lifestyle issues. Now I'll sound nasty, but what part if this on him too? If we are cutting payments to docs are we upping copays for self induced illness? Devils advocate question.


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Kris -- I agree with this and yet how do you mandate it and deal with the ethics involved?

It's all so screwed up!



If you go into medicine for ANYTHING other than "I had to be a doc" you will pay for it over and over and over again. It's just not worth it.

[PrincessFiona]

Re: The end of medicine as we know it ...

Here is another food for thought question.

If we are currently in the process of health care reform, why not address these issues while coming up with a global solution and not sneaking it in while the country is distracted?



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