It’s Official. Medicare is on Death Row. Scheduled to Walk that Last Mile on December 31, 2011.

[McCamy Taylor]

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates payment policies and rates for physicians for services paid under the Medicare Physician Fee Schedule (MPFS) in calendar year (CY) 2012. The Final Rule assumes a 27.4 percent payment cut for physicians in CY 2012 – less than the 29.5 percent reduction that CMS had estimated in March because Medicare cost growth has been lower than expected. As the final rule was released, Secretary for Health & Human Services Kathleen Sebelius issued a statement indicating the Obama Administration is committed to fixing the sustainable growth rate (SGR) and ensuring these payment cuts do not take effect.

http://www.hematology.org/News/2011/7168.aspx

Yes, I know I sound like a broken record. Yes, I know that Congress has kicked this can down the road so many times that it should qualify for frequent flyer miles. But, that was before Citizens United vs. FEC. That was before the U.S. House of Representatives voted along party longs to get rid of Medicare. That was before the Cato Institute (i.e. the Koch Brothers) declared that the nation could no longer afford to keep its old folks alive. (For links, see my recent journals).

Why should Grandma care that doctors---overpaid doctors who drive expensive cars and own their own homes----are going to see their Medicare reimbursements cut by 27.4%? Because a typical office overhead for a primary care MD is now 70%. Meaning that only 30% of payments received from Medicare are profit. And Medicare is about to cut the profit. So, unless your physician is independently wealthy and can see patients without writing himself a check each month to pay the mortgage on his house, he or she is likely to drop Medicare altogether. Or, at the very least, stop taking new patients.

When will I stop writing abut the SGR? When both houses of Congress get off their lazy butts and do something about it. The Obama administration is doing everything it can. But it can not change the law. Only Congress can do that.

[NYC_SKP]

1. Recommended.

[alc]

2. not all doctors are overpaid

There are family practice doctors who work on their own, spend time with patients, and take medicare, and lose money most months and don't pay themselves (live off their spouses income). The worst thing about this is that it it forces those doctors to spend less time with each patient or even join a group practice where each patient gets 10 minutes. It also encourages med students to specialize instead of going into the low paying fields if they care at all about money.

[n2doc]

5. And they have to pay off their student loans as well

So why be a GP and barely make ends meet after paying said loans, when one can be a plastic surgeon and make the big bucks? People want to complain, but we supposedly live in a capitalistic society where folks are encouraged to seek maximum wealth.

[WinkyDink]

9. I know of no GP who can "barely make ends meet."

[n2doc]

11. I Do n/t

[McCamy Taylor]

33. I do. Me. But I choose to work at a public health clinic, because the poor and uninsured

need health care too. Guess what will happen to my public hospital if Medicare cuts its fees? The local government will have to raise property taxes in order to cover the gap between what Medicare pays and what they hospital actually spends. And as private docs drop Medicare, the public clinics will go from a three month waiting list for new appointments to a six month waiting list for new appointments as Medicare folks with complex problems start lining up at the door of last resort. The public health system can hardly handle the uninsured. How can it take on Medicare as well? The emergency room wait will double. They already don't have enough beds. It will be a nightmare.

And seniors in the suburbs and rural areas that do not have a county public hospital will have to drive hundreds of miles for care.

[tomp]

54. you are absolutely right.

the powers that be are finding many excuses for cutting reimbursements. remember, too, that municipal hospitals also depend on those reimbursements to survive. lower reimbursements mean staff reductions or attempts to attain givebacks from unionized hospital workers and increased workloads (which always contribute to decreased quality of care).

[emcguffie]

16. Lately I've noticed more and more doctors without an office staff.

They have less office hours too. I guess they do their own office work? Many of them now also do not take insurance at all, and folks like me cannot see them. These are doctors who treat CFS/CFIDS/ME, which is complicated and hard to treat, if it gets treated at all.

There's an immunologist/rheumatologist my daughter and I go to, and he has one receptionist who answers the phone and makes appointments. Letters and notes and prescription refills and all that stuff, he does himself from home. Now I'm having troubles with my daughter's school because they don't like the way he did a letter for her.

His office isn't even on line. No internet. No email.

But he spends lots of time with his patients.

I suppose someone somewhere does the insurance stuff for him, as he does accept it.

[Downwinder]

3. So, are they going to send me a euthanasia pill so I can go

out with dignity or must I go mindless in pain.

[Javaman]

12. What do you think? Pain is money in the bank for many doctors.

pump you up with over priced meds. Ones they get kick backs from promoting. Run your insurance tab up so high, that it's more beneficial for you to die than to live. but hell, you can't die, you owe them too much money. So the pump you up with expensive meds, ones that the docs get kick backs from...on and on...rince and repeat...and so it goes.

[JDPriestly]

46. If you got caught in the back pain/medication cycle, go to

physical therapy, something based on Pilates might be good, instead.

I was wracked with back pain and asked to try physical therapy before pain meds.

It took many months, but the freedom from both pain and pain medications has been worth the effort.

Sometimes pain medications cannot be avoided, but often they can.

[Javaman]

55. I think you missed the point.

There are a number of crooked docs out there that think nothing of handing out pain meds when there are alternatives.

they get a cut from distribution from the drug companies.

this isn't about pain management or actually helping people. It's about lining their pockets.

[inna]

4. "The Obama administration is doing everything it can."

That it certainly is.

:nuke:

[Javaman]

13. Slavery is freedom.

"-fill in the blank- administration is doing everything it can".

[county worker]

6. You don't understand the meaning of overhead. There are direct costs and there are

indirect costs. The direct costs are the costs of things that go directly into providing care, such as the doctor's salary, nurses salary, medicines, medical supplies and others.

Overhead are costs that are necessary and ordinary but are not directly related to providing care. They are costs like administration, insurance, accounting, rent, utilities and others. Now in cost accounting these costs are allocated to the departments that provide care such as X-ray, pediatrics, surgery, and others. So the cost of providing care has a direct and indirect component. Overhead costs are never 70% of the cost to provide care. Doctors in a clinic who are employees are paid a percentage of the revenue they generate. The clinic may pay them 40% to 60% of the cash they generated. So if there is a dollar of reimbursement, the doctor might get 50 cents and the other 50 cents go to covering the other direct costs and the overhead. The overhead may take 20 cents and the other direct costs may take the remaining 30 cents.

Doctors in private practice get 100% of the revenue they generate but out of that they have to pay for the other direct costs and the overhead.

The problem that doctors face is that their revenue comes from reimbursement for procedures they preform. Each procedure has a distinct procedure code. Medicare and insurance companies reimburse the doctor or clinic for procedures preformed at different rates per procedure code. Insurance companies usually tie their reimbursement rates to Medicare. They may be the Medicare rate plus 20%. So the income is dependent on a mix of different rates paid for the same procedure. It depends on what coverage the patient has. A clinic or practice that has mostly private insurance covered patients receives more revenue for those procedures preformed than ones with mostly Medicare, Medicaid, private pay and indigent.

The costs of providing the care is about the same no matter who the payer is therefore the net income (revenue minus expense)is higher with clinics or private practices with mostly patients with private health insurance.

What is driving up health care costs is mostly the cost of insurance, pharmaceuticals and medical supplies. The rate of income (percentages of the revenue generated) paid to doctors hasn't varied much and is not the main driver in increasing medical costs.

If medicare reimbursement is reduced then the reimbursement from every source except private pay is reduced since they are tied to Medicare reimbursement rates. Now I am only talking here about Medicare part B. Part A covers hospital daily bed rates. There is a spread between the hospitals cost per day and the Medicare reimbursement rate per day. The hospital needs to cover it's costs plus a profit. If Medicare reimbursement is reduced the spread gets narrower. As it gets narrower the portion of reimbursement paid by the patient increases.

This is a very complex issue and does not lend itself to simple one sentence explanations.

[dotymed]

20. Sometimes I wonder how Dr.'s who take insurance make money.

I look at my insurance statements and I am blown away by the small percentage that insurance pays on the bill. They negotiate around 90% of the charges away. If the uninsured were charged what the insured are charged then they could maybe afford medical care.

[county worker]

27. You are right. The billing rate has nothing to do with the amount of reimbursement

and some providers bill the uninsured the billing rate which is higher than insurance reimbursement.

[joeglow3]

25. My wife does billing for her office - medicare is much less than 20% of private insurance

For that reason, they are accepting no new medicare/medicaid patients and are not upset when existing ones leave.

[county worker]

26. A lot is based on the insurance company's reimbursement schedule

It is different with each insurance company and different for different providers with the same insurance company.
My 20% was just for example.

[McCamy Taylor]

34. Overhead is salaries. Because of insurance demands, one doctor will need

a receptionist, someone on the phones, two nurses---one to room patients and give shots one to answer phone calls, someone just to do insurance paperwork and make referrals, someone to do billing.Then there are all the miscellaneous things like OSHA, CLIA, fire codes etc that someone has to do, either the doctor or a staff member. Oh, and someone has to do payroll, supervise the employees and hire new employees when the old ones leave. Five employees per physician is not uncommon. This is especially true in family practice, internal medicine. Then, there is the new law requiring electronic medical records---another money sink. If you want to offer benefits it will cost an arm and a leg. But, if you don't offer benefits, all the good employees will eventually move to hospital jobs so they can get benefits and then you will have to start over training new people, which sometimes means having even more staff to take up the slack.

Doctors who do lab and xray in their offices are able to make a living, because these pay better than the actual visit. However, unless your office lab/xray has been grandfathered in, it is just about impossible to start one.

Doctors are pretty much forced to join large groups now. But that doesn't necessarily make it better. There are problems in large clinics. For instance, you will need several people just to keep track of where the charts are. Employees will need more supervisors---and they cost more. And benefits will still cost and arm and a leg.

[Generic Other]

7. Prepare to see more of this then

[Firebrand Gary]

8. Sorry , Doctors are not overpaid. Facilities, drug makers and insurance companies are.

[WinkyDink]

10. Doctors deserve every penny they make/earn. Unless there are people here who think something

supercedes their own good health?

[Fumesucker]

15. In 1997 there were nearly 800,000 iatrogenic deaths in the USA..

http://www.ourcivilisation.com/medicine/usamed/deaths.htm

[xchrom]

14. Recommend

[county worker]

17. Un recommend because the OP is oversimplified and does not represent reality.

Yes I was a controller of a medical clinic and now work for a Alcohol, Drug and Mental Health Services dept of a CA county. We have medical clinics, a psychiatric hospital, mental health clinics, intervention and drug and alcohol rehabilitation programs. We are paid by Medicare, Medical (Medicaid), private insurance, private pay, tax revenue of various kinds.

We always talk about Fox misrepresenting reality for political gain. We can be guilty of the same thing at times.

I am no expert but by the same token I know something about medical reimbursement and the problems that arise.

I would not post something that I didn't know anything about because I knew I could get lots of recs.

If we are going to make informed decisions we need accurate information.

[Islandlife]

18. +1

End of thread.

[Name removed]

19. Deleted message

Message removed by moderator. Click here to review the message board rules.

[county worker]

21. A little research and reading would not lead to the OP's conclusions.

I work in the medical field as and accountant and cost analyst currently and as a controller prior to that.

We want easy solutions and if it sounds good we accept it. Read my post #6. Don't call bullshit unless you know what you are talking about.

On edit,

You can slam me all day long if you want, I don't care. It will not change the facts and will not solve the problem. Unless we all sit down together and come up with a real workable solution we will not solve the problem.

[Jakes Progress]

22. Still nothing to back up your words.

You tell us to just trust you. You say that my post won't change the facts. What facts? Do you have anything other than a bunch of words without links? Wait. Links won't do any good when you don't really say anything. Instead of mushy talking points like working solutions and a lot of "I know what I'm talking about", how about actually making a point.

You say the OP is not telling the truth. What did she say that was not so? Is cutting the medicare reimbursements a good thing? Is that your point? Why is it a good thing? How does cutting medicare/medicaid reimbursements make things better for patients?

I read your post 6. How does it disagree with the OP? You say the money is going to insurance companies. Do you not know that the insurance companies will take their cut before doctors get theirs? I thought you worked in this field.

Could congress fix the problem of insurance companies stealing? Yep. But cutting the funding for doctors will not serve any one.

You take it as a slam when someone disagrees with you. When someone simply asks you to back up what you have to say. You went after the OP but find it terrible when someone holds you responsible for your own words. You seem to see this picture through the very narrow view from you desk at work. Some here have a bigger picture and a broader view. Open you mind.

[county worker]

23. Your not worth responding to anymore. You don't set the terms of a discussion.

[Jakes Progress]

28. You're not worth reading anymore.

You still don't indicate that you understand the OP or the issues involved. You still aren't able to back up anything in your unwarranted attack on the OP.

You work in a medical office of some kind. Have someone explain myopia to you. THen think about it.

Or you could actually engage rather than just attack. Why won't you tell us why you think cutting reimbursements is a good thing? Why won't you tell us, from your privileged point of view, how having fewer doctors taking medicare patients will benefit people? Why don't you actually have something to say other than attacking one of the finest researchers and writers on DU?

[county worker]

24. Here is a paper I wrote explaining how Medicare reimburses a hospital for a bed day.

Now research this! Don't look for it on line because it isn't on line. A link can be a lie or the truth, depends you your point of view I guess.




Medicare Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS)

Ref. Federal Register / Vol. 75. No. 83 / Friday April 30, 2010/ Notices Part IV

Prepared by Bob Cochran 06-09-10

The IPF PPS payment consists of a Federal Per Diem Base Rate adjusted by Patient Level Adjustments and Facility Level Adjustments.


Federal Per Diem Base Rate

RY 2008 was the third and last year of the 3-year transition that accompanied the
implementation of the IPF PPS. Beginning in RY 2009, (July 1, 2008 – June 30, 2009) IPFs are paid on the basis of 100 percent of the applicable Federal per diem rate.

The IPF PPS Federal per diem base rate for RY 2010, (July 1, 2009 – June 30, 2010) is $651.76 and is made up of a labor related share of 75.889% and a non labor related share of 24.111%. The per diem rate for RY 2011 is $665.71.




Patient-Level Adjustments

There are four patient-level adjustments. The adjustments include:

1. Medicare Severity Diagnostic Related Group (MS-DRG) adjustment.

There are 17 MS-DRGs recognized in the IPF PPS, and each receives a specific adjustment.






2. Comorbidity Groupings

There are 17 Comorbidity categories of specific diagnostic codes that have been identified as more costly on a per diem basis. Each of the groupings receives a specific additional adjustment.




3. Age Adjustment

There are 8 adjustment factors beginning with the age groupings 45-50 years of age to patients 80 years of age and over.













4. Variable Per Diem Adjustment

This adjustment will account for the higher administrative and ancillary costs associated with assessing and evaluating a patient’s condition during the initial days of an inpatient psychiatric stay. For example, any additional costs associated with the patient specific behaviors related to the admission process, intake assessments, various medical and psychiatric tests i.e. blood test for levels of prescribed medications, observation (which requires monitoring by appropriately trained staff), and more intensive staff involvement, etc. The adjustment for day 1 increases to 31 percent for IPFs with a qualifying Emergency Department (ED) (19 percent without a full- service ED). The adjustments will gradually decline each day of the stay through day 21. The adjustment for day 21 continues through the remaining days of the stay.














Facility Level Adjustments

There are four facility-level adjustments. The adjustments include:

1. Wage Index Adjustment

In providing an adjustment for geographic wage levels, the labor-related portion of the Federal per diem base rate used in an IPF’s payment is adjusted using an appropriate wage index.

CBSA code Urban area Wage index

42060 ................ Santa Barbara-Santa Maria-Goleta, CA .......................................... 1.2213
Santa Barbara County, CA

2. Adjustment for Rural Location

A 17 percent payment adjustment is provided for IPFs located in a rural area.

3. Teaching Adjustment

The teaching adjustment accounts for the higher indirect operating costs experienced by hospitals that participate in graduate medical education (GME) programs.

4. Cost of Living Adjustment for IPFs Located in Alaska and Hawaii

The FY 2002 data demonstrated that IPFs in Alaska and Hawaii had per diem costs that were disproportionately higher than other IPFs.


Inpatient Psychiatric Facility Federal PPS Per Diem Example

Assumptions:

Patient Age Patient is 61
Principal Diagnosis DRG 896: Alcohol/drug abuse or dependence w/o rehabilitation therapy.
Comorbidity Cardiac Condition
Length of Stay 57 Days
Geographic Location Urban
ER No ER
Teaching Adj N/A
Wage Area Santa Barbara
COLA Adjustment Rest of U.S.



IPF PPS Federal PPS Per Diem Calculation










The IPF PPS provides additional payment policies for outlier cases; stop-loss protection (which was applicable only during the IPF PPS transition period) interrupted stays; and a per treatment adjustment for patients who undergo ECT (Electroconvulsive Therapy).


Outlier Payments

Outlier payments provide a per-case payment for IPF stays that are extraordinarily costly and reduces the incentives for IPFs to under-serve these patients.

The outlier payments are for discharges in which an IPF’s estimated total cost for a case exceeds a fixed dollar loss threshold amount (multiplied by the IPF’s facility-level adjustments) plus the Federal per diem payment amount for the case.

In order to establish an IPF’s cost for a particular case, the IPF’s reported charges on the discharge bill is multiplied by its overall cost-to-charge ratio (CCR).

(Santa Barbara County Mental Health CCR based on 06-30-09 cost report is 1.525 and is effective for discharges on and after 02/18/2010 per Palmetto GBA letter of 02/04/2010)

The payment is 80 percent of the difference between the estimated cost for the case and the adjusted threshold amount for days 1 through 9 and 60 percent of the difference for day 10 and thereafter.

The fixed dollar loss threshold amount for RY 2011 is $6,372.



Outlier Calculation Example

Assumptions are the same as in the IPF PPS calculation.



















ECT (Electroconvulsive Therapy)



Inpatient Psychiatric Facility (IPF) will receive a payment for each electroconvulsive therapy (ECT) treatment furnished during the IPF stay. These payments are not included in the Federal Per Diem Base Rate.

The ECT payment for RY 2011 is $286.60 and is adjusted by the wage index and COLA.

In order to receive the payment, an IPF must report revenue code 0901 along with the number of units of ECT on the claim. The units should reflect the number of ECT treatments provided to the patient during the IPF stay. In addition, IPFs must include the ICD-9-CM procedure code for ECT (94.27) in the procedure code field and use the date of the last ECT treatment the patient received during their IPF stay.







Interrupted Stays


By definition, an interrupted stay occurs when the patient is discharged from an Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) and returns to any IPF before midnight on the third consecutive day following discharge. The case is considered continuous for applying the variable per diem adjustment and applicable outlier payment. Under the interrupted stay policy, where the patient is officially discharged from the psych hospital, the psych hospital is not responsible for the patient's services during those intervening days. If the patient is not officially discharged from the psych hospital, then the psych hospital would be responsible for any services during the stay. The purpose of the interrupted stay is to avoid overpayment under the IPF PPS for readmissions.











The following information was taken from two actual ADMHS PHF EOBs and a detailed PS&R report






The Medicare Part A deductible for 2009 is $1,068.00 per benefit period.
Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2010 = $1,100) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.
For each benefit period you pay:
A total of $1,100 for a hospital stays of 1-60 days.
$275 per day for days 61-90 of a hospital stay.
$550 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).
All costs for each day beyond 150 days

[Jakes Progress]

29. So? What does any of that have to do with the OP?

Do you not understand the OP? If you ask we can explain it for you.

But you can help us by telling us why you dislike the OP and why you think cutting benefits is a good thing. I think that would help us all see where you are coming from. Some of us can already guess.

[Jakes Progress]

31. I recommended because views like yours are limited and inchoate.

You don't support your rant against McCamy. You offer nothing but an "I know what I'm talking about" argument.

So tell us why cutting medicare and medicaid is a good thing? How do you reach that conclusion?

[county worker]

37. I never said that. You are arguing against a thing in your mind that doesn't exist.

I am for reducing Medicare costs by phasing in single payer.

My idea is that we all pay into a fund that pays for medical costs. The single payer dictates what the reimbursement is and what the drugs and supplies will cost. The insurance companies go by the board.

We will need more workers in the medical fields, so I recommend increases in educational opportunities for those in the medical field and a forgiveness student loans for a promise of service in community clinics and hospitals among other things.

My ideas will create jobs, reduce costs and offer medical care to almost everyone.

[Jakes Progress]

39. Then what was your post all about? Why fuss if you agree with the OP?

The upshot of the OP is that it is terrible to be cutting the reimbursement amounts, that this will be bad for people. Then you piped in with how the OP didn't know what she was talking about. Did you read the OP? Again. Did you understand it?

Not one of the things you prate about in this post disagrees with the OP. Nothing about adding education or single payer has anything to do with the OP.

Just figure out why you posted. Maybe you don't really have a beef with the OP. If you read here regularly, you won't be so quick to dismiss her writings.

[JDPriestly]

48. Thank you, County Worker. Virtually everyone here is with you on that.

My view is that the Republicans have attacked teachers by vilifying public education. Now they want to attack doctors and seniors in one big kick by attacking Medicare.

There is plenty of money to kill foreigners in our continuous wars, but no money to save the lives of American citizens.

Something is wrong when a family father spends his entire paycheck on a security fence around his yard to keep his dog happy and has nothing left with which to feed, clothe and care for his children. Something very wrong.

And that is where we are in America.

The money is there. It just isn't where the needs are.

[McCamy Taylor]

35. I have a Master Public Health and many years experience in both private and group practice.

Office overhead was about 50% for an FP back in 1990. And it has risen steadily. A recent New York Times article described a doc with 70% overhead which salary is now down to the 5 digits even though he works full time seeing lots of patients.

If you have not run a small office---the kind where the nurses know the patients by name---you have no idea how many employees contribute to every visit, even the most uncomplicated. Let's see. There is the operator who took the phone call. (You really will need a designated operator, because of the sheer volume of calls from patients, pharmacies, labs etc.) Then, there is the receptionist who scheduled the appointment. Except sometimes the call goes to the nurse first to see how soon the patient needs to be seen. She juggles that in between rooming patients/assisting the doctor and giving shots such as flu and allergy shots and calling in drug refills to pharmacies and calling patients about test results. So, make that two nurses. There is a computer system for the appointments. When that breaks down, there is chaos, so someone has to back it up daily and print out the appointments in advance so there is a hard copy. Once the patient finally gets to the office, someone has to call the insurance to make sure that it is 1) active 2) the doctor is the PCP of record and 3) find out what copayments must be charged. Not collecting the copayment (except in emergencies) is considered fraud and will get you dropped from an insurance plan and prosecuted by the federal government. The receptionists has to make sure that a copy of the patients living will is on the chart (if the patient has one) and has to verify ID.

Then, a nurse gets the patient back to the room, does vitals, goes over the medications etc. Then, the doctor sees the patient. For a really simple visit, he writes a prescription which the nurse copies, the patient goes back to reception. A bill is completed. You will need diagnosis codes. There is an encyclopedia size book for this. You have to make sure your procedure code (type of office visit in this case) is justified by the record, or else Medicare will nail your ass to the wall. That means writing down everything. Or dictating---but that can cost thousands a month in transcription fees.

The billing sheet then goes to the person who bills the insurance. All of it gets entered into a computer. If you are lucky, the HMO pays the bill. You enter the check into a computer and it goes to the bank. However, insurers routinely deny a certain percentage of claims so that they can sit on the interest payment. When a claim is denied, the biller has to copy records and resubmit the bill. Sometimes, she is force to get on the phone and stay there forever until she can talk to someone who actually knows something and is willing to help. Sometimes the doctor has to take time out from seeing patients to file an appeal. If he has to dictate a letter, that will probably cost more than the fee he is trying to collect.

Now, if the patient needs any tests or a referral to a specialist it is even harder. Each insurance has its own list of preferred providers. The doctor is expected to keep a library of provider lists, one for each insurer. Someone will have the job of finding the right specialist for the patient's insurance. This is a thankless job that no one enjoys so turn over is high. Many insurance plans have a very limited provider directory, since this saves them money. So, you can not give the patient the referral and tell him to make the appointment. No, the office staff has to do it, to make sure it is done in a timely manner. Then, the referral clerk has to call the insurance to make sure the test/referral/lab will be covered by the insurer. Nothing makes patients madder than doing what the doctor said and then finding out that their insurer won't pay the bill. However, insurers often refuse to authorize payment for necessary tests or referrals, until the doctor gets on the phone. It is a game they play, to limit the amount of money they spend.

Did I mention all the federal and state laws that medical offices have to follow? OSHA requires that you have an MSDS sheet for every f***ing thing in the office---even Liquid Paper- and that staff has routine in-services about safety and that the office have a designated safety director and a written safety plan and everyone has to have immunizations that are updated regularly, and when OSHA comes through to inspect someone has to take time off work to show OSHA around. And you'd better pray that OSHA doesn't need money or you will be fined for something. Anything. Then, there is CLIA. The same applies for CLIA. And Medicare and every other insurance plan you have a contract with will expect to be taken on a tour and will expect charts to audit on a regular basis. Right now, offices all over the country are tearing their hair out trying to go electronic. This will allow hackers like the Chinese Government and Microsoft and the FBI and Big Pharm to access all your private medical records, which is why the law was called the Patient Privacy Act. It's a joke, you see. You are about to lose your privacy---and your doctor is being forced to pay top dollar to make it happen.

Someone has to do payroll including withholding. Someone has to pay the bills. Someone has to order supplies. And a doctor's office uses lots of supplies. Vaccines are an especially big problem. They cost a lot and if the refrigerator is not checked regularly by a nurse, they can all spoil. If you order too much, you eat the cost.

What else? Be sure to check the oxygen tank regularly and calibrate the EKG machine. Go through meds and eliminate any that are expired. If you have a sample closet, log in every sample you receive, every one you hand out and have someone rotate the samples and get rid of expired drugs on a regular basis.

Laundry! You could eliminate this one by going paper, but that is not eco-friendly and it costs more.

And then there are all the regular expenses/problems associated with a business like the phones, the leaky roof, handicapped access.

Oh, and you have to provide an interpreter at no charge to the patient if she speaks a foreign language. So, bilingual staff is a must and you will have to use an expensive phone translation for all your Urdu/Ebong/Kurdish speakers.

And everything that is marketed for doctors is sold at two or three times the price a non physician would be charged for a similar product or service. And reimbursements----the amount a doctor is paid for a service only go in one direction. Down. If one insurer cuts its rate (say, for instance Medicare) all your other insurance companies demand the same discounted rate. It is in your contract. Because they figure if you can see one patient for $5 (after overhead) you can see all your patients for $5 (after overhead).

"I live my life in seven-minute intervals," says Laurie Green, a obstetrician-gynecologist in San Francisco who delivers 400 to 500 babies a year and says she needs to bring in $70 every 15 minutes just to meet her office overhead.

http://online.wsj.com/article/SB10001424052702304410504575560081847852618.html

And OB-Gyns make a lot of their money in the hospital (where they have no overhead except for the office staff that sends on the bill for the delivery or surgery).

And this NYT piece about the long time family doctor whose overhead is now 75% is a must read.

http://www.nytimes.com/2011/04/23/health/23doctor.html?_r=2&pagewanted=3

Altogether, Dr. Sroka employs 10 part-time employees, or the equivalent of five full-time workers. He does not provide his staff members with health insurance. His expenses amounted to $420,000 last year, or about $200 an hour. Most of his patients have either Medicare or CareFirst, the local Blue Cross Blue Shield plan, which pays him $69 (including a $20 co-pay) for most consultations. At that rate, he breaks even at three visits an hour and needs a fourth to turn a profit.

While Medicare reimbursements have been unchanged for 10 years, private reimbursements have declined twice in that period while his costs — and those of family practices across the country — rose steadily.

If you are seeing just colds, you can see 6 or more patients an hour. If your patients actually have real medical problems, 3 or 4 is the max. I am a very efficient doctor, but I try to see no more than 3 an hour, because most of the folks have a huge list of diseases, disease being the number one cause of unemployment, poverty and lack of health insurance in this country. If I were in private rather than public practice, I would never be able to give my patients the care they need. Imagine trying to manage diabetes, coronary artery disease, chronic pain from spinal stenosis, Hepatitis C and depression in one visit. I do this three times an hour. I shudder to think that some doctors may have to do this five or six times an hour.

One solution is the Canadian model. Give everyone a card. You read the card and send the (one insurer) a bill. Every specialist is on the plan so there is no need for a separate referral clerk. You could cut the five employees per doctor down to three that way.

[Jakes Progress]

40. But, but. She works in an office.... you know

with phones and paper clips and stuff. And she said she knows what she's talking about. So I guess that proves it.

[JDPriestly]

47. Text removed by DUer. Question answered.

[defendandprotect]

30. We're still expecting Democrats to "do something about it " .... ?????

Wow --

Democratic Party is now under control of Third Way -- after 20 years and more of

infiltration and influence over the party by Koch Bros. DLC -- !!

Who knows what's left of the party now --

But here's what Jonathan Cowan, Pres. of Third Way has to say about the future of

the Democratic Party . . .


C-span -- about three weeks ago -- Washington Journal --

Cowan makes clear the stance/policy of Third Way is that "the base of the party is

to be ignored" ---

and further that, "populism and populist discussions/debages are the equivalent of

Karl Rove propaganda of extremism" -- !!


Hear that -- the New Deal is Karl Rove extremism!!



Funny -- if it wasn't so sad -- !!

[defendandprotect]

32. In general, doctors have figured out insurance isn't the way to go -- damaging to all of us ....

Doctors and Nurses are for MEDICARE4ALL NOW --

About 50% of GP's would like to get out of the business --

Doctors were turned into "pill poppers" long ago -- now they're simply

assets of Big Pharma pushing drugs for them --


Obama really trampled the nation when he made back room deals with Big Pharma and

the privatge h/c industry to preserve it -- !!

[McCamy Taylor]

38. "Concierge" medicine is the next big thing. Docs closing their practice and providing care

for cash for a handful of rich patients. This trend is alarming. We could see the number of primary care doctors decline even more.

[defendandprotect]

42. It's natural progression --- an end result of the dollar bill chasing --

Meanwhile, with all the chaos in medicine we shouldn't fail to notice that the

training of doctors/dentists seems to have been quite lacking over last decades!

[defendandprotect]

43. dupe

Meanwhile, with all the chaos in medicine we shouldn't fail to notice that the

training of doctors/dentists seems to have been quite lacking over last decades!

[StarsInHerHair]

52. I wonder how many med students would be black market doctors, not in a bad

way but in an old fashioned, who-else-is-around sort of way? for everything from flus to diebetes.....would be bad tho, without the ability to prescribe medicines....

[Name removed]

36. Deleted message

Message removed by moderator. Click here to review the message board rules.

[rucognizant]

41. And so is Medicare

going to stop taking $100. out of my social security income every month now? It goes into the general kitty, I use very little of it!

[JDPriestly]

49. My very, very elderly mom did not use Medicare until the past few years,

and now, she really needs it.

So you will use your share. Work to make sure you can still rely on it. You will need it. Try falling down and breaking your hip -- or having a stroke -- or a heart attack. You will need it.

[dflprincess]

44. Doctors' and clinics have already seen a drop in income thanks to high out of pocket insurance

Fewer patients are showing up for routine care or even the screening tests that are covered (why bother with those if you can't afford the follow up?) It used to take 6 weeks to get an appointment for a routine mammogram and the waiting room was always crowded, this year it took a week and I only saw two other women in the waiting room.

Meanwhile, the parasitic insurance companies that Obama and the Congressional Democrats were so anxious to protect are reporting record profits.

[JDPriestly]

45. Agreed. Becerra's wife is a doctor, but she went to medical school

back when it was not so expensive. I doubt that he realizes just what the doctors who are not from wealthy families owe when they finish medical school.

[SixthSense]

50. Your impression of doctors is very dated

Many doctors these days can barely make it by through the cost squeeze. Many have been forced to drop Medicare already because they can't afford to operate at a loss, and it doesn't cover their costs.

If you follow the money in the medical industry it all leads to the health insurers and the pharmaceutical companies. The entire system has been rigged to the benefit of those two groups, to the detriment of government budgets, the ability of private citizens to afford care, the welfare of patients, and the very field of medicine itself.

[freshwest]

51. I've watched doctors refuse to take on Medicare patients for a decade now.

The GOP worked ceaselessly during the Clinton years to strip Medicare coverage in closed door sessions so that by the time Dubya got in some areas you were denied up to the point of death on the doorstep of hospitals. Different areas of the country have different situations. Bush slashed Medicaid brutally when he got in. Nothing short of a progressive majority in the Congress will change any of this. They write the laws, they cut the funding. Get out and vote, toss the tea party and the GOP out, or lose everything.

[eridani]

53. Why the FUCK does anyone ever think that just hitting on providers will control expenses?

When we were biking in the Netherlands, my husband had an emergency root canal don for $25 American (100 Dutch guilders in 1996). Why did the dentist not mind that low rate? Because the government not only set prices for his services, but also for ALL OF HIS INPUTS! Not to mention paying for his education from kindergarten through dental school.

Without price controls throughout the system, picking on providers only is totally counterproductive.