Is obama not good for family medicine?

[deleted87716]

if the aafp puts out a position statement on the issue that doesn't mean that's how it will go. as i understand it, the reality is that NPs will be in direct competition with FPs under Obamas policies.

Maybe. Who cares, really? Most mid-levels don't want to practice independently. The DNP is a paper tiger.

If mid-levels think they can do my job as well as I can, I say let 'em try. Any doctor who is worried that they can be replaced by a nurse probably should be.

The only thing we have to fear is fear itself.

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Members don't see this ad.

 

[scubadoc78]

Maybe. Who cares, really? Most mid-levels don't want to practice independently. The DNP is a paper tiger.

If mid-levels think they can do my job as well as I can, I say let 'em try. Any doctor who is worried that they can be replaced by a nurse probably should be.

The only thing we have to fear is fear itself.

why do you say the DNP is a paper tiger?

 

[deleted87716]

why do you say the DNP is a paper tiger?

It's a purely political construct designed to increase the prestige of advanced practice nursing, nothing more.

It doesn't change what nurse practitioners can actually do. It just makes it more expensive for them to do it.

 

[andwhat]

It's a purely political construct designed to increase the prestige of advanced practice nursing, nothing more.

it will pan out to nothing. NPs in general do not like unsupervised medicine. There is a huge liability risk. Who is going to be liable for their mistakes??
Wouldn't life be perfect? Practice medicine, and be free from liability. I think that N.P.s got it good.
That is too bad that they are being turned away from Hospitalist medicine.

 

[NOsaintsfan]

LOL. End of what America stands for... Really?

Out of business:
1. Name 1 industry where Gov't is more efficient than the private sector. I doubt Gov't can be more "efficient" than private insurers, although private insurers haven't exactly set the bar that high.

2. Gov't can provide the money, but they don't know the insurance business better than private insurers do. I'm guessing that private insurers will still "administrate" public plans, so efficiency will still be the same.

3. The concern here is the classic economic argument that public investment "crowds out" private investment. But, the assumptions that underly that argument doesn't apply to health insurance, which is highly regulate, where the market is incredibly distorted. Insurance companies exist on a state-wide basis and therefore already do not compete nationally. Insurance works best with "pooling" (pooling of risk, pooling of funds), so there is no such thing as a small business insurance company. Given that, new investments into insurance companies are very few and far between to begin with. So this argument is currently irrelevant.

4. As such, the public option would break up current oligopolies that exist in various markets, such as Pennsylvania, where there's only 2 or 3 major insurers who corner the market. Like I said above, there's such a high barrier to entry to the insurance business that those that make excessive profits don't see new entrants to compete for profits.

5. The key thing we can be happy about is portability. This was half-ass attempted with COBRA. As PCP's, we can be happy that when our patients whom we see continuously can continue to have coverage (i.e. pay us) when they become unemployed. I like that.

Pushing Medicare down our throats:
You don't have to accept the public option if the contracted price isn't good for you. You can always opt out and just take cash. Agreed, not the best solution to have a huge gov't set prices, but it's better than what we have now. Ideally, you want insurance companies to compete across state lines, that's how you make it more of a free market. But until they pass those laws, we gotta go with this one.

Waiting times:
There's a waiting time now already. And that's to see your PCP. Or see your county health district doctor. MRI/Hips waiting time is a theoretical thing. I'll worry about when it's time to worry about it.

Rise in taxes:
Again, you pay for the uninsured/unemployed now. You just don't know you are because the health care market economy is so incredibly distorted.

The one thing that nobody seems to take into account is the role of individual business in the whole insurance coverage thing. Keep in mind that when most employees have their insurance deducted out of their check, that is only a fraction of the cost that the business pays to provide that insurance. I can assure you employee insurance is a BIG expense for most businesses.

So if the government offers free health care, then why would any business take on the expense of providing health care for their employees when uncle sam will do it. This will lead to a single payer system al la Canada/England. I don't think this is where we want to go.

Most people agree that reform/change is needed, however the current plan isn't the answer. Their needs to be serious debate on the subject and not a rush to pass something now. This is one area where we don't need to hurry a bill through, the implications for the future are too big to completly screw it up.

 

[scubadoc78]

It's a purely political construct designed to increase the prestige of advanced practice nursing, nothing more.

It doesn't change what nurse practitioners can actually do. It just makes it more expensive for them to do it.

this issue hasn't been addressed much at all. the whole healthcare reform debate is ignoring the expense of education. we keep saying healthcare pros should be reimbursed to pay off their loans but what about providing an education that isn't so expensive?

put aside the $250,000 it costs to become a physician for a moment. the cost of getting a bsn, msn or arnp is climbing as well. add to that the fact that you have wait lists of up to 2 years just to get in to nursing school. funny thing is, at the community college my wife is attending, you can't STAY on the waiting list unless you're actively taking X number hours at that school! sounds like a pretty good racket to me.

then, once you're happy with your degree the requirements to be 'certified' or 'licensed' get changed. who changes it? the organizations who profit from increasing the standards! the 'new' requirement is a phd to be an NP. at the current rate, in 20 years you'll need a phd to put in a foley.

and cost issue aside, i'm not convinced all the certifications, licenses, etc make people better at what they do.

bottom line is, we need more scrutiny of governing education/accreditation organizations to ensure they're not having too much 'fun' in bed together at the expense of our bright, young, idealistic minds. education, like healthcare, should not be a privilege for the wealthy.

 

[Ariee]

I'm part of a listserv amongst my med school...e-mails get fwded...the ASA seems to be the group going the most nuts, trying to rally against HR 3200.
My personal opinion....viva primary care, it's bout time!


Dear colleagues:

New developments in the U.S. Congress require your immediate attention.

Despite the Energy and Commerce Committee of the House of Representatives still working on its version of a health system reform bill, some House members are pushing for expedited consideration of the issue and a vote in the House this week!

Anesthesiology needs to act.

As you may know, the moderate/fiscally conservative House Democrats known as the "Blue Dog Coalition" have become increasingly influential in the health care reform debate. Members of the Coalition have been heavily involved in negotiations on H.R. 3200, "America's Affordable Health Choices Act," the health reform bill currently under consideration in the House of Representatives.

Currently, the Coalition is pushing House leadership to make changes to H.R. 3200 prior to any final action by the House.

Of special interest to anesthesiology, the Blue Dogs have consistently opposed a public plan option based upon Medicare payment rates. As you would imagine, some in Congress are pushing the Blue Dogs to acquiesce on this issue. We need for the Blue Dogs to stand firm.

Because your Representative is a member of the Blue Dog Coalition, I'd like to ask you to make a special phone call on behalf of ASA.

Please take this opportunity to call your Member of Congress and ask him or her to continue fighting to delink a public plan option from Medicare payment rates. Even if you have already reached out to your Representative, this is a new chance to call some of the most important players in the health reform effort. We want to ensure that every single member of the Blue Dog Coalition hears from dozens of ASA members.

The ASA CapWiz Action Center includes simple call instructions, as well as talking points for your use.

The timeline is still uncertain, but some reports indicate that the U.S. House could vote on health reform legislation this week. It is absolutely imperative that you call your Member of Congress today.

Use this link to access call instructions and ASA's talking points: http://www.capwiz.com/asa/callalert/index.tt?alertid=13799251&type=co

 

[lowbudget]

The one thing that nobody seems to take into account is the role of individual business in the whole insurance coverage thing. Keep in mind that when most employees have their insurance deducted out of their check, that is only a fraction of the cost that the business pays to provide that insurance. I can assure you employee insurance is a BIG expense for most businesses.

Agreed that it is a big expense for businesses, but it's the cost of doing business... it's all part of "Total Compensation" (=payroll+benefits). And because it's a business cost, employers don't pay payroll taxes on health insurance benefits, so in effect, there's some government subsidization of health benefits already (Republicans want to repeal this and force employers to pay taxes on health insurance, but labor unions won't go for it because labor unions have negotiated super-rich & expensive insurance benefits for their members).

The problem is there currently isn't an even playing field between large employers and small employers. When insurance carriers underwrite large employers, they have a lot of employees which allows them to spread the financial risk over larger number of people. When premiums are quoted, it's quoted for the entire population, and this in the insurance world is called "Community Rating". All the employees of that large corporation constitute a "community" and basically you're getting a group discount. Small employers can't do that and subsequently are subjected to higher premiums, and as a result many small employers don't carry health benefits (or they carry shoddy ones, or they'll ask employees put money into an HSA and cover catastrophic insurance which has a high deductible).

The plan sets up purchasing cooperatives where you can buy insurance through so that insurance companies aren't underwriting you as an individual. They underwrite an entire group that's purchasing through cooperative. So if you're in a small business, you still have the ability to purchase insurance.

Would a public option cause large employers to dump health insurance coverage? Maybe, maybe not? Because as a large employer, you have to mindful of minimizing Total Compensation, while remaining competitive to attract employees. A large employer will continue to provide health insurance if they can get a better community rating compared to public option. If not, they dump it, pay the employees the Total Compensation in payroll, and have the employees go purchase it and apply for the tax deduction later. Either way, employees benefit because they're getting a cheaper premium for the same product.

I believe Obama is in favor of a "pay or play" system, where companies MUST provide health insurance and if they don't and decide to dump it, they have to pay a fee which makes its way back to underwriting those who are purchasing via public option.

Personally, I don't think Congress is going far enough to help out the small businesses. Because small businesses don't have the capital, they must provide insurance through insurance carriers, who are regulated by the State Government. Large businesses sometimes have enough capital and so they will "self-insure" their employees (i.e. create a fund from which insurance payouts come from) and bear all the risk. They can do this because they have lots of employees and the risk is distributed/diversified and cost potentially lower. The problem is that when large employers self-insure, they "technically" are NOT insurance companies and therefore are not regulated by the State Government anymore. They're regulated by the Federal Government under ERISA and ERISA is much more liberal/lenient that what some of the states do.

So if you really cared about small businesses, you'd push for reform of the ERISA regulations... but this is a huge undertaking and no one has mentioned it yet...

I say, let's tax health benefits, like Republicans want (so there's no pay-or-play). Set up a public option, like the Democrats want. And once and for all, get rid of employer-based health insurance and put the purchasing decision making in the hands of the people. You would side-step ERISA without having to repeal it, which is pro-small business. I just hate it when employers are making health care decisions on behalf of their employees, whom they don't give a crap about (it's all about cost-minimization).

Mandate guarantees (can't be denied because of pre-existing conditions) and allow a mechanism to community rate (group discount on premiums) and let's get these effin' uninsured covered! What sucks more than losing your job and your paycheck? Losing your health insurance with it!

So if the government offers free health care, then why would any business take on the expense of providing health care for their employees when uncle sam will do it. This will lead to a single payer system al la Canada/England. I don't think this is where we want to go.

No one, Democrat or Republican, has proposed free government health care. No one. The public option provides the opportunity for individuals to purchase health insurance through a different party other than their own employers (if they're employed). This allows for community rating (the group discount I mentioned). You still have to purchase the insurance. I think there might be an exception for the very poor who might get subsidized, but usually there's a cost/risk-sharing (copay, coinsurance, deductible) to stave off abuse.

 

[lowbudget]

Of special interest to anesthesiology, the Blue Dogs have consistently opposed a public plan option based upon Medicare payment rates. As you would imagine, some in Congress are pushing the Blue Dogs to acquiesce on this issue. We need for the Blue Dogs to stand firm.

Anesthesia doesn't want the pay from the public option to be pegged to Medicare rates because Anesthesia (at least those in their SDN forum) state that Medicare pays 1/3 of what private insurance pays. I wrote on their forum: What? Your private pay is 3x Medicare rates? That's pretty damn good! And they replied, no, Medicare is way below.

In primary care, we're lucky to get 5, 10, 20% ABOVE Medicare and some people are happy to get private payers to pay them EQUAL to Medicare. I would love to be paid 300% ABOVE Medicare rates. No wonder they are against it. Sh^t.

They want status quo, which puts Medicare so below market that people stop accepting Medicare. That means, no doctor is going to take care of our parents! And when we get old, no one will want to take care of us.

It sounds like the AMA is tired of negotiating year after year for Medicare to waive the automatic pay cut to doctors (in the order of 20-30%) under SGR. So if you maintain status quo, for Anesthesia, the gap between Medicare and private care will widen even more because at some point, CMS is going to say, hell no, we're not waiving SGR. Then you're really screwed.

At least with the Congressional plans, AMA has agreed with CMS that if you get rid of SGR and we'll play ball. I'd rather us get rid of SGR so that AMA doesn't have to spend all that politicking every single year to waive SGR and can instead spend their time politicking other issues within health care reform. Every year, the SGR debate ties up AMA that they can't adequately represent us. So, for me, AMA is stuck and fed up, and is ready to wheel and deal, much to the chagrin of the specialists.

 

[andwhat]

Well actually, as I am hearing, the greatest waste of funds right now is Radiologic Imaging. This is an astronomical cost yearly, and will need to get cut down. This will help cut costs greatly.

 

[NOsaintsfan]

Agreed that it is a big expense for businesses, but it's the cost of doing business... it's all part of "Total Compensation" (=payroll+benefits). And because it's a business cost, employers don't pay payroll taxes on health insurance benefits, so in effect, there's some government subsidization of health benefits already (Republicans want to repeal this and force employers to pay taxes on health insurance, but labor unions won't go for it because labor unions have negotiated super-rich & expensive insurance benefits for their members)..

The problem is there currently isn't an even playing field between large employers and small employers. When insurance carriers underwrite large employers, they have a lot of employees which allows them to spread the financial risk over larger number of people. When premiums are quoted, it's quoted for the entire population, and this in the insurance world is called "Community Rating". All the employees of that large corporation constitute a "community" and basically you're getting a group discount. Small employers can't do that and subsequently are subjected to higher premiums, and as a result many small employers don't carry health benefits (or they carry shoddy ones, or they'll ask employees put money into an HSA and cover catastrophic insurance which has a high deductible).

The plan sets up purchasing cooperatives where you can buy insurance through so that insurance companies aren't underwriting you as an individual. They underwrite an entire group that's purchasing through cooperative. So if you're in a small business, you still have the ability to purchase insurance.

Would a public option cause large employers to dump health insurance coverage? Maybe, maybe not? Because as a large employer, you have to mindful of minimizing Total Compensation, while remaining competitive to attract employees. A large employer will continue to provide health insurance if they can get a better community rating compared to public option. If not, they dump it, pay the employees the Total Compensation in payroll, and have the employees go purchase it and apply for the tax deduction later. Either way, employees benefit because they're getting a cheaper premium for the same product.

I believe Obama is in favor of a "pay or play" system, where companies MUST provide health insurance and if they don't and decide to dump it, they have to pay a fee which makes its way back to underwriting those who are purchasing via public option.

Personally, I don't think Congress is going far enough to help out the small businesses. Because small businesses don't have the capital, they must provide insurance through insurance carriers, who are regulated by the State Government. Large businesses sometimes have enough capital and so they will "self-insure" their employees (i.e. create a fund from which insurance payouts come from) and bear all the risk. They can do this because they have lots of employees and the risk is distributed/diversified and cost potentially lower. The problem is that when large employers self-insure, they "technically" are NOT insurance companies and therefore are not regulated by the State Government anymore. They're regulated by the Federal Government under ERISA and ERISA is much more liberal/lenient that what some of the states do.

So if you really cared about small businesses, you'd push for reform of the ERISA regulations... but this is a huge undertaking and no one has mentioned it yet...

I say, let's tax health benefits, like Republicans want (so there's no pay-or-play). Set up a public option, like the Democrats want. And once and for all, get rid of employer-based health insurance and put the purchasing decision making in the hands of the people. You would side-step ERISA without having to repeal it, which is pro-small business. I just hate it when employers are making health care decisions on behalf of their employees, whom they don't give a crap about (it's all about cost-minimization).

Mandate guarantees (can't be denied because of pre-existing conditions) and allow a mechanism to community rate (group discount on premiums) and let's get these effin' uninsured covered! What sucks more than losing your job and your paycheck? Losing your health insurance with it!



No one, Democrat or Republican, has proposed free government health care. No one. The public option provides the opportunity for individuals to purchase health insurance through a different party other than their own employers (if they're employed). This allows for community rating (the group discount I mentioned). You still have to purchase the insurance. I think there might be an exception for the very poor who might get subsidized, but usually there's a cost/risk-sharing (copay, coinsurance, deductible) to stave off abuse.[/QUOTE]

 

[NOsaintsfan]

Agreed that it is a big expense for businesses, but it's the cost of doing business... it's all part of "Total Compensation" (=payroll+benefits). And because it's a business cost, employers don't pay payroll taxes on health insurance benefits, so in effect, there's some government subsidization of health benefits already (Republicans want to repeal this and force employers to pay taxes on health insurance, but labor unions won't go for it because labor unions have negotiated super-rich & expensive insurance benefits for their members)..

The main thing that comes from all of this is their needs to me a more lengthy debate in washington about this issue.

The fact that government doesn't tax payroll benifits still doesn't take away from the fact that its an expense for the business. If the government sets up a low cost insurance option for business here's what will happen.

Business will have their hr department or whoever is currently handling their insurance for employees faciliate employees getting on the government insurance, which will end up creating a single payer system. Some businesses may offer a "upgradable" health package that will go beyond what the government will offer but this will not be the standard for everyone.

The overall "total compensation" to the employee will be the same however the cost to the business will be less. Less expense for a company could be a great thing however I personally don't trust or have any faith in Uncle Sam running the health care show.

Its not that I'm a conspiracy theorist or anything, I just have plenty of first hand experience with the government and efficient is something that the government is not. If someone can think of even one program that the government has control of that is on budget and efficient then.....well you get the point.

I know that the system needs reform, however their has to be another way besides letting the government control it.

 

[thethom]

For those that were wondering what Obamas plans are from primary care, I hope you are watching his speech in Raleigh, NC today. He just stated that primary care docs should make just as much as the specialists, the Family doc that treats diabetes should make just as much as the surgeon that cuts off the toe. Sounds good to me...so far, we'll see.

 

[Kitra101]

For those that were wondering what Obamas plans are from primary care, I hope you are watching his speech in Raleigh, NC today. He just stated that primary care docs should make just as much as the specialists, the Family doc that treats diabetes should make just as much as the surgeon that cuts off the toe. Sounds good to me...so far, we'll see.

Beware of what you wish for - if Obama decides that specialists makes too much money for what they do, he just slashes it. What happens if he decides that NPs and PAs can do primary care just as efficiently as a PCP and cuts your pay down to that of an NP/PA? The fact is, he brilliantly is putting up PCPs against specialists to split us and stop any opposition to his plans. I would feel more comfortable if I did not feel like he cares nothing for medical students, residents and physicians. There is no talk about reducing medical school tuition, about a bail out for our hundreds of thousands of dollars of debt nor about any sort of real tort reform. In fact, he basically scoffed at it at the AMA address. The fact is he and other lawyers care nothing about us and their quick fix is to chop away at our payments year after year. There has yet to be ANY discussion about patient responsibility/compliance which is a major issue. They do not want to pay for the amputation of the foot, rather the PCP's advice to make lifestyle changes, dietary modifications and take your meds. Well, it is not like patients arent told that and go straight to foot amputations! I, as a medical student, have seen numerous patients who outright refuse to adhere to diet, exercise or medicine. They get their amputations because they do not comply with medical advice. Doctors are not the only ones to blame in this, nor are insurance companies or drug companies. However, the general public does not want to accept this fact and no politician in his/her right mind is willing to point this out because it will be political suicide. Therefore, it is our role, as a physician to say "We do not discriminate against you because you are obese - contrary to what "experts" such as Elizabeth Cohen on CNN's empowered patients section reports - we want you to work to lose weight in order to decrease your risk for CAD, MI, PVD, CVA, breast cancer, colon cancer, DM, blindness, pancreatic insuff, HTN, pulmonary HTN, cor polmonale, CHF, sepsis, etc etc.

 

[andwhat]

For those that were wondering what Obamas plans are from primary care, I hope you are watching his speech in Raleigh, NC today. He just stated that primary care docs should make just as much as the specialists, the Family doc that treats diabetes should make just as much as the surgeon that cuts off the toe. Sounds good to me...so far, we'll see.

This is exactly what I figured was coming. Finally. However, I feel as if there is too much compensation towards certain specialties, and General Surgeons should actually make more, for their hard work. Trauma call is ridiculously hard at times, and should be compensated better, for instance. The fact that certain specialists can rip off the system, and do multiple procedures in one day, is going to end finally.
N.P.s and P.A.s cannot run Primary Care. N.P.s and P.A.s would rather work in collaboration with Physicians, due to Liability risks. There will not be very many Independent Practitioners out there, as Specialists love to wish, so that there exists 'competition' between Primary Care docs and N.P.s P.A.s Don't believe the hype, not true. This is a fact. This will have to be worked out somehow. However, the point is that Primary Care will finally be compensated fairly.
Who cares how much N.P.s and P.A.s make? It has no relevance to what I am doing. Primary Care pay will not be 'slashed'.
Preventive Medicine saves lives, this is a fact.
Certain specialists do make way too much, and this should be slashed.

 

[Kitra101]

This is exactly what I figured was coming. Finally. However, I feel as if there is too much compensation towards certain specialties, and General Surgeons should actually make more, for their hard work. Trauma call is ridiculously hard at times, and should be compensated better, for instance. The fact that certain specialists can rip off the system, and do multiple procedures in one day, is going to end finally.
N.P.s and P.A.s cannot run Primary Care. N.P.s and P.A.s would rather work in collaboration with Physicians, due to Liability risks. There will not be very many Independent Practitioners out there, as Specialists love to wish, so that there exists 'competition' between Primary Care docs and N.P.s P.A.s Don't believe the hype, not true. This is a fact. This will have to be worked out somehow. However, the point is that Primary Care will finally be compensated fairly.
Who cares how much N.P.s and P.A.s make? It has no relevance to what I am doing. Primary Care pay will not be 'slashed'.
Preventive Medicine saves lives, this is a fact.
Certain specialists do make way too much, and this should be slashed.

Im going to go on a limb and say that I have seen personally NPs and PAs who do the job of a PCP without problems and the patients are happy. The truth is that preventative care can be done by alternative health care providers which would take from PCPs this preventative medicine push being made. You may have a bump now, but the point is that if we are looking to cut costs in any way possible, do not kid yourself that you will be paid a physician salary to do preventative healthcare while an NP or PA will do it for 2/3 to 1/2 of what you get paid to do it.

Who cares how much N.P.s and P.A.s make? It has no relevance to what I am doing.

You, the PCP, should care how much NPs and PAs get paid because it will be what you get paid if you do not do something. Mark my words, as the push to cut costs on the backs of physicians continues, you will become a new target for reimbursement cuts. The only way to get the system functioning in a sustainable way is to:

1. Incentivize (with increased health care coverage) patient compliance (HbA1c in range, HTN in range, serum cholesterol, LDL in range or at least prove effort is being made) and participation with preventative care (which means patients MUST assume responsibility for their actions or pay out of pocket for their CHF exacerbation or foot amputation).

2. Slash education costs for medical training at US medical school. What smart person is going to go to medical school to sit with 200-500K debt after undergrad and med school, work for 11 dollars an hour during residency and then continue to work 60-80 hours a week for 100K (while trying to support a family)?

3. Put tax dollars into R and D for drugs so drug companies cannot charge what they charge

4. Cap malpractice and penalize lawyers and patients involved in frivolous cases to curb defensive med

5. Shift all fields of medicine to shift work

6. Greatly expand medical school and residency spots in the US

7. Provide catastrophic, non-self induced health care insurance for all citizens

8. Provide only emergency health care for undocumented people in the US - everyone contributes to health care

9. Mandate employer health coverage

10. One EMR system accessible to all providers with back up flash drives for patients so they can have access to their records and take it from provider to provider

11. Mandate salaries for all physicians across the board. Consider either doing it by years of training, or consider the imminent shortage of neurosurgeons, radiologists, ENTs, orthopedic surgeons and general surgeons. Be honest with yourself, if you can become a PCP after three years of residency and get paid the same, why would someone train for double or more time to be paid the same? Sure, some will have a passion, but others will say "I am a human being, an American citizen and just like everyone else, I want to be able to support my family, send my children to college and live a normal life."

12. Cut salaries of other "overpaid" citizens. For example, there is no reason congressmen should make what they make and Obama should not make 400,000 a year. Lead by example. Furthermore, entertainers such as movie stars, musicians, athletes, etc should NOT be paid over a million a year to do what they do. It sends the message that we, as a society, are willing to pay for our entertainment, but not our health and our lives. The idea is absurd and justice should be done if the government has the power to dictate who can make what salaries (and we are leaving the idea of a free market). Additionally, lawyers - they are being pushed back to some degree by the recession. It appears there has been a major shift from big firms billing out at hundreds of dollars an hour to smaller firms billing less and being less upscale as clients no longer want to pay those outrageous fees. However, just because the market is starting to dictate their worth does not mean that they should not be regulated or capped as well. We are regulating physician salaries and CEO salaries, perhaps we need to regulate all salaries of all citizens? Wait a sec...

So what we are saying is in the last year, government has taken a large control in the housing market, the banking industry, the automotive industry, the energy industry, now the healthcare industry and is beginning to make mandated salary caps for citizens? Hmm...this is beginning to sound a lot like the former Soviet Union, dont we think? If we had known this is where we are heading anyway, maybe we should have just surrendered to them in the first place?

But seriously, I am all for government protecting those who cannot protect themselves - afterall, that is one of the purposes of government. However, scape goating physicians and others instead of placing blame in all of the places it needs to go is the wrong move by government and will make this situation much worse. Let me remind you of this regarding primary care:

It was Obama himself who made reference to the pediatrician who decides to perform a tonsillectomy instead of undergo conservative medical management for the child with a sore throat because the reimbursement system rewards such actions. (This was last week at his Wednesday town hall meeting) What pediatrician does T and As? The answer is none. He does not understand how health care works and yet you want him to lead the charge to change your field?

 

[deleted87716]

You, the PCP, should care how much NPs and PAs get paid because it will be what you get paid if you do not do something.

That's not how it works. The vast majority of mid-levels are paid by physicians. If we make less, they make less.

as the push to cut costs on the backs of physicians continues, you will become a new target for reimbursement cuts.

Um...we're already the target, and have been for years. That's the point.

Incentivize[sic]...patient compliance

Good luck with that.

Slash education costs for medical training at US medical school.

Hard to justify, unless the goal is to increase the number of folks going into primary care.

Put tax dollars into R and D for drugs so drug companies cannot charge what they charge

I don't think pharma needs a bailout.

Cap malpractice and penalize lawyers and patients involved in frivolous cases to curb defensive med

Good luck with that.

Shift all fields of medicine to shift work

Huh..? What would that accomplish?

Provide catastrophic, non-self induced health care insurance for all citizens

I don't know what "non-self induced" means. It makes no sense to provide catastrophic coverage alone without some sort of primary care coverage/incentives. Otherwise, what's to stop folks from partying with their bodies like it's 1999, knowing the gov't. will pick up the tab if they break?

Provide only emergency health care for undocumented people in the US

That's pretty much the way it works now, thanks to EMTALA.

Mandate employer health coverage

That's a great way to kill companies. Ask anyone in the U.S. auto industry.

One EMR system accessible to all providers with back up flash drives for patients so they can have access to their records and take it from provider to provider

Don't hold your breath.

Mandate salaries for all physicians across the board.

Again...why? Salaries are the root of all mediocrity. If you give someone a floor, they'll sit on it. That's the last thing we need in healthcare.

Cut salaries of other "overpaid" citizens.

Go read up on the free market, then come back after you understand it. Seriously. Sure, it's stupid that coked-up rock stars make ten times what the best-paid doctor makes. However, how is that the government's business?

there is no reason congressmen should make what they make and Obama should not make 400,000 a year.

Are you serious? The President's salary may not be much, but you have to admit that the fringe benefits are hard to beat.

I do think that members of Congress should have Medicare as their insurance policy, however.

Additionally, lawyers ...

Again, good luck with that. Who do you think is in Washington making all these laws, anyway?

Hmm...this is beginning to sound a lot like the former Soviet Union, dont we think?

I hope you voted for the other guy last November, then.

 

[andwhat]

Im going to go on a limb and say that I have seen personally NPs and PAs who do the job of a PCP without problems and the patients are happy. The truth is that preventative care can be done by alternative health care providers which would take from PCPs this preventative medicine push being made. You may have a bump now, but the point is that if we are looking to cut costs in any way possible, do not kid yourself that you will be paid a physician salary to do preventative healthcare while an NP or PA will do it for 2/3 to 1/2 of what you get paid to do it.



You, the PCP, should care how much NPs and PAs get paid because it will be what you get paid if you do not do something. Mark my words, as the push to cut costs on the backs of physicians continues, you will become a new target for reimbursement cuts. The only way to get the system functioning in a sustainable way is to:

1. Incentivize (with increased health care coverage) patient compliance (HbA1c in range, HTN in range, serum cholesterol, LDL in range or at least prove effort is being made) and participation with preventative care (which means patients MUST assume responsibility for their actions or pay out of pocket for their CHF exacerbation or foot amputation).

2. Slash education costs for medical training at US medical school. What smart person is going to go to medical school to sit with 200-500K debt after undergrad and med school, work for 11 dollars an hour during residency and then continue to work 60-80 hours a week for 100K (while trying to support a family)?

3. Put tax dollars into R and D for drugs so drug companies cannot charge what they charge

4. Cap malpractice and penalize lawyers and patients involved in frivolous cases to curb defensive med

5. Shift all fields of medicine to shift work

6. Greatly expand medical school and residency spots in the US

7. Provide catastrophic, non-self induced health care insurance for all citizens

8. Provide only emergency health care for undocumented people in the US - everyone contributes to health care

9. Mandate employer health coverage

10. One EMR system accessible to all providers with back up flash drives for patients so they can have access to their records and take it from provider to provider

11. Mandate salaries for all physicians across the board. Consider either doing it by years of training, or consider the imminent shortage of neurosurgeons, radiologists, ENTs, orthopedic surgeons and general surgeons. Be honest with yourself, if you can become a PCP after three years of residency and get paid the same, why would someone train for double or more time to be paid the same? Sure, some will have a passion, but others will say "I am a human being, an American citizen and just like everyone else, I want to be able to support my family, send my children to college and live a normal life."

12. Cut salaries of other "overpaid" citizens. For example, there is no reason congressmen should make what they make and Obama should not make 400,000 a year. Lead by example. Furthermore, entertainers such as movie stars, musicians, athletes, etc should NOT be paid over a million a year to do what they do. It sends the message that we, as a society, are willing to pay for our entertainment, but not our health and our lives. The idea is absurd and justice should be done if the government has the power to dictate who can make what salaries (and we are leaving the idea of a free market). Additionally, lawyers - they are being pushed back to some degree by the recession. It appears there has been a major shift from big firms billing out at hundreds of dollars an hour to smaller firms billing less and being less upscale as clients no longer want to pay those outrageous fees. However, just because the market is starting to dictate their worth does not mean that they should not be regulated or capped as well. We are regulating physician salaries and CEO salaries, perhaps we need to regulate all salaries of all citizens? Wait a sec...

So what we are saying is in the last year, government has taken a large control in the housing market, the banking industry, the automotive industry, the energy industry, now the healthcare industry and is beginning to make mandated salary caps for citizens? Hmm...this is beginning to sound a lot like the former Soviet Union, dont we think? If we had known this is where we are heading anyway, maybe we should have just surrendered to them in the first place?

But seriously, I am all for government protecting those who cannot protect themselves - afterall, that is one of the purposes of government. However, scape goating physicians and others instead of placing blame in all of the places it needs to go is the wrong move by government and will make this situation much worse. Let me remind you of this regarding primary care:

It was Obama himself who made reference to the pediatrician who decides to perform a tonsillectomy instead of undergo conservative medical management for the child with a sore throat because the reimbursement system rewards such actions. (This was last week at his Wednesday town hall meeting) What pediatrician does T and As? The answer is none. He does not understand how health care works and yet you want him to lead the charge to change your field?

he was making a point, procedures for the most part are worthless, as far as health care outcomes, and costs.....

 

[Kitra101]

"That's not how it works. The vast majority of mid-levels are paid by physicians. If we make less, they make less."

Nothing is set in stone as we now see. Our profession is dictated by the government as they set the reimbursements for medicare and the private insurance companies follow suit. If they want to cut costs, all they need is some study showing PAs or NPs who do your job for half the cost and they "can re-write the laws. They can allow NPs and PAs to run their own practice and then who would go to a PCP if they can pay half and see a PA and still get their HCTZ. Come on - really? The only thing separating you from the PAs in the eyes of the public is your medical education and right now, with our names being dragged through the mud as it is, public perception may allow for a change where PAs and NPs can work in government owned and insured offices without the need of an overseeing PCP. It is the stoke of a pen my blue dog friend.

"Um...we're already the target, and have been for years. That's the point."

You have been the target for years? Well, get ready to be the target for a little longer until you are competing with PAs and NPs that work for a government backed practice and charge half of what you charge.


"Hard to justify, unless the goal is to increase the number of folks going into primary care."

Why is that? Do you think you have the training to perform surgeries, read imaging, read slides, etc as a PCP? No, this is why there are specialists. Do not kid yourself into thinking that you really can be the generalist of old who is the expert in everything. I do not care how smart you are, no person can do that anymore - no one who does not hope to be sued constantly that is.


"I don't think pharma needs a bailout. "

Agreed. However, no one works for free. Why would a smart biochemical engineer have incentive to create new medicine? Out of the goodness of his/her heart? Please, lets be realistic. This all comes down to money. You want cheaper drugs, you need to pay for the R and D and not just leave it up to drug companies to be the sole developer of medicine.




"I don't know what "non-self induced" means. It makes no sense to provide catastrophic coverage alone without some sort of primary care coverage/incentives. Otherwise, what's to stop folks from partying with their bodies like it's 1999, knowing the gov't. will pick up the tab if they break?"

What I mean is a child with leukemia is very different than a diabetic who refuses to make lifestyle changes and be compliant with meds. If that patient refuses, he or she should pay for their own amputation - not make society do it for them. This is what I mean by "incentivize." Yes, maybe I am making up a word, but you get the point. Coverage should be based on what you put in (investing in your health effort, not necessarily monetarily). If you dont care about your health and keep smoking and refuse to even try to quit, why should society pay for your surgery, chemo, XRT and hospice?


"That's pretty much the way it works now, thanks to EMTALA."
If it is, they are doing a great job with it now - rolls eyes.



"That's a great way to kill companies. Ask anyone in the U.S. auto industry."
Agreed, but there is no stopping this mob anymore. They are going to have their socialized medicine here whether we like it or not. Everyone should make sacrifices, not just physicians.


"Again...why? Salaries are the root of all mediocrity. If you give someone a floor, they'll sit on it. That's the last thing we need in healthcare."

Agreed. I am not for this government takeover, but again, I think the mob will win out on this one because the health care industry is not pointing out that it is not just the health care industry causing these problems. We are letting the politicians and so called experts who have never set foot into a hospital talk about how health care is run now and how it should be run. Shame on us.


"Go read up on the free market, then come back after you understand it. Seriously. Sure, it's stupid that coked-up rock stars make ten times what the best-paid doctor makes. However, how is that the government's business?"
It is not. That is EXACTLY MY POINT. Where does the government get off dictating our salaries but not others? I am not for this massive government control of housing, banking, health care, auto making, etc, but who is going to say enough is enough? Bush polarized the country so far to the left and it could not have come at a worse time. There is no one to stop them. My point is if we are going down, I will be damned if I have massive debt, will be paid 11 dollars an hour as a resident and then spend the rest of my life working 60-80 hrs a week trying desperately to pay my loans back while avoiding frivolous law suits. If they are not caring about helping us at all, I think that it should be fair across the board. Celebrities, politicians and lawyers contribute no more to society than doctors and do not deserve any more of a salary than doctors.


"Are you serious? The President's salary may not be much, but you have to admit that the fringe benefits are hard to beat."
I am dead serious. Not that wikipedia is a credible source, but in looking at it, it does appear he is paid an annual salary of 400,000 and congressmen/women get paid between 100-200K annual salary (not including benefits, speaking, etc).

"I do think that members of Congress should have Medicare as their insurance policy, however."
Agreed. I also think medical schools need to nurture some interested medical students into public policy so that we can have a voice that is not just the AMA and Howard Dean. Our lives are run by lawyers who see us as nothing but giant bullseyes. I have sat in on some law school classes including ethics and health law and it is frightening.



"Again, good luck with that. Who do you think is in Washington making all these laws, anyway?"
Amen brother.

"The shift work good luck with that type comment (it was deleted)"
I say we should all go to shift work because if they are not going to pay us to work 60-80 hours a week, why should we? No one else works that and we should not have to either. I am tired of the underappreciation of physicians and the lifestyle we live. People think it is all fun and games and living on the golf course and playing on yachts, but this is far from truth.

"I hope you voted for the other guy last November, then."
I do not support any politicians to be honest with you. Power corrupts them all. Though I am not an anarchist, I would say that I do not support Obama moreso than ever as he cares nothing for me (and I am far from rich). The fact that he is not even willing to talk seriously about tort reform disgusts me. The fact that he spreads false lies at his nationally televised town hall meetings makes me ill. The fact that he dodges all the politically risky topics such as obesity and end of life care at all of his town hall meetings just highlights what is wrong with this whole process. This reminds me of campaigns - lots of empty promises that may or may not be possible to achieve in an effort to muster support for some massive bill that no citizen will ever have a chance to read or understand prior to its passing.

Lastly, I do not mean to sound condescending to my primary care brethren. I am only a medical student, but I plan to specialize because I am actually interested in some of the specialty areas and I found primary care to be very frustrating. It is a very difficult field indeed and takes a special doctor to want to do it. Nevertheless, I think it is a mistake to think we are somehow independent from one another and are "finally making right what is wrong." This will ultimately lead to both of us losing.

 

[spacedout]

Agreed that it is a big expense for businesses, but it's the cost of doing business... it's all part of "Total Compensation" (=payroll+benefits). And because it's a business cost, employers don't pay payroll taxes on health insurance benefits, so in effect, there's some government subsidization of health benefits already (Republicans want to repeal this and force employers to pay taxes on health insurance, but labor unions won't go for it because labor unions have negotiated super-rich & expensive insurance benefits for their members).

The problem is there currently isn't an even playing field between large employers and small employers. When insurance carriers underwrite large employers, they have a lot of employees which allows them to spread the financial risk over larger number of people. When premiums are quoted, it's quoted for the entire population, and this in the insurance world is called "Community Rating". All the employees of that large corporation constitute a "community" and basically you're getting a group discount. Small employers can't do that and subsequently are subjected to higher premiums, and as a result many small employers don't carry health benefits (or they carry shoddy ones, or they'll ask employees put money into an HSA and cover catastrophic insurance which has a high deductible).

The plan sets up purchasing cooperatives where you can buy insurance through so that insurance companies aren't underwriting you as an individual. They underwrite an entire group that's purchasing through cooperative. So if you're in a small business, you still have the ability to purchase insurance.

Would a public option cause large employers to dump health insurance coverage? Maybe, maybe not? Because as a large employer, you have to mindful of minimizing Total Compensation, while remaining competitive to attract employees. A large employer will continue to provide health insurance if they can get a better community rating compared to public option. If not, they dump it, pay the employees the Total Compensation in payroll, and have the employees go purchase it and apply for the tax deduction later. Either way, employees benefit because they're getting a cheaper premium for the same product.

I believe Obama is in favor of a "pay or play" system, where companies MUST provide health insurance and if they don't and decide to dump it, they have to pay a fee which makes its way back to underwriting those who are purchasing via public option.

Personally, I don't think Congress is going far enough to help out the small businesses. Because small businesses don't have the capital, they must provide insurance through insurance carriers, who are regulated by the State Government. Large businesses sometimes have enough capital and so they will "self-insure" their employees (i.e. create a fund from which insurance payouts come from) and bear all the risk. They can do this because they have lots of employees and the risk is distributed/diversified and cost potentially lower. The problem is that when large employers self-insure, they "technically" are NOT insurance companies and therefore are not regulated by the State Government anymore. They're regulated by the Federal Government under ERISA and ERISA is much more liberal/lenient that what some of the states do.

So if you really cared about small businesses, you'd push for reform of the ERISA regulations... but this is a huge undertaking and no one has mentioned it yet...

I say, let's tax health benefits, like Republicans want (so there's no pay-or-play). Set up a public option, like the Democrats want. And once and for all, get rid of employer-based health insurance and put the purchasing decision making in the hands of the people. You would side-step ERISA without having to repeal it, which is pro-small business. I just hate it when employers are making health care decisions on behalf of their employees, whom they don't give a crap about (it's all about cost-minimization).

Mandate guarantees (can't be denied because of pre-existing conditions) and allow a mechanism to community rate (group discount on premiums) and let's get these effin' uninsured covered! What sucks more than losing your job and your paycheck? Losing your health insurance with it!



No one, Democrat or Republican, has proposed free government health care. No one. The public option provides the opportunity for individuals to purchase health insurance through a different party other than their own employers (if they're employed). This allows for community rating (the group discount I mentioned). You still have to purchase the insurance. I think there might be an exception for the very poor who might get subsidized, but usually there's a cost/risk-sharing (copay, coinsurance, deductible) to stave off abuse.

Wow. I've been googling for hours trying to really get an understanding of this public option thing, and your post is the best explanation I've found by far. You should be a teacher.

Just so that I really understand, let me try to explain it myself. Please correct me if i'm wrong:

Many get health insurance through their employers which is affordable because they are in a group with many others and the insurance companies are able to spread the risk and offer lower premiums.

Some people, such as members of small businesses, the unemployed, or those whose employer does not offer health insurance must pay higher premiums for individual insurance. By buying insurance from "The Public Option", these people would all be grouped together, which would create a large pool of people that would bring premiums down.

So, in theory, most people would still be in a "better" group with their employers' health insurance, and the public option wouldn't apply because it would actually be like jumping into a smaller, less efficient community?

I'm still a bit confused: would the government-run public insurance company behave identically to a private firm (deductibles, premiums, etc) but be more affordable because it also has access to tax funds/penalties from companies that choose not to provide insurance?

But, like you said, companies always want to reduce costs. If they deem that paying the penalty for sending employees to the public option is better than providing the insurance themselves, what do you think is stopping the public option from just swallowing up everyone? That would create a pretty large community for risk to be spread amongst...

I'm trying to learn health insurance for my interviews, so forgive the muddled thoughts. I'd appreciate some clarification here, though.

 

[deleted87716]

Kitra: I'm having too much trouble making sense of your rant at this point to respond. Many of your comments suggest that you have much to learn about how medicine works in the real world, and how government approaches healthcare issues. Good luck to you in medical school, and whatever field you choose. Whatever you do, don't choose it for the money...it may not be there by the time you finish your training.

 

[lowbudget]

So, in theory, most people would still be in a "better" group with their employers' health insurance, and the public option wouldn't apply because it would actually be like jumping into a smaller, less efficient community?

Yes! Wow, whenever I post, I'm usually just talking to myself, like I have end-stage dementia or something. I do it for fun, never really think anyone's listening... But yes, you got it... well, at least you're up to par with what policywonks are talking about. Unfortunately, I don't have good answers for your questions... since I have the same information as you do.

I'm still a bit confused: would the government-run public insurance company behave identically to a private firm (deductibles, premiums, etc) but be more affordable because it also has access to tax funds/penalties from companies that choose not to provide insurance?

The answer is I don't know.
1. I don't think government will run an insurance "company". The money goes into a fund, and I'm guessing the Fed Gov't will subcontract out the "administration" of the fund to insurance professionals (e.g. Aetna, United, etc.)

2. In theory, it should be more "affordable" (than the alternative) because of pooling. But also in theory, the people who are more likely to pick the public option will tend to be "higher risk":
-people previously rejected for pre-existing conditions like cancer or AIDS,
-people who work for small employers doing manual labor like construction, restaurants, seasonal workers, part-time workers (remember, if you're young, healthy doing desk work in the above categories, you'll likely choose to be uninsured. It's those most likely to be injured/sick who can't afford private individual insurance who will most benefit from the public option). I'm going to guess that young healthy women in their 20's will choose the public option (so their pregnancy is covered... potentially very devastating financially).

So I'm guessing there will be some selection bias in the public option for high utilizers which may prevent it from being super cheap (the other term for this is called "adverse selection")

But, like you said, companies always want to reduce costs. If they deem that paying the penalty for sending employees to the public option is better than providing the insurance themselves, what do you think is stopping the public option from just swallowing up everyone? That would create a pretty large community for risk to be spread amongst...

This remains a mystery to me also. But I can give you 3 reasons. At least in theory.
1. Insurance companies don't want to lose the employers' business. So they will compete with better rates or better benefits. This is Obama's argument.
2. No reason for the government to swallow everyone up. The larger the enrollment in the government option, the more it needs to go into administering it. Gov't approaches a diseconomies of scale and it ends up being so expensive/inefficient that private companies start entering the market and will to compete for small chunks of the business. This is American economics.
3. Democracy. Democracy is a free market of ideas, and for every $1 sunk into administering the public option, there's $1 less that goes into national defense, environment, education, welfare, etc. And so there will be competition on the national level for that $1. This is American politics.

There's no way, IMO, they can pull this off without there also being insurance industry reform. Private sector must provide insurance or else the government will eff it up royally, so Congress needs to be careful.

IMO, in order for private sector insurance to successfully compete with the public option is for the government to deregulate insurance and allow insurance companies to compete across state lines (like I said before, currently Aetna in Delaware cannot compete with United in Rhode Island for business... insurance is state regulated). I hope they put in federal regulations and convince all 50 state governments to "give up" that jurisdiction... but, that's near impossible politically because states don't want to give up their "state rights" to the federal government. But who knows. Maybe it'll happen. I'm waiting for them to bring it up, but I see this as 1 potential scenario where the public option puts private sector out of business, unless they open the whole damn thing up and let the state-by-state insurance companies consolidate to compete with the public option.

 

[scubadoc78]

Kitra: I'm having too much trouble making sense of your rant at this point to respond. Many of your comments suggest that you have much to learn about how medicine works in the real world, and how government approaches healthcare issues. Good luck to you in medical school, and whatever field you choose. Whatever you do, don't choose it for the money...it may not be there by the time you finish your training.

I get lost in many of the details but I also believe Kitras points are legitimate in the sense that they echo the fears of many medical students in the country right now. If Obama wants medical students in primary care he has to address this issue specifically: Will he replace primary care MDs with an army of cheaper mid-levels? The AAFP specifically published a statement disagreeing with his plans to do so, so why shouldn't we believe that's his intent?

I'm sure it sounds naive to someone who's in the real world, but the fear of losing our career is large enough that it is trumping the authority of even good mentors like you, Blue Dog.

 

[deleted87716]

If Obama wants medical students in primary care he has to address this issue specifically

He has. See yesterday's thread.

Incidentally, nobody has recommended replacing physicians with mid-levels in primary care or any other specialty. I'm not sure where you're getting that.

Perhaps you're referring to the issue of NP-led medical homes. The AAFP didn't actually disagree with this concept (it's going to be necessary, frankly, as there simply aren't enough doctors to do the job, esp. in rural areas), but wants the performance standards to be the same regardless of whether or not the medical home is physician-led or NP-led. I have no problem with that.

 

[benjee]

He has. See yesterday's thread.

Incidentally, nobody has recommended replacing physicians with mid-levels in primary care or any other specialty. I'm not sure where you're getting that.

Perhaps you're referring to the issue of NP-led medical homes. The AAFP didn't actually disagree with this concept (it's going to be necessary, frankly, as there simply aren't enough doctors to do the job, esp. in rural areas), but wants the performance standards to be the same regardless of whether or not the medical home is physician-led or NP-led. I have no problem with that.

There are always misconceptions 1.It's not ethical and not professional to replace a specialty by some non-qualified staffs simply because there is a shortage of that specialty. Does that means we can replace a surgeon with a surgical tech??
2.Primary care actually is not as simple as what non health care lawmakers thought . It is a specalty provide comprehensive care which requires extensive education at least medical education and postgraduate training which Np or other allied health professionals do not have. This extensive education is necessary in order to provide quality care.
I really do not agree any replacement of primary care in name of shortage ..etc. When someone consider of replacement, think about if a surgeon can replace a primary care physician. A surgeon may not be able to necessarily provide qualify care since that's not their scope of practice.

 

[porsche518]

Incidentally, nobody has recommended replacing physicians with mid-levels in primary care or any other specialty. I'm not sure where you're getting that.

Really...

http://forums.studentdoctor.net/showthread.php?t=651537

http://forums.studentdoctor.net/showthread.php?t=651237

I think there are some midlevels who are going to disagree with you.

 

[deleted87716]

Really...

I was referring to those who are actually involved in the healthcare reform process, not opinionated SDNers.

 

[lowbudget]

Here's a good explanation on the role of government in the health care system. It's written as an Op-Ed by Krugman who is a respected economist (I think he's got a Nobel) but his writings in the NYT tend to lean more to the Left, which is interesting since most economists will leave politics to the politicians, but I guess this is his forum.

http://www.nytimes.com/2009/07/31/opinion/31krugman.html?hpw

Anyways, whatever your political leanings, think through what Krugman is trying to explain to you. The middle part of the piece is fairly professorial.

 

[andwhat]

Really...

http://forums.studentdoctor.net/showthread.php?t=651537

http://forums.studentdoctor.net/showthread.php?t=651237

I think there are some midlevels who are going to disagree with you.

I can speak from a Hospitalist setting, I will bet money that N.P.s and P.A.s would not want to do our work full time, and they cannot do it.
I think that 'midlevels' could not handle a busy practice, without supervision. This is so well hyped and over-rated. Yes they can do Anesthesia, but not what we do.

 

[deleted87716]

Here's a good explanation on the role of government in the health care system. It's written as an Op-Ed by Krugman

The bottom line in his piece seems to be "Medicare and other government-funded programs provide good coverage to beneficiaries, hence the government will probably do a good jub with single-payer."

This ignores two things. First of all, the status quo is not sustainable. Medicare is spending too much money. Something will have to change in order to keep it solvent (read: rationing in one form or another). Furthermore, the government's reimbursement to providers under Medicare, and particularly under Medicaid (a state-funded program) does not cover the cost of providing care. The only way the system sustains itself is by cost-shifting from better-paying (commercial) insurance plans. Even than, most doctors and institutions (such as skilled nursing facilities) have to limit the number of Medicare patients they see, lest the balance be thrown off.

IMO, you can't rely on Medicare's current "success" from the beneficiary standpoint as any guarantee of future performance.

 

[lowbudget]

The bottom line in his piece seems to be "Medicare and other government-funded programs provide good coverage to beneficiaries, hence the government will probably do a good jub with single-payer."

This ignores two things. First of all, the status quo is not sustainable. Medicare is spending too much money. Something will have to change in order to keep it solvent (read: rationing in one form or another).

Absolutely. We're always balancing how to best utilize scarce resources. At this time, I think policymakers are trying to figure out how to provide universal coverage, but there is no way that coverage can be comprehensive. Universal coverage does not guarantee universal access. And like you said, we will need to make choices about how those resources are deployed (i.e. ration). Do we cover everyone with minimal services provided (i.e. explicit rationing), or do we let people go uninsured while allowing others to get more comprehensive services (i.e. implicit rationing)? Classic argument.

With the focus of the debate on the former, at some point in the future, we will be arguing about how the public option is inadequate and the alternative (employer-based insurance) is just as inadequate. My fear is that we trade the uninsured few for the underinsured many. Does this case of the underinsured remind you of something we see everyday?:http://online.wsj.com/article/SB124898627892394853.html

Clearly, being underinsured has its own set of problems and drives up costs in its own ways as that case illustrates. There's no way government can solve all our problems.

Furthermore, the government's reimbursement to providers under Medicare, and particularly under Medicaid (a state-funded program) does not cover the cost of providing care. The only way the system sustains itself is by cost-shifting from better-paying (commercial) insurance plans.

Yea, Obama has talked about this problem specifically. He has said that right now hospitals overcharge private insurers to compensate for being under-reimbursed by the public system (Medicare/Medicaid/county) or private individuals (uninsured-cash pay). He wants universal coverage so that all patients will reimburse hospitals/providers (i.e. increases quantity) and cut the price that CMS will pay out (i.e. decrease price) in hopes that private insurers will follow. He's hoping dollar-wise this will be budget neutral (Hospital Revenue = Government Expense = [decr] Price x [incr] Quantity). This is what he's talking about when he's talking about paying for reform based on savings.

We'll see. It does make me a bit nervous. Higher quantity (the more patients we take care even if they're insured) increases expenses to absorb that quantity (i.e. hire more nurses, more PCP's, more tests, more meds, more admissions). At the end of the day, hospitals don't care about the top line (gross revenue) as they do about the bottom line (net income... which is after all the expenses are accounted).

I don't know. Do we trust that these people will get it right (or even get it done)?

 

[scubadoc78]

Absolutely. We're always balancing how to best utilize scarce resources. At this time, I think policymakers are trying to figure out how to provide universal coverage, but there is no way that coverage can be comprehensive. Universal coverage does not guarantee universal access. And like you said, we will need to make choices about how those resources are deployed (i.e. ration). Do we cover everyone with minimal services provided (i.e. explicit rationing), or do we let people go uninsured while allowing others to get more comprehensive services (i.e. implicit rationing)? Classic argument.

With the focus of the debate on the former, at some point in the future, we will be arguing about how the public option is inadequate and the alternative (employer-based insurance) is just as inadequate. My fear is that we trade the uninsured few for the underinsured many. Does this case of the underinsured remind you of something we see everyday?:http://online.wsj.com/article/SB124898627892394853.html

Clearly, being underinsured has its own set of problems and drives up costs in its own ways as that case illustrates. There's no way government can solve all our problems.



Yea, Obama has talked about this problem specifically. He has said that right now hospitals overcharge private insurers to compensate for being under-reimbursed by the public system (Medicare/Medicaid/county) or private individuals (uninsured-cash pay). He wants universal coverage so that all patients will reimburse hospitals/providers (i.e. increases quantity) and cut the price that CMS will pay out (i.e. decrease price) in hopes that private insurers will follow. He's hoping dollar-wise this will be budget neutral (Hospital Revenue = Government Expense = [decr] Price x [incr] Quantity). This is what he's talking about when he's talking about paying for reform based on savings.

We'll see. It does make me a bit nervous. Higher quantity (the more patients we take care even if they're insured) increases expenses to absorb that quantity (i.e. hire more nurses, more PCP's, more tests, more meds, more admissions). At the end of the day, hospitals don't care about the top line (gross revenue) as they do about the bottom line (net income... which is after all the expenses are accounted).

I don't know. Do we trust that these people will get it right (or even get it done)?

Perhaps it's already been mentioned and I was lost in the vocabulary, but why not have differential coverage depending on someone's assessed competency to provide for themselves? For example, have government coverage for children pre-natal to 18 and then only basic coverage for healthy, working adults 18-65 who presumably can contribute to their own healthcare coverage via employer benefits. Retiree coverage could be a mix of retirement benefit coverage + government coverage.

Wouldn't this take some burden off a government system while still preserving commercial participation via employment coverage? No child should go without coverage b/c parents are unable (or unwilling) to work and it perhaps it would encourage people to contribute to society knowing they would lose benefits at 18?

Just a thought...

 

[Taurus]

In the recently released House health-reform bill, nurse practitioners (and physician's assistants, another relatively new, but smaller, category of medical professionals who can perform medical procedures and often prescribe medication) are listed alongside doctors as primary-care providers. Nurse practitioners lobbied hard for this legislative language in meetings with White House health officials, including Nancy-Ann DeParle, Obama's health-reform czar. The nurse-practitioners lobby is hoping such federal recognition of the central role the profession can play in a revamped health system will exert pressure on states to ease up on restrictions. A patchwork of state laws now dictates how much freedom nurse practitioners have, ranging from states like Alabama, where nurse practitioners can only work under the supervision of a physician, to Oregon, where nurse practitioners are permitted to run their own private practices.

 

[scubadoc78]

In the recently released House health-reform bill, nurse practitioners (and physician's assistants, another relatively new, but smaller, category of medical professionals who can perform medical procedures and often prescribe medication) are listed alongside doctors as primary-care providers. Nurse practitioners lobbied hard for this legislative language in meetings with White House health officials, including Nancy-Ann DeParle, Obama's health-reform czar. The nurse-practitioners lobby is hoping such federal recognition of the central role the profession can play in a revamped health system will exert pressure on states to ease up on restrictions. A patchwork of state laws now dictates how much freedom nurse practitioners have, ranging from states like Alabama, where nurse practitioners can only work under the supervision of a physician, to Oregon, where nurse practitioners are permitted to run their own private practices.

Yeah, this is what I've been reading/hearing too. We'll see how it goes. For now, though, I'm hedging my bets and applying to IM as well as FM. I know it's a risk, but I enjoy both fields.
Honestly, I can't see FM docs going away even if NPs take over. I live in a midwest state which has independently practicing NPs and as most attendings on here have said, it would be a disaster for healthcare if we gave primary care to much less qualified individuals. All the talk about mismanaged diabetics getting their money bags er, I mean legs, chopped off aren't going to get better outcomes by having less qualified people treat them.

 

[Taurus]

Yeah, this is what I've been reading/hearing too. We'll see how it goes. For now, though, I'm hedging my bets and applying to IM as well as FM. I know it's a risk, but I enjoy both fields.
Honestly, I can't see FM docs going away even if NPs take over. I live in a midwest state which has independently practicing NPs and as most attendings on here have said, it would be a disaster for healthcare if we gave primary care to much less qualified individuals. All the talk about mismanaged diabetics getting their money bags er, I mean legs, chopped off aren't going to get better outcomes by having less qualified people treat them.

The solution is not at the legislative or political level; it's in the marketplace. Educate the insurance companies and trial lawyers on the training that NP's go through. Do they feel that someone with 700 hours of clinical training and possible online degree is riskier than a board-certified physician who has gone through 17000 hours of training? Make it so risky and expensive for NP's to practice autonomously. Do your part by pointing out malpractice to patients and informing your local trial lawyers and insurance companies.

 

[scubadoc78]

The solution is not at the legislative or political level; it's in the marketplace. Educate the insurance companies and trial lawyers on the training that NP's go through. Do they feel that someone with 700 hours of clinical training and possible online degree is riskier than a board-certified physician who has gone through 17000 hours of training? Make it so risky and expensive for NP's to practice autonomously. Do your part by pointing out malpractice to patients and informing your local trial lawyers and insurance companies.

If there's one thing I have faith in it's lawyers/businesses ability to sniff out money. They don't need my help.

After 18 months in Iraq I have a very low threshold for politics, but I'd tune in to see Obama address the issue of mid-level vs. MD competition in his vision of primary care. I honestly feel he's talking out both sides of his mouth. On one hand he wants more students in FM, but on the other he's legislating an army of NPs and apparantly planning to pay them equivalently to MDs.

How is shifting money to primary care going to raise anyones salary if he's going to add an enormous number of NPs to the pot?

 

[Irish37]

Government run / regulated health care: Because i trust politicians with my health care.

 

[ZuperZtar]

In case no one reads my thread, these are some of my thoughts.

"I am trying to get some opinions on this topic without creating a flame war. I am a medical student interested in primary care. I am concerned however about Obama's support for increasing the number of privately functioning NP's. I know Oregon allows NP's to practice seperately from MD's. Do you guys think this trend will continue? It worries me because I see this trend as having the potential to drive primary care salaries down and at the very least keep them constant.

My thoughts on future scenarios are as follows. Obama's plan: Increase primary care salaries by 8% (maybe a pay increase of 10k a year, maybe?). Decrease specialist (ie Radiologist) salaries by 15% ( a drop of perhaps 100k per year) thus decreasing the average physician salary on average. Increase the number of training programs in NP, PA, FP and IM. The new FP/IM spots will go primarily to foreign grads. (as you could fill 3000+ spots in primary care residency programs with foreign grads if you wanted to). The supply of NP's PA's FP's IM's increases as a whole, thus filling the demand and hence limiting the pay increase to primary care, ie primary care will never be making 250k+ salaries in the long run. (of course i am talking about the starting salaries that you get hired into and not Dr. X who is entrepreneurial enough to make 500k+ off his business model bc this isnt the avg Physician).

I thus think that Obama is "pretending" to favor primary care docs but creating a rift between physicians to decrease the avg salaries of all docs and simultaneously sticking it to GP physicians by increasing competition from NP/PA's that could function privately, thus increasing supply and stagnating pay increases to primary care in the long term.

Ok, that was really long, but what are your thoughts on this? 20 years from now will it still be much better (financially speaking) to be a specialist?

I mean sometimes I feel insulted that starting salaries in primary care in cities are 100k-140k (7 yrs education post bac; goes up to 200k) PA's make 90-120k (2 yrs education; goes up to 160k), CRNA's make 120k-180k (2 yrs education; goes up to 300k+) and our fellow docs start at 200-500k+ ( (8-11 yrs education; goes up to 250k-800k+). Why does society value us so poorly? The politicians say they want primary care and value PCP's but where is the proof? An 8%/7k increase in salaries (half of which goes for taxes)????? Are you kidding me???? No wonder no US grad wants to go into primary care. I suppose it doesnt matter bc you can fill the demand with IMG's.

As future PCP's can we do anything to change this? Should we move to Canada or GB? Or maybe all start concierge practices?

I sacrificed a lot to be where I am and will be 160k+ in debt. This figure will grow in residency. I feel like society doesnt respect us at all. We get ridiculed by nurses, PA's, NP's and even our own physicians and patients. (i'm venting). I've had surgeons stop teaching me in the OR after I tell them I want to do general IM or FM?! Our own collegues! Peds, OB and IM attendings referring to FP residents as "there's the stupid FP resident." There's only so much you can take. And you know what, the sad thing is that it is all about dollars and cents. If we made 300k+ a year, people wouldnt be calling us "stupid GP".

I love primary care (particularly FP) and the interaction with patients/breath of practice, but i've had residency faculty members tell me not to do FM/IM bc they are so unhappy. The starting salary in my city is 90-110k for FM. My PA friends are making more than this 2+ years out. They are done paying their student loans, stable careers in big cities, moving on with their lives. We get nothing for our extra time/sacrifice/responsibility (and exposure to getting sued). Oh wait, Obama gave us an 8%/7k increase in salaries?!?

Honestly, someone should stick this post on CNBC or MSNBC. People would probably just write it off as another "greedy doctor."

At least stop sueing us or cap litigation? (oh wait, Pres. Obama doesnt want to do that, not to trial lawyers (their value to society is equal to the bankers/financial institutions who got 700 billion dollars)).

20 yrs from now there will be VERY FEW US trained PCP's. But I suppose it doesnt matter bc IMG's, NP's and PA's will fill in the gaps. (until the IMG's realize its better to be a PCP in GB/Canada and incorporate.)

Maybe the new trend will be to make 2/3 year med schools with 2/3 year residencies to be a PCP (as has already started). Or maybe the 5 years of training that a PCP does over his PA/NP collegues is a waste. After all, it only takes 2 years to master the pathophysiology of the complex interactions taking place in multiorgan disease. ( sarcasm intended).

And I think the AMA needs to do a better job in restricting licensing. You dont see midlevel providers infiltrating into the field of dentistry. Dental school also do not accept foreign trained physicians. Dentistry will/is becoming a more attractive career option for undergrads and it is obvious why.

Being complacent and "sitting back and watching change happen" is why we are in this mess. GP's need to get more active in politics. PA's/NP's are very active and very aggressive, and hence, for better or worse, their practice privledges are increasing. The question is will our fellow physician specialists help us? If not, what is the point of even being part of the AMA. United we stand, divided we fall. Do we need a seperate body to support GP's?

Is that what it will come to? If 'yes' is the answer, then physicians, GP's and specialists, have already lost on a political front.

If we are not careful, we will fall into the trap of creating a civil war within our physician community and we will all fall. (which, by the way, is what the overall plan to "correct" h.care is)


For specialists who do not want to support the plight of the GP....maybe your opinions will change when NP's start opening CME clinics on colonoscopies, injections etc. Guess what, it doesnt take an Albert Einstein to do a lot of the procedures that specialists rake it in with. My last statement is that once you allow another political body to train in your field and do what you do for a living, they will continue to proliferate and grab turf until they are your equal. Currently DO's are the equivalent of MD's and are governed by a seperate licensing body that is allowed to create schools and residency programs. We work together and that is great. Perhaps it is time that our governing bodies stopped bickering on who is better/more prestigious, and joined together to create a unified governing council of Physicians that regulate who is allowed to practice medicine. Maybe one day allopathic docs can train at osteopathic residency programs as osteopaths can train at allopathic programs. Imagine that? If you want to learn OMM, you would be able to! And bill for it!!

Or our communities, MD's and DO's, specialists and generalists can squabble amongst ourselves and watch NP's create the AANP with one year residency programs in outpatient GI (scopes), Cards (EKG's/stress tests), Pain (injections), Cosmetics, Anesthesia (oh wait, CRNA's already exist...their first residency program!!) etc. Their argument might be that you dont need a physician to do simple procedures. Physicians are only needed for interpretations and more complex, hospital based procedures or to handle complications. "

 

[andwhat]

In case no one reads my thread, these are some of my thoughts.

"I am trying to get some opinions on this topic without creating a flame war. I am a medical student interested in primary care. I am concerned however about Obama's support for increasing the number of privately functioning NP's. I know Oregon allows NP's to practice seperately from MD's. Do you guys think this trend will continue? It worries me because I see this trend as having the potential to drive primary care salaries down and at the very least keep them constant.

My thoughts on future scenarios are as follows. Obama's plan: Increase primary care salaries by 8% (maybe a pay increase of 10k a year, maybe?). Decrease specialist (ie Radiologist) salaries by 15% ( a drop of perhaps 100k per year) thus decreasing the average physician salary on average. Increase the number of training programs in NP, PA, FP and IM. The new FP/IM spots will go primarily to foreign grads. (as you could fill 3000+ spots in primary care residency programs with foreign grads if you wanted to). The supply of NP's PA's FP's IM's increases as a whole, thus filling the demand and hence limiting the pay increase to primary care, ie primary care will never be making 250k+ salaries in the long run. (of course i am talking about the starting salaries that you get hired into and not Dr. X who is entrepreneurial enough to make 500k+ off his business model bc this isnt the avg Physician).

I thus think that Obama is "pretending" to favor primary care docs but creating a rift between physicians to decrease the avg salaries of all docs and simultaneously sticking it to GP physicians by increasing competition from NP/PA's that could function privately, thus increasing supply and stagnating pay increases to primary care in the long term.

Ok, that was really long, but what are your thoughts on this? 20 years from now will it still be much better (financially speaking) to be a specialist?

I mean sometimes I feel insulted that starting salaries in primary care in cities are 100k-140k (7 yrs education post bac; goes up to 200k) PA's make 90-120k (2 yrs education; goes up to 160k), CRNA's make 120k-180k (2 yrs education; goes up to 300k+) and our fellow docs start at 200-500k+ ( (8-11 yrs education; goes up to 250k-800k+). Why does society value us so poorly? The politicians say they want primary care and value PCP's but where is the proof? An 8%/7k increase in salaries (half of which goes for taxes)????? Are you kidding me???? No wonder no US grad wants to go into primary care. I suppose it doesnt matter bc you can fill the demand with IMG's.

As future PCP's can we do anything to change this? Should we move to Canada or GB? Or maybe all start concierge practices?

I sacrificed a lot to be where I am and will be 160k+ in debt. This figure will grow in residency. I feel like society doesnt respect us at all. We get ridiculed by nurses, PA's, NP's and even our own physicians and patients. (i'm venting). I've had surgeons stop teaching me in the OR after I tell them I want to do general IM or FM?! Our own collegues! Peds, OB and IM attendings referring to FP residents as "there's the stupid FP resident." There's only so much you can take. And you know what, the sad thing is that it is all about dollars and cents. If we made 300k+ a year, people wouldnt be calling us "stupid GP".

I love primary care (particularly FP) and the interaction with patients/breath of practice, but i've had residency faculty members tell me not to do FM/IM bc they are so unhappy. The starting salary in my city is 90-110k for FM. My PA friends are making more than this 2+ years out. They are done paying their student loans, stable careers in big cities, moving on with their lives. We get nothing for our extra time/sacrifice/responsibility (and exposure to getting sued). Oh wait, Obama gave us an 8%/7k increase in salaries?!?

Honestly, someone should stick this post on CNBC or MSNBC. People would probably just write it off as another "greedy doctor."

At least stop sueing us or cap litigation? (oh wait, Pres. Obama doesnt want to do that, not to trial lawyers (their value to society is equal to the bankers/financial institutions who got 700 billion dollars)).

20 yrs from now there will be VERY FEW US trained PCP's. But I suppose it doesnt matter bc IMG's, NP's and PA's will fill in the gaps. (until the IMG's realize its better to be a PCP in GB/Canada and incorporate.)

Maybe the new trend will be to make 2/3 year med schools with 2/3 year residencies to be a PCP (as has already started). Or maybe the 5 years of training that a PCP does over his PA/NP collegues is a waste. After all, it only takes 2 years to master the pathophysiology of the complex interactions taking place in multiorgan disease. ( sarcasm intended).

And I think the AMA needs to do a better job in restricting licensing. You dont see midlevel providers infiltrating into the field of dentistry. Dental school also do not accept foreign trained physicians. Dentistry will/is becoming a more attractive career option for undergrads and it is obvious why.

Being complacent and "sitting back and watching change happen" is why we are in this mess. GP's need to get more active in politics. PA's/NP's are very active and very aggressive, and hence, for better or worse, their practice privledges are increasing. The question is will our fellow physician specialists help us? If not, what is the point of even being part of the AMA. United we stand, divided we fall. Do we need a seperate body to support GP's?

Is that what it will come to? If 'yes' is the answer, then physicians, GP's and specialists, have already lost on a political front.

If we are not careful, we will fall into the trap of creating a civil war within our physician community and we will all fall. (which, by the way, is what the overall plan to "correct" h.care is)


For specialists who do not want to support the plight of the GP....maybe your opinions will change when NP's start opening CME clinics on colonoscopies, injections etc. Guess what, it doesnt take an Albert Einstein to do a lot of the procedures that specialists rake it in with. My last statement is that once you allow another political body to train in your field and do what you do for a living, they will continue to proliferate and grab turf until they are your equal. Currently DO's are the equivalent of MD's and are governed by a seperate licensing body that is allowed to create schools and residency programs. We work together and that is great. Perhaps it is time that our governing bodies stopped bickering on who is better/more prestigious, and joined together to create a unified governing council of Physicians that regulate who is allowed to practice medicine. Maybe one day allopathic docs can train at osteopathic residency programs as osteopaths can train at allopathic programs. Imagine that? If you want to learn OMM, you would be able to! And bill for it!!

Or our communities, MD's and DO's, specialists and generalists can squabble amongst ourselves and watch NP's create the AANP with one year residency programs in outpatient GI (scopes), Cards (EKG's/stress tests), Pain (injections), Cosmetics, Anesthesia (oh wait, CRNA's already exist...their first residency program!!) etc. Their argument might be that you dont need a physician to do simple procedures. Physicians are only needed for interpretations and more complex, hospital based procedures or to handle complications. "

ZuperZtar dont completely agree with all of youre philosophies. N.P.s and P.A.s will surely not be taking over Hospital Medicine. As a matter of fact, they are taking on less and less of a role in the Hospitalist model. In essence, they are being 'crowded out'
Hospitalist care is a part of Primary Care. I am not worried about N.P.s and P.A.s assuming the role of caregivers in our setting. As a matter of fact, I actually look forward to working with them.
The outpatient setting, we will see. The liability issue is key, who is going to cover these N.P. P.A. providers if not Physicians? I would not allow a bunch of P.A./N.P.s work under my name, if I didn't trust them.
I think this whole issue is blown way out of proportion.
The issue is the significant underutilization of Primary Care in our system, and the obvious detriental results we have facing us now.
Any idiot can perform procedures, "scope biopsy = $$$$" yet they are are reimbursed the highest?? It is absurdity, and yes you are completely correct, those days are done....

 

[Wrigleyville]

Do any of you really think that a 10% pay increase will attract more medical students into primary care when the price is allowing a tsunami of NP and PAs to perform the same job? Will medical students with $200000 in debt sign up for a residency that puts them on par with a nurse for a slight raise? If this passes, family practice by physicians will fall off an even steeper slope.

And for anyone who thinks this will reduce the number of useless tests and consults, get real... a flood of undertrained "providers" practicing primary care will only increase the amount of waste. Who do you think orders the most useless studies?

The studies from doctors, when not needed, are at least only "unlikely to yield useful information". The studies I see ordered from NP range much further, into the "incomprehensible" range. (U/S Arm. Reason: Bruising after workout. I call up the nurse to ask what on earth this means, and she explains that she wants to see if the patient's cells broke. ?!?!)

I am all in favor of increasing primary care compensation at the expense of specialists, but you need to fight like hell against inviting the fox into the henhouse. Don't let your jealousy and desire to "stick it to the specialists" blind you to the threat of allowing NPs and PAs to do your job. Their lack of training will injure your patients and further crowd doctors out of primary care.

 

[andwhat]

Do any of you really think that a 10% pay increase will attract more medical students into primary care when the price is allowing a tsunami of NP and PAs to perform the same job? Will medical students with $200000 in debt sign up for a residency that puts them on par with a nurse for a slight raise? If this passes, family practice by physicians will fall off an even steeper slope.

And for anyone who thinks this will reduce the number of useless tests and consults, get real... a flood of undertrained "providers" practicing primary care will only increase the amount of waste. Who do you think orders the most useless studies?

The studies from doctors, when not needed, are at least only "unlikely to yield useful information". The studies I see ordered from NP range much further, into the "incomprehensible" range. (U/S Arm. Reason: Bruising after workout. I call up the nurse to ask what on earth this means, and she explains that she wants to see if the patient's cells broke. ?!?!)

I am all in favor of increasing primary care compensation at the expense of specialists, but you need to fight like hell against inviting the fox into the henhouse. Don't let your jealousy and desire to "stick it to the specialists" blind you to the threat of allowing NPs and PAs to do your job. Their lack of training will injure your patients and further crowd doctors out of primary care.

ha ha ... .yes N.P.s and P.A.s will take over Hospitalist medicine.. misinformed Of course a Radiology resident will state that we are all 'jealous' ....
Money is not the point.
20% off specialists will not do anything to help the Primary Care situation.
Like I stated, Hospitalist lifestyle is safe from the so-called N.P. P.A. 'invasion', and affords a great lifestyle, income, etc.
I am more than economically comfortable, and love my lifestyle.
NEVER a threat of N.P.s and P.A.s 'taking over' this field, it is too demanding mentally for anyone other than a Physician.
Thanks for the concern though, appreciated. However, I think that you need to worry about outsourcing of the field you are in.

http://www.rivkinradler.com/rivkinradler/Publications/newformat/200403manko.shtml

Also, how many times have initial films been read as 'normal' by the radiologist in the middle of the night, and the next day read as either stroke (by the Neurologist) or Appendicitis? Alot actually.
Outpatient FM requires diligence, and a N.P. or P.A. unsupervised, cannot sustain it on a day to day basis. They are fine if they are supervised.

 

[scubadoc78]

ha ha ... .yes N.P.s and P.A.s will take over Hospitalist medicine.. misinformed Of course a Radiology resident will state that we are all 'jealous' ....
Money is not the point.
20% off specialists will not do anything to help the Primary Care situation.
Like I stated, Hospitalist lifestyle is safe from the so-called N.P. P.A. 'invasion', and affords a great lifestyle, income, etc.
I am more than economically comfortable, and love my lifestyle.
NEVER a threat of N.P.s and P.A.s 'taking over' this field, it is too demanding mentally for anyone other than a Physician.
Thanks for the concern though, appreciated. However, I think that you need to worry about outsourcing of the field you are in.

http://www.rivkinradler.com/rivkinradler/Publications/newformat/200403manko.shtml

Outpatient FM requires diligence, and a N.P. or P.A. unsupervised, cannot sustain it on a day to day basis.

andwhat,

i've seen you mention a couple times that hospitals are turning away from nps/pas yet everywhere i read there are articles stating exactly the opposite. they're apparantly cost effective and increase quality of care.

i'm not saying i don't believe you, but i'm curious as to why you believe mid-levels are not becoming part of the hospitalist landscape?

 

[andwhat]

andwhat,

i've seen you mention a couple times that hospitals are turning away from nps/pas yet everywhere i read there are articles stating exactly the opposite. they're apparantly cost effective and increase quality of care.

i'm not saying i don't believe you, but i'm curious as to why you believe mid-levels are not becoming part of the hospitalist landscape?

not sure? I am not sure as to why they are not accepted at certain institutions. N.P.s and P.A.s can be extremely helpful.
Personally, the majority of the time, I think that they are an asset -- big time. Do you have any articles supporting this?
i've seen you mention a couple times that hospitals are turning away from nps/pas yet everywhere i read there are articles stating exactly the opposite. they're apparantly cost effective and increase quality of care.
I would like to analyze the data.
Thanks.
There is no looming N.P. or P.A. takeover of Primary Care. I support their pay increase, if this is really happening. This rumor is started solely by insecure individuals, afraid of their new pay cut. It is a bit disconcerting, and annoying, but most of all funny.
Increased quality of care, with care provided by N.P.s and P.A.s? Compared to Physicians? I would like to analyze this study, and see this in writing. Cost effectiveness, sure an N.P. or P.A. is less expensive than a Physician. Improved quality of care, I would say that this could be true, in collaboration with Physician supervision. The only rationalization of this, is to 'free up' other Physicians, so that they can spend more time with more complicated patients. I would definitely say that this is a possibility, and would wholeheartedly support this rationalization of improved quality of care of N.P., P.A.s in a Hospitalist setting. This is true both in the outpatient and inpatient setting. Unsupervised work by N.P.s and P.A.s, that is just not going to happen in my opinion, in the outpatient or inpatient setting. It is not reality. I support their pay increases.
Midlevel providers are cost effective, and improve quality of health care. I do like the sound of that. I support them 110%.
I am not stating that they are all great. Some of the ones that work for the E.D., call me from the E.D. to 'admit' patients are just horrid

 

[Kitra101]

I am wanting to be optimistic like some of the older folks on here or the die hard Obama supporters/long time dems, but the reality is that this is NOT about who SHOULD be providing care or what is the best outcome for patients. This is about MONEY MONEY MONEY. When the dust settles, there will be losers and there will be winners. If you were running a business and could get 70% of the same service for one half the cost, you would do it because that means saving money. Think about this - people are so concerned with the growing numbers of illegal immigrants here in the US, but yet, these people find work. Why? They find work because Americans realize they can save money by paying them less than an American would require to do the same work. Radiology has a strong likelihood of outsourcing to other nations where their radiologists get paid less because it will cost the hospitals less. The only thing stopping that right now, ironically, is malpractice (someone here has to be responsible for law suit claims). However, you can bet that some sort of reform will eventually come that will allow for outsourcing and then people will do it because it is cheaper. If you think for one second that Obama knows what it is like to train to become a PCP and the hardships that you go through to get there or to practice daily - and if you think he actually cares to know - you are DEAD WRONG. He cares about one thing and that is re-election. If you, like the AMA, go belly up to him and his lawyer buddies, well, you are digging your own graves. Letting NP and PAs have increased autonomy because of looming shortages will gradually erode the role of the PCP until there are none left. Fight to expand the roles and reimbursements of PCPs NOT PAs or NPs. Oh and let me remind you what kinds of politicians are involved in the democratic leadership in case we forget where they stand on some relevant issues (and perhaps why tort reform and caps are not high on the list of priorities for the administration) http://en.wikipedia.org/wiki/John_Reid_Edwards#Legal_career
Very interesting- a one time dem VP is a huge ambulance chaser??? Huh?

 

[docschmenke]

Did you see in today's headlines that Obama is now considering NOT having a government option??
Anyone?
White House appears ready to drop 'public option' On yahoo news check it out...
http://news.yahoo.com/s/ap/20090816/ap_on_go_pr_wh/us_health_care_overhaul

 

[deleted87716]

Did you see in today's headlines that Obama is now considering NOT having a government option??

It's not really his decision. Nothing becomes law unless it first passes the House and Senate. Checks and balances, baby.

There simply isn't enough support for the public option, as I mentioned eleven days ago in another thread.

 

[scubadoc78]

It's not really his decision. Nothing becomes law unless it first passes the House and Senate. Checks and balances, baby.

There simply isn't enough support for the public option, as I mentioned eleven days ago in another thread.

i can't believe how complicated healthcare is. can anyone honestly say they'll know what will happen if so many changes are implemented at once? i don't think so. it's for the best that obama reaches for compromises. an intelligent move would be to push for an extreme agenda then 'settle' for the reform you wanted in the first place.

 

[tony montana]

In the recently released House health-reform bill, nurse practitioners (and physician's assistants, another relatively new, but smaller, category of medical professionals who can perform medical procedures and often prescribe medication) are listed alongside doctors as primary-care providers. Nurse practitioners lobbied hard for this legislative language in meetings with White House health officials, including Nancy-Ann DeParle, Obama's health-reform czar. The nurse-practitioners lobby is hoping such federal recognition of the central role the profession can play in a revamped health system will exert pressure on states to ease up on restrictions. A patchwork of state laws now dictates how much freedom nurse practitioners have, ranging from states like Alabama, where nurse practitioners can only work under the supervision of a physician, to Oregon, where nurse practitioners are permitted to run their own private practices.

This is terrible, this alone suffices me to not want to support health reform

 

[docschmenke]

Wow this is a great read, time to wake up people


AS OTHERS SEE US.......


Take note that the date this was published in Russia was April, 27, 2009!!!!! According to Snopes this did come from Pravda. I have provided the link: http://www.snopes.com/politics/soapbox/pravda.asp


The irony of this article appearing in the English edition of Pravda (Russian State Newspaper) defies description.

American capitalism gone with a whimper

It must be said, that like the breaking of a great dam, the American descent into Marxism is happening with breath taking speed, against the back drop of a passive, hapless sheeple, excuse me dear reader, I meant people.

True, the situation has been well prepared on and off for the past century, especially the past twenty years. The initial testing grounds was conducted upon our Holy Russia and a bloody test it was. But we Russians would not just roll over and give up our freedoms and our souls, no matter how much money Wall Street poured into the fists of the Marxists.

Those lessons were taken and used to properly prepare the American populace for the surrender of their freedoms and souls, to the whims of their elites and betters.

First, the population was dumbed down through a politicized and substandard education system based on pop culture, rather then the classics. Americans know more about their favorite TV dramas then the drama in DC that directly affects their lives. They care more for their "right" to choke down a McDonalds burger or a BurgerKing burger than for their constitutional rights. Then they turn around and lecture us about our rights and about our "democracy". Pride blind the foolish.

Then their faith in God was destroyed, until their churches, all tens of thousands of different "branches and denominations" were for the most part little more then Sunday circuses and their televangelists and top protestant mega preachers were more then happy to sell out their souls and flocks to be on the "winning" side of one pseudo Marxist politician or another. Their flocks may complain, but when explained that they would be on the "winning" side, their flocks were ever so quick to reject Christ in hopes for earthly power. Even our Holy Orthodox churches are scandalously liberalized in America .

The final collapse has come with the election of Barack Obama. His speed in the past three months has been truly impressive. His spending and money printing has been a record setting, not just in America 's short history but in the world. If this keeps up for more then another year, and there is no sign that it will not, America at best will resemble the Wiemar Republic and at worst Zimbabwe.

These past two weeks have been the most breath taking of all. First came the announcement of a planned redesign of the American Byzantine tax system, by the very thieves who used it to bankroll their thefts, loses and swindles of hundreds of billions of dollars. These make our Russian oligarchs look little more then ordinary street thugs, in comparison. Yes, the Americans have beat our own thieves in the shear volumes. Should we congratulate them?

These men, of course, are not an elected panel but made up of appointees picked from the very financial oligarchs and their henchmen who are now gorging themselves on trillions of American dollars, in one bailout after another. They are also usurping the rights, duties and powers of the American congress (parliament). Again, congress has put up little more then a whimper to their masters.

Then came Barack Obama's command that GM's (General Motor) president step down from leadership of his company. That is correct, dear reader, in the land of "pure" free markets, the American president now has the power, the self given power, to fire CEOs and we can assume other employees of private companies, at will. Come hither, go dither, the centurion commands his minions.

So it should be no surprise, that the American president has followed this up with a "bold" move of declaring that he and another group of unelected, chosen stooges will now redesign the entire automotive industry and will even be the guarantee of automobile policies. I am sure that if given the chance, they would happily try and redesign it for the whole of the world, too. Prime Minister Putin, less then two months ago, warned Obama and UK's Blair, not to follow the path to Marxism, it only leads to disaster. Apparently, even though we suffered 70 years of this Western sponsored horror show, we know nothing, as foolish, drunken Russians, so let our "wise" Anglo-Saxon fools find out the folly of their own pride.

Again, the American public has taken this with barely a whimper...but a "freeman" whimper.

So, should it be any surprise to discover that the Democratically controlled Congress of America is working on passing a new regulation that would give the American Treasury department the power to set "fair" maximum salaries, evaluate performance and control how private companies give out pay raises and bonuses? Senator Barney Franks, a social pervert basking in his homosexuality (of course, amongst the modern, enlightened American societal norm, as well as that of the general West, homosexuality is not only not a looked down upon life choice, but is often praised as a virtue) and his Marxist enlightenment, has led this effort. He stresses that this only affects companies that receive government monies, but it is retroactive and taken to a logical extreme, this would include any company or industry that has ever received a tax break or incentive.

The Russian owners of American companies and industries should look thoughtfully at this and the option of closing their facilities down and fleeing the land of the Red as fast as possible. In other words, divest while there is still value left..
The proud American will go down into his slavery with out a fight, beating his chest and proclaiming to the world, how free he really is. The world will only snicker.

Stanislav Mishin© 1999-2009.. «PRAVDA.Ru». When reproducing our materials in whole or in part, hyperlink to PRAVDA.Ru should be made. The opinions and views of the authors do not always coincide with the point of view of PRAVDA.Ru's editors.

Source: Pravda.Ru

URL: http://english.pravda.ru/opinion/columnists/107459-american_capitalism-0




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[aparecida]

It was a blog post, and it was reprinted on the Pravda website. Hardly an official Pravda opinion position, as your wording implies.

And a bitter old man who's lived under the Russian Communist party is not someone whose word you should take at face value. I had an attending who's come from Eastern Europe under that system tell me that primary care doesn't work at all and that people who can't pay for their health care should be allowed to die. He was trying to talk me into switching out of FM.