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Going back to the main point of this discussion, where are you practicing?
people seem so disillusioned...
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Going back to the main point of this discussion, where are you practicing?
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I do feel this discussion is being influenced by some that practice in very competitive markets with high costs of living.
However, these issues are very terrifying and real. I can't think of a specialist in any field of medicine who does not cringe at least a little with the thought of what is about to hit Medicare. As stated above, however, the current system is not sustainable (the current political powers have made it clear that taxes of any sort cannot be raised, payments by Medicare beneficiaries should not be increased much, the age to qualify should not be changed much, and every service known to man should be given to every Medicare beneficiary even when death is certain in the coming minutes– ie no rationing of care). These trends have nothing to do with Obama Care – we could see this coming in the 1980s.
However, now it is politically popular to "cut government spending" no matter what the consequences are. Therefore, I could see the 30% cut actually going through – now is the time if they want to make it happen.
You can also add the following on top of it:
EMR is going to drive a few out of practice in the coming 5 years (earlier than they would have). A 30% cut will force many more out and dramatically change how care is delivered (there will need to be clinicians and surgeons – clinicians sit in clinic all day and crank through patients, surgeons sit in the OR all day, every day of the week and crank through surgeries). ACOs will probably force some smaller practices to be bought out by larger organizations. Those doctors who own ASCs could suddenly realize their ASC value just fell in half overnight when the ACO says their patients cannot have surgery in the surgery center – they must go back to the hospital center ASC. Single payments for doctors and facilities will cause fights between specialists and hospitals...
Still ophthalmology is likely to be better positioned than most. We can sell glasses and do LASIK. People also do value vision. However, practices will need to ration equipment upgrades as we have big costs for equipment. Therefore, even if the government says every Medicare beneficiary should get the best care in the world, practices may have to "reduce" the standard of care for medicare patients in order to survive (A scan and not IOL master) (Contact lens exam – no OCT).
It is sure to be interesting – but no matter what, we will all have jobs making an above average salary. We also will be helping people. If the 30% thing goes through, they will have to forgive all medical school debt, however. You cannot have graduates leaving traning programs at age 31 with $400,000 in debt. That is not acceptable.
However, these issues are very terrifying and real. I can't think of a specialist in any field of medicine who does not cringe at least a little with the thought of what is about to hit Medicare. As stated above, however, the current system is not sustainable (the current political powers have made it clear that taxes of any sort cannot be raised, payments by Medicare beneficiaries should not be increased much, the age to qualify should not be changed much, and every service known to man should be given to every Medicare beneficiary even when death is certain in the coming minutes– ie no rationing of care). These trends have nothing to do with Obama Care – we could see this coming in the 1980s.
However, now it is politically popular to "cut government spending" no matter what the consequences are. Therefore, I could see the 30% cut actually going through – now is the time if they want to make it happen.
You can also add the following on top of it:
EMR is going to drive a few out of practice in the coming 5 years (earlier than they would have). A 30% cut will force many more out and dramatically change how care is delivered (there will need to be clinicians and surgeons – clinicians sit in clinic all day and crank through patients, surgeons sit in the OR all day, every day of the week and crank through surgeries). ACOs will probably force some smaller practices to be bought out by larger organizations. Those doctors who own ASCs could suddenly realize their ASC value just fell in half overnight when the ACO says their patients cannot have surgery in the surgery center – they must go back to the hospital center ASC. Single payments for doctors and facilities will cause fights between specialists and hospitals...
Still ophthalmology is likely to be better positioned than most. We can sell glasses and do LASIK. People also do value vision. However, practices will need to ration equipment upgrades as we have big costs for equipment. Therefore, even if the government says every Medicare beneficiary should get the best care in the world, practices may have to "reduce" the standard of care for medicare patients in order to survive (A scan and not IOL master) (Contact lens exam – no OCT).
It is sure to be interesting – but no matter what, we will all have jobs making an above average salary. We also will be helping people. If the 30% thing goes through, they will have to forgive all medical school debt, however. You cannot have graduates leaving traning programs at age 31 with $400,000 in debt. That is not acceptable.
You can't assume that small towns will automatically offer a better salary. I talked to one older doc who was looking to bring in an associate to eventually retire. He was thinking full-time salary something <$100K. Ummm... no.
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Fair enough. Some of the older docs may still try to bilk recently-graduated attendings and try to make side revenue while the younger associate does more work. However, the southeastern states have a lower standard of living, so your salary goes way more for your buck; a house that goes for 400K in California is less than 200K here. In general, southeastern states are trying to fight a medical brain drain because many ophthalmology graduates pick up their bags and get outta dodge as soon as residency is over.
But yes, what you say is true.
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A 30% cut in Medicare payments will mean the end of participation in part B for all those affected, plain and simple. The cuts for failing to comply with the e-prescribing initiative and adoption of EMR (with or without its incentive payment--a bitter joke of an offer, IMO) will seem an irrelevant and trivial concern. There is no possible way to make up in volume the losses when they are imposed at that level, and with private plans inevitably trying to follow Medicare, what will result will be unsustainable. Practices will drop all third-party contracts entirely, no Medicare, no insurance contracts, no staff to chase claims. All of that apparatus, with its expense and annoyance will have to go. For patients, it will mean cash or the street.
The upside, if there could be said to be one, is a simpler style of practice with lower personnel costs and fewer intermediaries between doctors and patients. Doctors will have to price attractively and competitively. With Medicare out of the way, there won't be a need for ICD or CPT coding, nor will there be any need to use e-prescribing or EMRs unless they prove to be both cost-effective and affordable, which under the present mandated adoption with penalties, their designers have not had to address. It will be back to the future.
Medicare has become a slow-motion disaster. There is no way to control costs when the entire program is controlled through a political process and when there is no politically feasible way to tell potential beneficiaries "no."
Part B should cost much more per month than it does now, and should cost those who take their benefits at younger ages more than it does those who delay retirement and enrollment, just as social security payments are lower for those who retire younger. Parts A and B should not be an unlimited smorgasbord of services, and certain services ought to be cut off after certain ages. To some, that might sound harsh, but everyone should have to sacrifice if the program is going to continue at all. Blanket reductions of fees, or slashing specialists payments at the expense of increasing payments to generalists, without demanding that generalists do more work will be a certain formula for failure.
The upside, if there could be said to be one, is a simpler style of practice with lower personnel costs and fewer intermediaries between doctors and patients. Doctors will have to price attractively and competitively. With Medicare out of the way, there won't be a need for ICD or CPT coding, nor will there be any need to use e-prescribing or EMRs unless they prove to be both cost-effective and affordable, which under the present mandated adoption with penalties, their designers have not had to address. It will be back to the future.
Medicare has become a slow-motion disaster. There is no way to control costs when the entire program is controlled through a political process and when there is no politically feasible way to tell potential beneficiaries "no."
Part B should cost much more per month than it does now, and should cost those who take their benefits at younger ages more than it does those who delay retirement and enrollment, just as social security payments are lower for those who retire younger. Parts A and B should not be an unlimited smorgasbord of services, and certain services ought to be cut off after certain ages. To some, that might sound harsh, but everyone should have to sacrifice if the program is going to continue at all. Blanket reductions of fees, or slashing specialists payments at the expense of increasing payments to generalists, without demanding that generalists do more work will be a certain formula for failure.
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OrbitsurgMD - I agree with most of what you said, but I do disagree that a 30% cut in physician services will lead to the end of the program.
I still believe the some in washington would view a 30% cut to doctors as a means of gaining political advantage. I do not feel the public believes doctors are underpaid (in general, I believe doctors were held in higher esteem in the 70s and 80s when they were paid significantly more for every single service provided. Now doctors take on 10 x as much debt, work twice as hard, and the public believes doctors are out to get them.).
If they choose not to implement such a cut all at once, they can implement it indirectly. How?
1. Single payments for surgeons and facilities (put simply, this will be a smaller payment than the combined "facility fee" and "surgeon's fee" - someone is going to be getting less money). If we are to avoid a true cut in this model, it will take political power on a local level - ophthalmology will likely loose often as we have been running from any hospital relationships over the past 15 years. Hospitals are often run by primary care providers. Many primary doctors hate us (and many other specialists as well).
2. Creating a new system of reimbursement in all of medicine. We will be paid based on what we accomplished at the visit (how did we change the patient's health - no change in health = no payment). The days of being paid based on the number of organ systems reviewed and physical exam measures evaluated will be over. Currently primary care doctors are the worst abusers of the current coding system. Someone comes in for an ear infection - they end up doing a complete physical and review of systems so they can code at a level 4. Do they really need to be checking that posterior tibial pulse before they prescribe the antibiotic and talk to the patient about otitis media. The PQRI system is a beta version of this (ie you coded this diagnosis - did you do the following things for the patient).
3. Paying doctors less if they are "expensive doctors." Some doctors cost more to the system because they perform more testing. These doctors are kicked out of insurance plans regardsless of what kind of doctor they are - ie a doctor who orders CT scans on average more time than his peers must be a bad doctor. Perhaps, medicare might not kick you out of the program but they could simply cut your reimbursement accross the board for all of your medicare services. It many of the analysis of healthcare delivery, experts look at "quality of care." These people believe quality care = cheep care. So a cut in reimbursement if you are an "expensive doctor" might not look bad to a politician. However, it would be devastating to neuro-ophthalmology (ie they are bad doctors because they order MRIs) or any doctor who takes care of complex things. In this system, there would be BIG rewards to not take care of real pathology (ie take care of the diabetic retinopathy patients with a single microaneurysm and a HAIC of 7.0. Send the 500 pound patient with florid CSME and a HAIC of 10.0 to your competitor down the road - the smart people at medicare will think you are great at treating diabetic retinopathy - they will think your competitor is pathetic).
4. More aggressive auditing of charts. The astronomical $ Obama likes to say is waste, fraud, and abuse of Medicare is very misleading. Large hospital systems have lost millions of dollars not because of inappropriate coding, but because of incomplete coding or incomplete documentation. For example, you forget to sign your chart, you are committing medicare fraud. The RACs will be coming to all of our practices they will find things in every practice. Sample 20 charts, find an incomplete record in a single chart for a medical service billed to medicare = 1 case of fraud. Therefore, 5% of your billings are fraudulent. You will be asked to pay medicare back 5% of your total medicare billings. In other words, signing your name is very important. (Never mind that scam artist on TV from Florida who is trying to get every medicare recipient a power chair).
I still believe the some in washington would view a 30% cut to doctors as a means of gaining political advantage. I do not feel the public believes doctors are underpaid (in general, I believe doctors were held in higher esteem in the 70s and 80s when they were paid significantly more for every single service provided. Now doctors take on 10 x as much debt, work twice as hard, and the public believes doctors are out to get them.).
If they choose not to implement such a cut all at once, they can implement it indirectly. How?
1. Single payments for surgeons and facilities (put simply, this will be a smaller payment than the combined "facility fee" and "surgeon's fee" - someone is going to be getting less money). If we are to avoid a true cut in this model, it will take political power on a local level - ophthalmology will likely loose often as we have been running from any hospital relationships over the past 15 years. Hospitals are often run by primary care providers. Many primary doctors hate us (and many other specialists as well).
2. Creating a new system of reimbursement in all of medicine. We will be paid based on what we accomplished at the visit (how did we change the patient's health - no change in health = no payment). The days of being paid based on the number of organ systems reviewed and physical exam measures evaluated will be over. Currently primary care doctors are the worst abusers of the current coding system. Someone comes in for an ear infection - they end up doing a complete physical and review of systems so they can code at a level 4. Do they really need to be checking that posterior tibial pulse before they prescribe the antibiotic and talk to the patient about otitis media. The PQRI system is a beta version of this (ie you coded this diagnosis - did you do the following things for the patient).
3. Paying doctors less if they are "expensive doctors." Some doctors cost more to the system because they perform more testing. These doctors are kicked out of insurance plans regardsless of what kind of doctor they are - ie a doctor who orders CT scans on average more time than his peers must be a bad doctor. Perhaps, medicare might not kick you out of the program but they could simply cut your reimbursement accross the board for all of your medicare services. It many of the analysis of healthcare delivery, experts look at "quality of care." These people believe quality care = cheep care. So a cut in reimbursement if you are an "expensive doctor" might not look bad to a politician. However, it would be devastating to neuro-ophthalmology (ie they are bad doctors because they order MRIs) or any doctor who takes care of complex things. In this system, there would be BIG rewards to not take care of real pathology (ie take care of the diabetic retinopathy patients with a single microaneurysm and a HAIC of 7.0. Send the 500 pound patient with florid CSME and a HAIC of 10.0 to your competitor down the road - the smart people at medicare will think you are great at treating diabetic retinopathy - they will think your competitor is pathetic).
4. More aggressive auditing of charts. The astronomical $ Obama likes to say is waste, fraud, and abuse of Medicare is very misleading. Large hospital systems have lost millions of dollars not because of inappropriate coding, but because of incomplete coding or incomplete documentation. For example, you forget to sign your chart, you are committing medicare fraud. The RACs will be coming to all of our practices they will find things in every practice. Sample 20 charts, find an incomplete record in a single chart for a medical service billed to medicare = 1 case of fraud. Therefore, 5% of your billings are fraudulent. You will be asked to pay medicare back 5% of your total medicare billings. In other words, signing your name is very important. (Never mind that scam artist on TV from Florida who is trying to get every medicare recipient a power chair).
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Hi mydodger,
I have been very satisfied, both financially and emotionally, from my decision to do general ophthalmology. Whatever field you choose, there will always be naysayers who will find something to complain about regardless of the situation. We are in a bit of a worse position than our predecessors, but overall I think we're still doing pretty well.
To address your specific questions:
1. Every single job I looked at coming directly out of residency paid more than $120,000. I did not look at jobs in big cities like New York, Chicago, or San Fran. If you want to live in a place like that, then you'll have to pay the price.
2. I do know of a few people working part time ophthalmology. The VA hospital will sometimes hire such people to work a few days a week. I don't have any clue what kind of income they pull, but I imagine it's substantially less than full time.
3. If you're interested in higher salaries, you could always be a retina specialist. They get paid quite a bit more on average than general ophthalmologists, but that extra money comes with a price. I found retina interesting, but chose to make less money and not have to (except on rare occasion) ever deal with any ophthalmic surgical emergencies requiring me to leave the house outside of office hours. For me, the convenience of being a surgeon who basically only does elective procedures (no one will go permanently blind from a cataract other than the once in a career you see an intumescent lens causing a pressure of 60) far outweighed any extra money earned. That's a decision you'll have to make based on your personal needs.
To balance some of the other comments, I can honestly say that I absolutely love life right now, and despite some worrisome trends in the field I think we'll be fine. And certainly better off than our primary care colleagues.
I have been very satisfied, both financially and emotionally, from my decision to do general ophthalmology. Whatever field you choose, there will always be naysayers who will find something to complain about regardless of the situation. We are in a bit of a worse position than our predecessors, but overall I think we're still doing pretty well.
To address your specific questions:
1. Every single job I looked at coming directly out of residency paid more than $120,000. I did not look at jobs in big cities like New York, Chicago, or San Fran. If you want to live in a place like that, then you'll have to pay the price.
2. I do know of a few people working part time ophthalmology. The VA hospital will sometimes hire such people to work a few days a week. I don't have any clue what kind of income they pull, but I imagine it's substantially less than full time.
3. If you're interested in higher salaries, you could always be a retina specialist. They get paid quite a bit more on average than general ophthalmologists, but that extra money comes with a price. I found retina interesting, but chose to make less money and not have to (except on rare occasion) ever deal with any ophthalmic surgical emergencies requiring me to leave the house outside of office hours. For me, the convenience of being a surgeon who basically only does elective procedures (no one will go permanently blind from a cataract other than the once in a career you see an intumescent lens causing a pressure of 60) far outweighed any extra money earned. That's a decision you'll have to make based on your personal needs.
To balance some of the other comments, I can honestly say that I absolutely love life right now, and despite some worrisome trends in the field I think we'll be fine. And certainly better off than our primary care colleagues.
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Don't mean to be a downer. There are definitely issues to be considered, both now and in the future, but I still wouldn't want to do anything else. Currently, pay is good, hours are good, and call is good. If you're open to practice location, I seriously doubt you'll have any problems finding work. Your specific hours/compensation questions are tough to answer, though. Too much variability. Still, while some may not be making as much as they want, I don't think you'll find many ophthalmologists who are "struggling" financially.
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Thank you so much for the advice. I tend to shy away from SDN because I end up worrying incessantly when I read the constant stream of negative posts. I have a feeling I'll find myself in a similar situation as yourself - possibly finding retina interesting, but choosing lifestyle and lower pay over the emergencies and money that come with retina.
Thanks. I need to hear this stuff sometimes!
So I'll continue to pursue the career in ophthalmology that intellectually excites me and try to take the bad-news-bears type future predictions with a grain of salt. I still think ophthalmology will be a rewarding career that, while it may not make me $200,000 a year, will allow me to provide well for my family and still allow me plenty of time to spend with them. All I ever wanted out of medicine was to make a decent living helping people with health problems. I still think Ophtho does that for me, and on top of that I really like it.
Thanks for the advice guys. I might stay away from here until I match because reading some of these these threads stress me out unnecessarily I think.
Salary-wise I think you'll be fine. Starting salaries rise quickly after a few years and if you do private practice and become a good partner, your salary will be comfortable considering you're not a huge sucker at negotiation. An attending told me that as a career, the four components to having a happy career are:
1) Having the job you want
2) Having the location you want
3) Having the hours you want
4) Having the life you want
He told me that if you get three out of the four, you'll be happy with your career. It's hard to line all four up if you're the "LA/NYC/Chi-town or bust", but if you prefer to practice in a middle-sized city and are open-minded about where you go, you'll do great.
So I'll continue to pursue the career in ophthalmology that intellectually excites me and try to take the bad-news-bears type future predictions with a grain of salt. I still think ophthalmology will be a rewarding career that, while it may not make me $200,000 a year, will allow me to provide well for my family and still allow me plenty of time to spend with them. All I ever wanted out of medicine was to make a decent living helping people with health problems. I still think Ophtho does that for me, and on top of that I really like it.
Thanks for the advice guys. I might stay away from here until I match because reading some of these these threads stress me out unnecessarily I think.
One other thing to consider: those of us in medicine are all subject to the whims of our elected officials. It is pointless trying to predict which specialties will be highly sought after and well compensated in the future, so you might as well pick something you really enjoy.
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I would bet $1000 that that won't happen. Doctors have been blustering for years about dropping medicare and yet the participation rate is still well over 95%. If payments are cut 30%, I still think most physician practices will be too scared even considering dropping medicare...especially specialities that deal mostly with seniors.
Dare to dream.
Medicare beneficiaries vote. That's the bottom line, because Stone Cold said so.
You are clearly just a heartless bastard politician who wants to force little old ladies to have to decide between their life saving heart medication or their food. Would you really have grandma eating cat food? Would you really have grandpa freezing to death in the winter time because he had to pay for his hip replacement instead of his home heating oil. You heartless, cruel bastard!
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That can't be overstaed.
Whatever people think of "obamacare" is largely irrelevant because before most of it takes effect, we are going to have two more congressional elections, a presidential election, a bunch of senatorial elections and a supreme court decision on it.
It's highly likely that the final version, even if there is a final version will resemble little what the current for is. So speculation on the future of health care at this point in time is about as valuable as speculation on the 2020 Superbowl.
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Unfortunately, most private insurers follow Medicare's pricing changes, and some undercut those.
A 30% cut in payment on a 50% overhead model goes straight to physician income, or whatever is done with the money you don't spend on overhead. Your overhead stays the same. So the cut means 60% (or more if your overhead is over 50%) against that residual. Your overhead is not going to change except go higher. How does buying that new OCT look now? How about that EMR with its $20K/yr amortized costs? How have you planned to live on 60% less than you earn now? How will you make your expected and necessary contributions to your retirement? (hey, at least your 15.3% SET won't be as much.)
They have avoided the big cuts in the past but there seems less ability by the Congress to come to a constructive terms in compromise to stop events that require difficult decision making. If nothing is done, the cuts take place.
Ophthalmology is a bit player. The collapse of Part B will be driven by primary care and larger specialties. It won't likely be all that cataclysmic, but a minority of doctors who can drop Medicare will do so. Many more will stop taking new Medicare and will drop a lot of "bad" insurances. Too bad if you have UHC, I guess. There will be a lot of patients scrambling to find anyone to see them with Medicare, and the arrival of lots of new patients whose payments don't include paying the doctor may find more and more practices closing to Medicare. Some doctors will have to close up shop and work for institutions. For some practices, continuing with Medicare-level payment won't be a viable option and neither will anything else. There will be business failures.
There is a fallacy in thinking that if something dramatic has never happened that it could never happen; that cutting Medicare hasn't caused doctors to exit the program so far therefore they would never exit the program. That is simply false. Medicare part B has not been around forever, and it has not always been around in the form it has today. And simply because the program hasn't failed yet does not mean that it cannot fail. Systems sometimes maintain stability until they reach a tipping point, at which point they become highly unstable. We may be reaching that point right now with Medicare.
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I really don't think a 30% medicare cut is going to be a viable option. Regardless, I imagine reimbursements are going to continue to be stagnant with some downward pressure and there are going to be attempts to drastically change the way we are paid by removing financial incentive from higher volumes of care and placing more emphasis on quality. There are several inherent problems with this strategy that are too long to list. To remain competitive and maintain revenues, comprehensive ophthalmology is going to have to focus on premium IOLs and the new laser assisted cataract systems that allow for significant billing above the standard Medicare reimbursement rates for cataract surgery. Some practices are now implanting >50% premium lenses and while this is certainly not the norm at present, as baby boomers flood our practices with cataracts, they are going to demand uncorrected 20/20 vision at distance and near and won't be happy with anything less. These new technologies will hopefully allow safer surgery with improved refractive results and help sustain the financial viability of comprehensive ophthalmology.
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No one can predict the future, that much is true. But I stand by my assertion that even with a 30% reduction in reimbursements you will still see an overwhelming majority of doctors participating, particularly among the surgical specialties.
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I don't think you really appreciate how much Medicare has already cut the payments to surgeons even without the imposition of global SGR-associated cuts. They have been slicing and trimming at surgery payments for years. So the additional cuts will be especially damaging. They have increased office service payments, by comparison. Also, don't forget that surgery locks out payment for nearly everything you might do (even unrelated services with their "modifiers"--a canard) for three months afterward.
You may believe no one can predict the future, but you would be fairly safe in guessing that if you pointed your car toward the edge of a cliff and hit the gas that bad things would follow. You don't need a crystal ball for that.
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You may be right, but I imagine that even politicians realize that allowing such cuts would be career suicide (and that's what they really care about anyway). Not only would access to care become a significant problem, but there would likely be substantial layoffs of healthcare support staff to try and reduce overhead. Healthcare is such a large part of the economy, that I could see unemployment rising to record levels. You think our economy is in the tank now...
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A huge enough cut to the point where profit from a patient visit becomes close to zero, or even negative, would certainly be a no-brainer decision to drop Medicare patients. A business like ours cannot function by losing money on each patient we see. It hasn't reached that point yet, but I'm sure for many specialties, a 30% cut would come dangerously close to the tipping point.
In that scenario, you'd be better off taking cash only, firing all but one or two of your staff, having a tiny office with low rent and the bare essentials, and seeing a handful of patients a day. Plus, you wouldn't have to spend tens of thousands of dollars on an electronic medical records system designed by jackasses that have no clue how to arrange a simple, clean interface (we've been looking at lots lately, and they're all terrible).
But hopefully it doesn't come to that.
In that scenario, you'd be better off taking cash only, firing all but one or two of your staff, having a tiny office with low rent and the bare essentials, and seeing a handful of patients a day. Plus, you wouldn't have to spend tens of thousands of dollars on an electronic medical records system designed by jackasses that have no clue how to arrange a simple, clean interface (we've been looking at lots lately, and they're all terrible).
But hopefully it doesn't come to that.
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And how many surgeons have actually dropped out of medicare? I'll bet less than 1%.
I understand that. But posters on here have claimed that their practices are 70% or greater medicare. I wonder how many people would be willing to just cut out 70% of their practice by dropping medicare? I'm willing to bet next to none. Doctors will bluster and beat their chests and threaten, but in the end, they'll cave. They have been for 30 years now.
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We aren't talking about the past. We are talking about what would happen if Medicare cut its payments by 30%, on top of what they have already cut. I do not think you can assume it will be business as usual, for reasons that should be obvious.
If you have a 70% Medicare practice, you are toast, especially if you are not an owner of an ASC or don't have a large conversion rate of cataract surgery bookings to high-dollar custom IOLs or refractive surgeries. It is not necessary that any viable option be present. Some doctors will find they can't make it with Medicare and can't make it without Medicare either. Their options: go work for someone else somewhere else, relocate, retire, find a new line of work. There may not be a viable option for some practices, I venture ones with high overhead, low-income patients and lots of Medicare.
Practices will fail. Some will revise what they do and who they see. Some patients will not be able to find a doctor willing to see them on terms other than cash up front. It could get ugly.
The Administration thinks it can cut spending but still end up like France, everyone covered and a high standard of living. They just want to ignore the much greater likelihood that we will end up like Brazil, except without all the nice stuff Brazil has.
It's interesting seeing the debate about who will cave first, physicians or the government. I'm not a physician yet but I have been a patient.
One thing is clear. If it truly were "cash or the street," more likely than not, it's the doctors who will end up on the street. There will be a few who will survive taking care of the rich. Middle class Americans though will not be able to afford medical care as we know it. Who would pay several hundred dollars for a routine eye exam? 3k for cataract surgery? Who could pay $40K for a hip replacement? 150k for a CABG?
One thing is clear. If it truly were "cash or the street," more likely than not, it's the doctors who will end up on the street. There will be a few who will survive taking care of the rich. Middle class Americans though will not be able to afford medical care as we know it. Who would pay several hundred dollars for a routine eye exam? 3k for cataract surgery? Who could pay $40K for a hip replacement? 150k for a CABG?
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I think your comments have a great deal of truth in them. However, if there were no "middle man" (insurance, the government, whomever) an eye exam or even cataract surgery would not cost nearly as much as may be currently listed, because the cost of the exam/procedure would reflect the actual cost (plus overhead) and not the Medicare (or the highest paying insurance company) "allowable." But actually, these questions lead to even bigger questions that aren't necessarily unique to ophthalmology--especially since cataracts and presbyopia are relatively unavoidable (in the long run). But the need for a CABG in a person with a BMI of 30+ who has a 20 year pack history of smoking (or whatever other risky behaviors you care to insert)? Or to be more relevant to ophthalmology, extensive PRP and other retinal surgery in a diabetic patient with a HbA1c of 13+? At some point society and healthcare may demand that people who engage in health-damaging behaviors deserve to bear a larger percentage of health related costs.
The end of Medicare/insurance control would also open the door for physicians and patients to negotiate payments and payment schedules in a way that is mutually acceptable. Medicine could conceivably become like any other service one pays for--whatever a willing buyer and a willing seller can agree upon becomes the bottom line. This would also enable physicians to provide care to those who cannot afford it because there would be less interference between the patient and the physician (currently it is not allowed to provide services to patients at a lower rate than those charged to Medicare patients unless those people provide documented proof of need).
You are totally right that most people can't afford "medical care as we know it."
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Exactly.
The end of the present third-party payer arrangement doesn't have to mean that patients won't be able to buy care, but it will likely mean that the costs of that care will no longer be hidden, and that pricing will have to be transparent, realistic and likely competitive. It will likely mean that patients will have to carefully think about running to specialists for simple problems and doctors will have to find ways to present services that will still attract patients.
New rules.
Without shared cost, this really means the person needing the CABG won't be able to afford it and society ends up needing less CT surgeons.
I'm sure you didn't mean "cash or the street" callously. I think it's important to remember we need patients as much as they need us.
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Though the disappearance of a third-party system sounds great and means less paperwork, going to a pre-1965 medical payment system also has problems on its own (grass is greener syndrome). There will likely be fewer patient visits, which may be a good thing to some people and a bad thing to others (good - less busy schedule; bad - possibility of less income). Phasing out Medicare would also likely mean less elderly patients, who represent a significant portion of the pathology in clinic; if retired patients don't have good pension plans (which these days seem to be the popular thing to slash and burn in companies) and/or good financial support from friends/family, they'll have less reason to come in for check-ups, or be seen before the disease processes get really out of control (to them, why see the doctor if they don't feel sick...yet?). The reduced overhead of less paperwork and staff may be less, which could make the lower negotiated payments more palatable, but the extent of the revenue gained from less overhead vs. reduced payments via negotiation and competitive pressures will always be large unknown until it actually happens. Even then, equipment is still expensive and represents another burden on any starting practice. Debt from medical school will also have to be forgiven or restructured for new graduates.
Even then, all this debate may only serve to get our daily frustrations off our chest. If Medicare were to be cut to a point in which dropping it becomes a no-brainer, there will be a revolt in this country. The Occupy Wall Street protests will be miniscule compared to the uproar if such a thing happened.
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Lots of doctors don't figure an adequate paycheck for their own work as a cost; they pay themselves on draw from their post-overhead residuals. Now suppose you shrank that residual by 60%, which is likely what would happen.
Suppose you earn $240K pre-tax, now you are earning $96K. Same risks, same overhead, which keeps rising, just no margin to pay for replacement of equipment or retirement savings, or possibly even a house. Just hope you don't have loans to repay.
Hopefully not, but that is the end game.
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Practices need cash to survive as businesses, whether in small amounts from lots of patients or larger amounts from a few. And they require payment on a timely and predictable basis, or those practices fail. "Cash or the street" means just that, that if insurers aren't covering costs adequately on behalf of patients, the patients have to step up and pay their part or they can't expect the practice to be around for them. The pretense that bills are only for insurance companies will be stripped away in this scenario.
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That's a legitimate point but the number of people on medicare is far greater than on state medicaid programs.
Also, people on medicare are more likely simply based on their age to need ophthalmic surgery than people on medicaid.
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It almost doesn't matter. If the Medicare payments don't cover costs, including the salary of a doctor, then the practice is operating at a loss. That never lasts for long, and lasts a lot less long when there are proportionately more patients whose payments are too low.
One possibility is that you will collapse the market in eye surgery. That isn't unknown, although it is unknown in this country. There are large parts of the world where people who need eyecare and surgery don't receive either simply because they don't have the money to pay for it.
One market condition is "no market."
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I agree with all of this. However, the current cataract surgery reimbursement in my area is around 680. I would contend that every single surgeon would still be doing it for 30 percent less.
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Oh i get it. But i stand by the assertion that surgeons would still be doing cataracts if the reimbursement was $450
The 30% cut ain't going to happen long term. Oh it will probably be implemented for a brief time, but the politicians will come up with some sort of crap patch fix (they will not address the sgr). What is assured is that reimbursements will continue to go down, or, not change, which is the same as going down relative to inflation and the cost of doing business. We all will have to continue to run more and more efficient practices and do more with less.
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Believe me, you won't "make up" the difference with blepharoplasty. Those would be cut by the same amount, and many patients don't have the money to pay a typical cosmetic fee. Everyone wants it done for the Medicare/insurance "fee."
Sure, you could try to up-sell premium IOLs, but most cataract surgeons are already doing that. I doubt the conversion rate would really work to bring in enough to cover the losses. You should assume a busy practice without any more significant capacity to expand.
Cataract is one of the highest payments for time in ophthalmology. Uncomplicated cases are under 20 minutes of OR time and frequently less than half that in very efficient settings. A carefully done blepharoplasty needs an hour, especially if you are combining it with levator advancement.
So you earn $680. Now that becomes $480. Overhead originally at 50%, or $340, not including any pay for the doctor. So instead of receiving $340 for the surgery and all the followup care--let's say three office visits with a refraction in a non-comanagement model, the doctor gets $140. If insurers follow, that is what everyone pays. Aren't you glad you worked so hard to become an ophthalmologist?
Surgery becomes a relative money loser, especially when you consider the relative liability risks.
There is no working around this with premium IOL and cosmetic surgery. Those veins are already mined, you don't get more of that just because now you want more.
It would be impossible to start a viable new practice with that kind of payment. KHE, even if you think business would continue as usual, banks would know better. The failure risk would make business lending to ophthalmologists very difficult.
Insurers cannot just impose lower payments and expect to retain a functioning and healthy private care industry. On top of that, their initiatives are costly. This would devastate private practice. Scaling up to big groups will not save you either, they are laden with disproportionally greater costs in management. Practices have already been working more efficiently, there are no more significant opportunities to cut, and in fact many will have to deal with substantial new costs for electronic records, the majority costs of which will be borne by the practices. Also, most of the practices that have implemented EMR are now realizing that ongoing costs are very substantial with software upgrades, vendor's maintenance fees and a relatively short replacement cycle needed for computing equipment.
KHE, doctors will likely continue to do surgery, but you will see widespread abandonment of Medicare participation along with private contracts that seek to follow Medicare. Ophthalmology will likely return to a pre-Part B practice model, similar to the way dentistry is practiced. (In many places, a dental crown costs $1500, so what should a cataract surgery cost?)
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I think you're underestimating how thin the profit margin is already. Remember that the $450 wouldn't just be for the surgery, it would also count for the overhead which includes 3 months of post-op care.
A 30 percent cut would just about push cataracts surgery into being non-economically feasible for most small practices. The result would be a few ophthalmologists would become "cataract technicians" and just chop cataracts all day in an ASC without doing anything else. Access to care would be okay in urban areas. However, no non-urban areas would not have access to cataract surgery anymore unless they were willing to pay extra. This might not go over so well with the population.
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Maybe ophthalmologists should start learning other unrelated eye procedures, seems others are: http://www.nycosmeticobgyn.com/botox-fillers/
I know of one refractive doc near me who also does sclerotherapy and skin peels. And since botox was recently FDA approved for urinary incontinence, why not tread new turf? Especially with "G-shot amplification!" lol. For $300K, Kentucky should have added that in their new law also!
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So what's your rock bottom then? I get that there would be regional differences but what is the absolute lowest reimbursement you would accept before you said "I will no longer perform cataract surgery.".
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That sounds more like something the KY optometrists would be trying to do.
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I am sure that number differs year-to-year and place-to-place. Considering that some patients are losing you money as-is, I do not think there is much more room at all for cutting cataract fees. They have already been cut 83% from their constant-dollar payment when Medicare Part B was created.
Some like to argue for a "world price" or at least a European comparable price as an end point, completely ignoring the rest of the social picture, from taxation, to funding of education, to vastly different legal and social security systems (over the failure of which we see today Rome burning again.)
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Exactly, medical school is heavily subsidized in Europe and also they don't have millions of individuals that revolve their lives around drugs and criminal acts that our public welfare system supports.
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Ummmmmm.......youve never been to Amsterdam or Switzerland, have you?
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Sorry to comment and then bail for a week, I don't get on here much anymore. I practice in rural Oregon.
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Not a problem but this just proves my point. I wish I could practice in a rural setting and enjoy opportunities that most other specilaities get to enjoy most places they go. Unfortunately, I grew up in a large metropolitan city and this is home. I can't uproot my parents, gradparents, aunts, uncles, etc because I get to make more money in a small town. And that kind of sucks.
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It is a shame to be geographically limited. I'm a small town guy and my wife (boarded psychiatrist) was insistent on being in a large city (preferably in FL where she has family). It's a tough position to be in. Her specialty is a bit easier and has more level pay across various locations (the call/pt load changes though). I ultimately looked at these larger metro "opportunities" to please her and had her read sites like this and speak with a few OMD's in FL. She was able to come to her own conclusion..... we are going to a small city and will both be starting at the 90th% for our specialties.... not 90th for early career, rather 90% for mid career. Her pay will stay relatively stable, while mine will be what I make of it (how busy do I want to be?).
The beauty? After 5yrs, we will be 100% financially independent and if she still doesn't like the small city life, we can move and start a life in "the big city" on our terms. And it's not like we are slumming it. There is an airport, nice university, less than 3hrs to 3 large cities by driving (45min flight). If you like ophtho and can consider this, it is well worth it. I met several people at AAO doing the same thing and they seemed to be much happier than those in the big metro rat race. Just my $0.02.
