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  1.    #1  
    Some on this board seem concerned about doctors dropping out of Medicare (which is quite unlikely to happen). Primary care doctors have been under-reimbursed in comparison to specialists for many years, and the lack of primary care contributes to poor patient care by minimizing the coordination of care across multiple providers....keeping track of what drugs patients are taking, making sure there isn't any duplication of services, etc. The workforce has been slowly losing primary care doctors because of student debt, "lifestyle" issues (which translates much of the time into income) and other reasons. In my town, patients may have to wait up to a month for a new patient visit to a primary care provider in private practice.

    This is a mailing I received from the Society of General Internal Medicine discussing the positive aspects of the bill from the primary care physician's viewpoint. I am sure many of you can find something here to flame about, but I thought it might be interesting to see how some doctors view these changes.


    At Last! Health Care Reform Will Affect General Internal Medicine!
    After months of debate, hard work and uncertainty, President Obama signed into law the Patient Protection and Affordable Care Act, approved by the Senate on Christmas Eve and passed by the House of Representatives on March 21. A separate reconciliation bill, including a package of revisions to this legislation, was also passed by the House on Sunday and must now go to the Senate for approval.
    SGIM is very pleased that this sweeping healthcare reform legislation includes many key provisions that are consistent with our mission. The bill will:
    Provide a 10% bonus payment to many primary care physicians for the next five years
    Require the Secretary of the Department of Health and Human Services to evaluate misvalued relative value units in the Medicare Physician Fee Schedule
    Raise Medicaid payments for primary care services for those in family medicine, general internal medicine, and pediatric medicine to 100% of Medicare payment rates in 2013 & 2014
    Strengthen education and training support by:
    o reauthorizing Title VII of the Public Health Service Act, the only source of federal training funds for primary care training
    o repealing the so-called “ratable reduction” to ensure that the allocation of training funds is based on national need and merit
    Expand the National Health Service Corps
    Establish a National Workforce Commission
    Redistribute unfilled graduate medical education residency positions and direct those slots for training of primary care physicians
    Support comparative effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute to identify research priorities and conduct research that compares the clinical effectiveness of medical treatments (SGIM advocated for this research to be done at the Agency for Healthcare Research and Quality, but is extremely pleased with the legislation’s commitment to this type of research.)
    We are thrilled to have achieved legislation that responds to our primary issues to provide support for more primary care physicians who are adequately reimbursed, with adequate training support and a Comparative Effectiveness Research program to promote high-quality decision making. Thanks to all of you who reached out to your legislators to urge them to support general internal medicine!
  2. drj400m's Avatar
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    #2  
    I love the non-informed:
    "Medicare gets cut; everyone adjusts; life goes on".
    I'm sure if I went to your job and said, you know you charge $20 for that service but I'm going to give $5, you would just adjust and move on, please!
    I'm all for imploding medicare/medicaid the abuses in both of these "services" is astounding. By the way there are plenty of doctors in larger cities that are giving up medicare because reimbursement is so low!
  3.    #3  
    Quote Originally Posted by drj400m View Post
    I love the non-informed:
    "Medicare gets cut; everyone adjusts; life goes on".
    I'm sure if I went to your job and said, you know you charge $20 for that service but I'm going to give $5, you would just adjust and move on, please!
    I'm all for imploding medicare/medicaid the abuses in both of these "services" is astounding. By the way there are plenty of doctors in larger cities that are giving up medicare because reimbursement is so low!
    Non-informed? Actually, that's exactly what has happened. Currently around 83% of all practices accept Medicare. This has not changed significantly. But large practices, and certain specialities, are much more likely to accept Medicare payments. Access to physicians is just fine for Medicare recipients....which is why they are so satisfied with it. Medicaid is a whole different animal.

    IRVINE, CA – About 87.4 million people are supported by government-sponsored health insurance, according to the Census Bureau, but a recent report shows that 83 percent of medical offices accept Medicare and only 65 percent accept Medicaid.
    The Physician Office Acceptance of Government Insurance Programs Report released by SK&A, a provider of healthcare information and research, surveyed 178,000 U.S. office-based physician medical offices about their acceptance of the government-funded programs Medicare and Medicaid.
    According to the survey, Medicare and Medicaid acceptance is largely influenced by variables such as the size, ownership, location and specialty of the physician practice. Practices with 26 or more physicians are more likely to accept Medicare (87.1 percent) and Medicaid (83.6 percent) than smaller practices with between one and 10 physicians.
    The higher the patient volume, the more likely it is that practices accept these programs, the survey indicates. Offices with a daily patient volume greater than 31 have acceptance rates of 84 percent for Medicare and 68.4 percent for Medicaid.
    The ownership of the practice is also influential in Medicaid acceptance policies, the study said. Acceptance of Medicaid is higher with hospital-owned practices (82.1 percent) than non-hospital-owned practices (62.9 percent). For Medicare, acceptance patterns did not vary significantly by ownership.
    SK&A found that acceptance rates vary by physician specialty. Those with the highest Medicare acceptance rates are podiatry (97.6 percent), thoracic surgery (97.5 percent) and colon-rectal surgery (97 percent). Those with the lowest Medicare acceptance rates are occupational medicine (16 percent), holistic medicine (23.2 percent) and bariatrics (27.7 percent).
    The top three physician specialties that accept Medicaid are dialysis (95.8 percent), nephrology (91.8 percent) and thoracic surgery (91.5 percent). The lowest acceptance rates for Medicaid come from occupational medicine (10 percent), holistic medicine (10.7 percent) and bariatrics (13.1 percent).
    Census: Fewer physicians' offices accept Medicaid than Medicare | Healthcare Finance News


    I guess the real question is the relative value of what you charge, now, isn't it? Maybe, just maybe, it might not be worth $20.
  4.    #4  
    And guess what? Medicare patients are more satisfied with their care than private insurance users. Soup kitchen? Not really.

    According to a national CAHPS survey conducted by the Centers for Medicare and Medicaid Services in 2007, 56 percent of enrollees in traditional fee-for-service Medicare give their "health plan" a rating of 9 or 10 on a 0-10 scale. Similarly, 60 percent of seniors enrolled in Medicare Managed Care rated their plans a 9 or 10. But according to the CAHPS surveys compiled by HHS, only 40 percent of Americans enrolled in private health insurance gave their plans a 9 or 10 rating.More importantly, the higher scores for Medicare are based on perceptions of better access to care. More than two thirds (70 percent) of traditional Medicare enrollees say they "always" get access to needed care (appointments with specialists or other necessary tests and treatment), compared with 63 percent in Medicare managed care plans and only 51 percent of those with private insurance.
    link
  5.    #5  
    Quote Originally Posted by UntidyGuy View Post
    Right now, doctors and hospitals subsidize Medicare and Medicaid patients by charging private insurance more. Eventually, those subsidies will go away. We're not just talking about customer satisfaction, here. We're talking about what keeps your local Emergency Department open. Medicare rates simply will not keep it open 24/7. However, people adjust to having to travel further for care. Life goes on.

    Really? That's funny. My hospital overcharges private insurers to cover the cost of the indigent patients they take care of, for which they get nothing. Imagine what might happen if doctors and hospitals started getting reimbursed for that care? Think it might make a difference? Think THAT might keep the ER doors open? My hospital lost $19 million in uncompensated care last year. Medicare is like manna compared to that, dontcha think?

    Oh...and our affiliated urban hospital provided $215 million in uncompensated care. Getting some of that money back will be wonderful, thank you.
    Last edited by davidra; 03/25/2010 at 03:53 PM.
  6. #6  
    davidre, do hospitals charge mlre or less or same for patients that pay cash or otherwise pay there own bikks rather than through insurance?

    ie, if I loose my job and have to carry a really high deductable/catastrophhic policy until I findd another job.

    any dr vists or minor costs would be cash.

    more, lesss, or same?
  7.    #7  
    Quote Originally Posted by Cantaffordit View Post
    davidre, do hospitals charge mlre or less or same for patients that pay cash or otherwise pay there own bikks rather than through insurance?

    ie, if I loose my job and have to carry a really high deductable/catastrophhic policy until I findd another job.

    any dr vists or minor costs would be cash.

    more, lesss, or same?
    Not easy to answer, because not all hospitals are the same. Some get various resources for indigent patients (city hospitals, state hospitals and some community hospitals). In general, patients who do not have insurance are labled "self-pay". In my hospital, all self-pay patients can set up a payment plan. Patients who are below a certain income level are eligible for some discounts, depending on which department has seen them. Each department has the right to determine how they agree to take care of patients in their clinics. For instance, in many academic hospitals, some departments limit their outpatients to a certain percentage of Medicaid patients, or require Medicaid patients to be seen by residents. But this is Florida, so every department gladly sees Medicare patients and accepts assignment (which means the patient will not be charged for any charges that Medicare doesn't pay). The problem is that the charges to both insurance and Medicare are higher than the hospital/doctor will get paid from those entities...but those are the same charges provided to self-pay patients. So the unfortunate answer is that self-pay patients actually have larger bills than those with insurance, whether private or public insurance. However, they are also more likely to get them at least partially written off, and may are totally written off if the money can't be collected. Millions and millions of dollars in our hospital are written off each year.
  8. #8  
    Quote Originally Posted by davidra View Post
    Not easy to answer, because not all hospitals are the same. Some get various resources for indigent patients (city hospitals, state hospitals and some community hospitals). In general, patients who do not have insurance are labled "self-pay". In my hospital, all self-pay patients can set up a payment plan. Patients who are below a certain income level are eligible for some discounts, depending on which department has seen them. Each department has the right to determine how they agree to take care of patients in their clinics. For instance, in many academic hospitals, some departments limit their outpatients to a certain percentage of Medicaid patients, or require Medicaid patients to be seen by residents. But this is Florida, so every department gladly sees Medicare patients and accepts assignment (which means the patient will not be charged for any charges that Medicare doesn't pay). The problem is that the charges to both insurance and Medicare are higher than the hospital/doctor will get paid from those entities...but those are the same charges provided to self-pay patients. So the unfortunate answer is that self-pay patients actually have larger bills than those with insurance, whether private or public insurance. However, they are also more likely to get them at least partially written off, and may are totally written off if the money can't be collected. Millions and millions of dollars in our hospital are written off each year.
    yea, this is on the money. Unfortunately our system rapes anyone who wants to pay in cash, you are probably paying at least double what the insurance company or the government is paying.

    A general surgery private practice I worked for would cut the bill in half(or even less) if you were paying in cash and asked for a financial break, and I assume many others would do similar. But many people don't know to ask, and they shouldn't have to ask to get the same price as everyone else (what insurance companies pay).

    I think there should be a law written that makes all payments equal, regardless who is paying (government, insurance company, out of pocket) -there is no reason government should get a better deal than someone paying out of pocket.
  9.    #9  
    Quote Originally Posted by ninjab View Post
    yea, this is on the money. Unfortunately our system rapes anyone who wants to pay in cash, you are probably paying at least double what the insurance company or the government is paying.

    A general surgery private practice I worked for would cut the bill in half(or even less) if you were paying in cash and asked for a financial break, and I assume many others would do similar. But many people don't know to ask, and they shouldn't have to ask to get the same price as everyone else (what insurance companies pay).

    I think there should be a law written that makes all payments equal, regardless who is paying (government, insurance company, out of pocket) -there is no reason government should get a better deal than someone paying out of pocket.

    I agree totally, but there is a reason for this currently. Hopefully when hospitals start getting reimbursed for all the uncompensated care they deliver, they will no longer have to overcharge to make their bottom line. And yes, for doctor charges, many doctors will accept less if they are aware of financial stresses in their patients. Interestingly enough, the doctors that have the most problem doing this are those that work for practices that are owned by private corporations...like HCA, the poster child for bad behavior within the private health care industry.
  10. #10  
    Quote Originally Posted by davidra View Post
    I agree totally, but there is a reason for this currently. Hopefully when hospitals start getting reimbursed for all the uncompensated care they deliver, they will no longer have to overcharge to make their bottom line. And yes, for doctor charges, many doctors will accept less if they are aware of financial stresses in their patients. Interestingly enough, the doctors that have the most problem doing this are those that work for practices that are owned by private corporations...like HCA, the poster child for bad behavior within the private health care industry.
    well this will be a moot point in 4 years, as out of pocket payment will no longer exists as health insurance is required, right?
  11.    #11  
    Quote Originally Posted by ninjab View Post
    well this will be a moot point in 4 years, as out of pocket payment will no longer exists as health insurance is required, right?
    Hopefully. Not that anyone can predict, but it's possible that the only out of pocket payment might be for those patients who want to go to doctors that will not accept whatever insurance and/or Medicare/Medicaid pays.
  12. #12  
    Quote Originally Posted by ninjab View Post
    well this will be a moot point in 4 years, as out of pocket payment will no longer exists as health insurance is required, right?
    What? Ummm....they have not outlined what the "gold, silver, platinum and bronze" plans will actually be. These will be the minimum benefits put together by the Secretary of DHHS, of which companies will have to establish for their employees. I don't see anything in there that says there will no longer be any "out of pocket payments". In fact, for those under the age of 30 there will be a special "catastrophic only" plan, and so there would definitely be out of pocket expenses here. Are folks thinking that there will be no out of pocket expenses any more? Again, I'm not reading that in any material that I'm getting and if this is what people think, they will be disappointed. Davidra, are you seeing anything about no more out of pocket expenses?
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  13. #13  
    Quote Originally Posted by ninjab View Post
    yea, this is on the money. Unfortunately our system rapes anyone who wants to pay in cash, you are probably paying at least double what the insurance company or the government is paying.

    A general surgery private practice I worked for would cut the bill in half(or even less) if you were paying in cash and asked for a financial break, and I assume many others would do similar. But many people don't know to ask, and they shouldn't have to ask to get the same price as everyone else (what insurance companies pay).

    I think there should be a law written that makes all payments equal, regardless who is paying (government, insurance company, out of pocket) -there is no reason government should get a better deal than someone paying out of pocket.
    I've even had some doctor practices try and get me to pay the discounted price (the price between their initial charge and what they agreed to accept from the insurance company) after the insurance company paid what they were contracted to pay. I simply call the practice and explain that I'm not responsible for the discount and they act like it was a mistake. I think what goes on is that many people don't know better and pay the doctor this discount when they bill you, and then they cuss the insurance company, when they should be cussing the doctor. My experience is that when clients call with an issue, it is usually an issue that began at the doctor's office (wrong code is common, but is amazing how often a claim was never even filed or sent to the wrong place). I know davidra will likely disagree with this, but it is what I see and have experienced personally.
    PalmPilot, PalmIIIc, Treo 650, Pre, Pre 3, Nokia 1020, Lumia 950

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  14. #14  
    Quote Originally Posted by clemgrad85 View Post
    What? Ummm....they have not outlined what the "gold, silver, platinum and bronze" plans will actually be. These will be the minimum benefits put together by the Secretary of DHHS, of which companies will have to establish for their employees. I don't see anything in there that says there will no longer be any "out of pocket payments". In fact, for those under the age of 30 there will be a special "catastrophic only" plan, and so there would definitely be out of pocket expenses here. Are folks thinking that there will be no out of pocket expenses any more? Again, I'm not reading that in any material that I'm getting and if this is what people think, they will be disappointed. Davidra, are you seeing anything about no more out of pocket expenses?
    Think you are talking about co-pays, which is completely different than what we were talking about (uninsured, paying full out of pocket expenses, which are greater than what insurance companies pay).

    It is correct right that catastrophic only plans (didn't know these were allowed) and elective (not covered by insurance) would still have the problems we were discussing.
  15. #15  
    Quote Originally Posted by ninjab View Post
    Think you are talking about co-pays, which is completely different than what we were talking about (uninsured, paying full out of pocket expenses, which are greater than what insurance companies pay).

    It is correct right that catastrophic only plans (didn't know these were allowed) and elective (not covered by insurance) would still have the problems we were discussing.
    Well....not exactly co-pays. A co-pay is a fee for a particular procedure like a visit to the doctor (some might have a $25 or $50 co-pay depending upon whether routine or specialists). These should not be confused with your co-insurance amount, which is the amount you are responsible for after your deductible. If you have a $1000 deductible plan in which the insurance pays 80%, you are then responsible for the 20% up to an out-of-pocket limit (say, $3000). So....you have a $50,000 hospital bill....you pay the ded of $1000, then 20% up to your out-of-pocket limit of $3000, for a total exposure of $4000 out of the $50,000 bill. I believe you will still have these out-of-pocket amounts and co-pays. By the way, the co-pays generally don't count towards your out-of-pocket limit.

    I have no idea what their catastrophic plan will be, but it might be a $5000 deductible then 100% plan, which would mean you would need to come up with $5000. Normally a hospital or provider will set up a payment schedule.

    I had an interesting experience when a doctor thought I didn't have insurance. I needed to be referred to a cardiologist (the insurance company didn't require this, but was needed by the providers) and for some reason my routine care provider was under the impression I had no insurance (I don't have a plan with co-pays as I have an HSA plan). Well, I kept waiting for my doctors office to call and tell me which cardiologist they had referred me to. After a couple of weeks I called them and they were acting odd about referring me and somehow it came up that I had no insurance. When I explained that I in fact had insurance, their attitude changed completely and I had a referral that day. I think that no cardiologist wanted to see me if I didn't have health insurance. How crazy is that?
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  16.    #16  
    Quote Originally Posted by clemgrad85 View Post
    I've even had some doctor practices try and get me to pay the discounted price (the price between their initial charge and what they agreed to accept from the insurance company) after the insurance company paid what they were contracted to pay. I simply call the practice and explain that I'm not responsible for the discount and they act like it was a mistake. I think what goes on is that many people don't know better and pay the doctor this discount when they bill you, and then they cuss the insurance company, when they should be cussing the doctor. My experience is that when clients call with an issue, it is usually an issue that began at the doctor's office (wrong code is common, but is amazing how often a claim was never even filed or sent to the wrong place). I know davidra will likely disagree with this, but it is what I see and have experienced personally.
    That's not always correct. Currently, depending on their network status, you might have to pay an additional charge for seeing a specific doctor above and beyond what insurance pays. However, it should be known when you make the appointment with a specific doc whether or not you are responsible for the difference. This is true in many PPO's that allow out-of-network coverage. Many HMO's don't allow out-of-network payments at all, and have more "management" of who you can see and who you can't.
    Whether the situation you bring up happens as part of a conspiracy to overbill people, I suppose that's possible. In my experience it comes from hiring poorly trained people in billing services, which are almost always horribly organized and inaccuracies abound.
  17.    #17  
    Quote Originally Posted by clemgrad85 View Post
    I had an interesting experience when a doctor thought I didn't have insurance. I needed to be referred to a cardiologist (the insurance company didn't require this, but was needed by the providers) and for some reason my routine care provider was under the impression I had no insurance (I don't have a plan with co-pays as I have an HSA plan). Well, I kept waiting for my doctors office to call and tell me which cardiologist they had referred me to. After a couple of weeks I called them and they were acting odd about referring me and somehow it came up that I had no insurance. When I explained that I in fact had insurance, their attitude changed completely and I had a referral that day. I think that no cardiologist wanted to see me if I didn't have health insurance. How crazy is that?
    Like I said, offices can be very disorganized. And as far as a cardiologist not wanting to see you if you didn't have health insurance, welcome to the land of 30-45 million uninsured. Tell me, did you enjoy it?
  18. #18  
    Quote Originally Posted by davidra View Post
    Like I said, offices can be very disorganized. And as far as a cardiologist not wanting to see you if you didn't have health insurance, welcome to the land of 30-45 million uninsured. Tell me, did you enjoy it?
    Sounds like an issue with the providers (doctors) not the insurance industry. Do physicians assume that someone without insurance (even though I did have it) simply won't be able to pay?
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  19. #19  
    Quote Originally Posted by davidra View Post
    That's not always correct. Currently, depending on their network status, you might have to pay an additional charge for seeing a specific doctor above and beyond what insurance pays. However, it should be known when you make the appointment with a specific doc whether or not you are responsible for the difference. This is true in many PPO's that allow out-of-network coverage. Many HMO's don't allow out-of-network payments at all, and have more "management" of who you can see and who you can't.
    Whether the situation you bring up happens as part of a conspiracy to overbill people, I suppose that's possible. In my experience it comes from hiring poorly trained people in billing services, which are almost always horribly organized and inaccuracies abound.
    Yo...davidra...not going to win this one. I am referring to in-network visits where the physicians have tried to charge the discount back to the patient. They picked the wrong patient to do that to on me. I don't remember the exact numbers....but if the original charge was say....$250, the agreed upon reimbursement was $180, and they billed me for the $70 discount (they had received their $180). Many patients just pay this amount, and they cuss their insurance plan for not paying. When I called them (doctor) on this, they quickly back tracked, said it was an error, and said I didn't have to pay it. I've also had this happen with clients and I've told them to call their provider, tell them they aren't responsible for the discount, and this usually solves the issue. I guess I don't blame the physicians from trying to get more money, but certainly seems sneaky to me. Of course, it could be just a "horribly organized" office as you say....but....it does happen more than you think.

    And yes....I understand the out-of-network issues and being more than "normal and customary". Not referring to that issue.
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  20. sweaner's Avatar
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    #20  
    I am a physician participating in Medicare. We are again on the verge of having our payment cut 21%.

    Venture to guess what happens to my salary if payment is cut 21%? Answer to follow.
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