"Doctors are not forced to make decisions based on a fee payment schedule. They make decisions based on medical data." Part of making decisions includes which tests to order, which specialists to call, whether to admit the patient or not and many other decisions all of which involve $. There are few absolute decision making rules, much is up to the physician's discretion. To imagine that no doctor anywhere has ever taken payment into consideration is a nice thought but not remotely accurate. It is wonderful that during your career you did not have to make decisions based on cost but that doesn't mean that no other doctors are in this position. I never suggested that physicians are submitting bills randomly but rather that when there is a choice to be made SOMETIMES upcoding occurs. And yes, downcoding occurs as well. Neither is an evil but rather a natural part of the system. Pretending it doesn't exist doesn't make it not exist like the proverbial ostrich that sticks its head in the sand.

"Obama's statements implied that most or all doctors operate that way. Physicians are FURIOUS about his statements. You can't join Sermo, as you are not a licensed physician, but if you could, you would have seen the universal outrage in the postings on the board, even from some of the docs who support his plan. Obama is no friend of doctors. "

Thank you for reminding me of the my status before I get carried away thinking that I might have something to contribute to this forum. If that is the general feeling among members than I would gladly refrain from making use of this website as such a stance would show how outdated it is. "Being a student pistachio, I'm not sure you realize what's involved in getting prior authorization " and "You can't join Sermo, as you are not a licensed physician but if you could, you would have seen the universal outrage in the postings on the board,"

Clearly you feel that someone who is a student and/or not a licensed physician couldn't possibly know anything about health care reform. That you have worked in health care for so long and yet have not encountered physicians who have been encouraged to upcode is not evidence that I have too few credentials to comment but rather a demonstration of the fact that you must have worked in a hospital or specialty free from such concerns. That is wonderful. It is also simply not the case for many physicians I know personally who complain of this problem. I am sure on the SERMO website there aren't many physicians advertising the practice in some hospitals in some departments by some doctors of upcoding. By the way, most of the doctors I know don't have time to hang out at SERMO because they are too busy working so it hardly represents ALL physicians. In fact I would venture to guess that most younger physicians in demanding specialties do not participate in this site on a regular basis.

I cannot bare to repeat this again but I will, when Obama stated that some physicians are forced to make decisions based on fees he did not say all physicians. I have no idea why he would be an "enemy" of physicians. This sort of absolutist rhetoric reminds me of the Bush administration, i.e., "good vs. evil". You would think from all of the anger that Obama had wrongly claimed that all physicians possess WMDs.

I agree with AnnaM and pathdr2b. I also think that BO is taking advantage of the unfortunate article by Atul Gawande about doctors in one town in Texas, as discussed in this other thread:

http://www.mommd.com/cgi-bin/ubb-cgi/ult...oprofile#000019

And as for eriberry's original question: it is too soon to tell. We don't know if it will pass, what it will look like if it does pass, and how it will be interpreted by the powers that be. However, the fact that physicians have not had a lot of input into it does not bode well.

About the tonsillectomies:
If you don't focus on the example chosen, but on the big picture, what he's saying is that right now, financial incentives place emphasis on procedures, and this reward system isn't in the patient's best interest. Isn't that true?

I agree that most physicians do not outright perform procedures solely for financial gain (we all know some who do though), but you cannot deny that even good physicians are often insidiously pressured to do things (or NOT do other things such as spend time on health education and prevention) due to time constraints, which are directly related to finances.

The current reimbursement system is just plain backwards. I do believe in rewarding specialists for increased level of skill and training, but why does the pedi GI get $1,000+ for scoping a kid in half the time it takes the general pediatrician to do a well-baby for $50? Won't the well-baby visit have just as great an impact on the child's health?

*Disclaimer - I am not accusing any pedi GI on this forum or elsewhere. Their services are very much needed. This is just AN EXAMPLE to get the point across*

We wanted to make sure that doctors are making decisions based on evidence, based on what works. That's not how it's happening right now. Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out."

There's the exact quote from BO. Nowhere does he say SOME doctors.

There are a few bad eggs in every profession. You're never going to get around that. It seems that the percentages are quite a bit higher in politics than they are in medicine. It won't matter what plan Congress ultimately comes up with. There will always be a few who game the system.

"Part of making decisions includes which tests to order, which specialists to call, whether to admit the patient or not and many other decisions all of which involve $. "

In general, particularly among primary care docs, none of those decisions particularly involve reimbursement to the doc directly. My office didn't make money on tests--they were sent to a reference lab or done at the hospital. We didn't make money when we decided to refer to a specialist. Fee-splitting was outlawed decades ago. We didn't make more money admitting a patient to the hospital either. The hospital might, but they don't share it with the doc.

Again, studies done on doctors' coding have shown that, overall, docs tend to undercode, not overcode. There may be a few who purposely overcode, but private insurance companies, medicare and medicaid, all send out auditors to review charts, both in the office and in the hospital, and computers pick up patterns of overcoding pretty quickly.

Pistachio, I never said that you do not have anything to contribute to the discussion. Everyone's contributions are valued here. I spent 25 years teaching medical students, and I found that, in general, they know very little about the financial aspect of medicine. If you know more than the average med student, good for you.

The economic position of doctors has been steadily eroding over the past 20 years. There isn't a single other profession in this country where reimbursement has gone DOWN, while costs have continued to go up. Medicare once paid $2000 for cataract surgery. Now they pay $500-$600. Obama plans to save over 300 billion dollars on medicare in his plan. Where exactly does he think that 300 billion is going to come from? Medicare payments to physicians are scheduled to be cut by 21% in 2010. Most of the docs I know will stop taking Medicare if that happens. Many of the docs I know are working on their exit strategies from medicine now. If the plan that Congress comes up with is not acceptable to docs, many will just leave. Massachusetts has pretty much universal coverage, but there aren't enough docs to see all the patients. Obama has not been interested in getting input from real physicians on this plan. He and the rest of the country will eventually regret that decision.

I think Massachusetts is a very good example. It is problematic to say that we should follow Canada's example or the UK's example because our country has so many important differences from those other countries. But in Massachusetts you can see what happens if you enact universal coverage in America. Here are the results: 1) there is not universal coverage (not everybody chose to take advantage of it), 2) people still have trouble finding a primary care physician, as above, and 3) it has the highest healthcare costs in the nation.

Maybe we should learn from what happened in Massachusetts before applying it to the entire country.

Ain't a dam thing free in the entire world! There, I said it. So lets talk about some sources of all this "free" health care:

1) Higher taxes

2) Decrease reinbursements for Docs

3) Turning the life support off grandpa and using it on highly deformed Baby Premie.

4) Higher taxes

4) All of the above


Does anyone else have a way to pay for this "free" health care?

Just increase the national deficit!

The economic position of doctors has been steadily eroding over the past 20 years. There isn't a single other profession in this country where reimbursement has gone DOWN, while costs have continued to go up. Medicare once paid $2000 for cataract surgery. Now they pay $500-$600. Obama plans to save over 300 billion dollars on medicare in his plan. Where exactly does he think that 300 billion is going to come from? Medicare payments to physicians are scheduled to be cut by 21% in 2010. Most of the docs I know will stop taking Medicare if that happens. Many of the docs I know are working on their exit strategies from medicine now. If the plan that Congress comes up with is not acceptable to docs, many will just leave. Massachusetts has pretty much universal coverage, but there aren't enough docs to see all the patients. Obama has not been interested in getting input from real physicians on this plan. He and the rest of the country will eventually regret that decision.

AnnaM, that was a very good point. I love the debate you all have going on and I'm going to hijack the discussion for a second to ask, is this a reason why perhaps a person should consider becoming a mid-level practitioner rather than an MD/DO (my eternal debate)? Please don't hesitate to answer and then carry on with the discussion. Thank you for your insight.

i was wondering when this topic was going to get started.

we need something done, at america's prosperous times, there were ~47 million without insurance. All of the lay offs and unemployment, i am sure the latest count is astronomical. That does not include the UNDERinsured. I see it every day in the clinic, a patient that has to choose between BP meds or breathing meds. So we give all the samples that we can, get them on the wal-mart $4 plan....even with copays, it is over $200/month. For someone who works for low wages (IE CNA) can not afford even copays.

Should the abused woman with health issues leave the abuser, just to lose health insurance? I do not think there is any debate about whether we need a change to the system. What the change is, though, is the tough part.

I do not believe for a second that a change would ration health insurance to not treat the elderly. I think that is such a scare tactic. Our country values our elderly and I do not think would stand for it. If someone is a candidate for a procedure, age would not be a factor.

A national system, I am not keen on, because of how medicare and medicaid are handled. BUT I am totally for regulation of companies to protect consumers from business practices that affect their health. I think health care is RIGHT to all citizens, not a privelege. I feel priveleged to be able to buy a personal policy with my loan money...no restrictions on my "pre-existing" conditions. Still, no maternity coverage, and an enormously high deductable and unaffordable rx copays.

As for higher taxes, I think some classes don't pay enough. Middle class bears the brunt of taxes.

As a country, we have the highest per capita health care costs. It would take time to reap the financial benefits of preventative care, but is the concern really money? People (hard working people) suffer needlessly due to an inept system. Personally, I do not think it should be tied to employment, that everyone should buy it, and the costs are affordable, a person can not be dropped or refused, or charged an enormously high premium (well beyond their means) because they have an illness, whether self induced or inborn.

From what I understand, that is more of germany's system. I know america is all about capitalism, but there are some aspects of our society that should not be left to the whim of a purely capitalist market. There are times when it is appropriate for a government to step in and protect its people from fraud.

to continue a long post, the reimbursements need to change as well. There needs to be incentives for primary care, especially if so many previously uninsured suddenly get coverage. I know that with my loan burden, i can not go into primary care, if I wanted to. I remember what my Family Doctor said to me when I talked to him about going into medicine. He said that unless I graduated with LESS than $100K in loans, do not go into family medicine. Needless to say, my "state school" runs themselves like a prestigous private school, so I am out of luck.

The litigations also need to be addressed. I think that a "jury of peers" should be just that, other doctors that hear a case, decide its validity and details of the case.

I read a good email from the ACP. I like their stance on the issue. I sincerely hope that BO listens to doctors about what really needs to be fixed. I was a strong supporter of him, and hope I am not let down. I know the gay/lesbian/bi community has felt like he "abandoned" them (but that is another can of worms) If i can find the link (open to non-members) I will post it.

To summ up, it is a very complicated process, so I do not expect any one instance to change everything to be perfect. We need to start somewhere and continue to make changes, perfecting the system.