Given lower reimbursements, I imagine that many practices that accept Medicaid try to keep Medicaid patients below a certain percentage of their patient load to maintain revenues.

A couple of problems I see with the article: The secret shoppers posed as parents calling on their own. If asked, they said they were referred by a doctor or ER. Most specialists want a direct call from another doc's office for the referral, and if I thought a kid needed a particular specialist, I could just pick up the phone myself and get the kid seen.
Some of the diagnoses they called about (broken bone, uncontrolled asthma, seizures, severe depression) sound like stuff that should be seen in the ER (and frequently is).
I have NO idea where she got the figure of 99+ bucks reimbursement for a moderate complexity problem as payment from Illinois Medicaid. That is pure fantasy. A 99213 used to pay something like 30 bucks, if memory serves.

No - in my opinion that encourages what is already a problem - low reimbursements. I don't think anyone should have to see any percentage. I'm not a huge fan of socialism.

This cost would be completely eliminated if we got rid of private insurance.

No - in my opinion that encourages what is already a problem - low reimbursements. I don't think anyone should have to see any percentage. I'm not a huge fan of socialism. I think if people aren't able to see them due to cost - then reimbursements should be higher. Physicians' time needs to be valued. It isn't right now. Plus, I've heard physicians on the phone arguing with Medicaid insurance for their patients to get certain treatment courses, because they hardly approve anything. Medicaid costs way more than just an office visit.

There was a professor who decided one day to teach his class a lesson. He said that everyone would get the average grade of the class for a test. So the first test, the A students brought everyone up, and the F brought everyone down. Everyone got a C. The A students were pissed and said they weren't going to work so hard if they got something so average for all their work. The F students said - well, this isn't bad, I got a C for doing nothing. So the second test, the grades went down to a D. The F students said, well this is still better than nothing, so I'll continue to do nothing. The A students were even angrier, and they did even less next time, because no matter what they did - they didn't get a return on their investment. So the next test - everyone got an F.

Socialism doesn't work. I don't think you can just say - everyone let's just see 20% Medcaid for the good of the people. If you want people to invest in this population, just pay them what it is worth. What's the harm in actually reimbursing someone fairly for their time and effort?

I'm also a libertarian, and apparently we are a minority in this country. Actually, I really should say I'm a Republican that is developing a libertarian problem. LOL.

PS - there are several physicians in the rural town I'm precepting in right now that have gone without a salary this past year, because they see too many Medicaid patients, and they decided to pay their office staff and had to forego paying themselves this year bc they didn't earn enough money.

Government, as we've seen time and time and time again, does not make a better product than the private sector, health insurance included.

Gosh, it's difficult to imagine a worse product than the current medicare/medicaid system (wasted resources, nonprovision of care, nonpayment for care, care decisions delegated to bureaucrats over physicians, etc.). Almost anything would be better.

Maybe if we went completely free-market, fee-for-service for health care then market forces could improve the product. But not with the insurance model. Insurance has to go hand-in-hand with universal enrollment. Otherwise you just have a mess, which is what we have now.

See how such awful systems are interchangeable?

There's really no "maybe" about it. The insurance business sucks on our end mostly because of the massive regulations that keep good competition from lowering prices and providing better product.

It just pays the claim. Granted, it doesn't pay *enough* of the claim, but again, this is related to the fact that it carries the bulk of the high-cost patients while private insurance companies cherry-pick the cheap ones.

An unregulated insurance industry would simply go even farther in the current direction of improving profits by reducing product quality (i.e., refusing to insure the ill, and refusing to pay legitimate claims).

My practice is about 80% public assistance (medicaid and government subsidized programs). The reimbursements for medicaid are abysmal, not enough to cover my expenses. I recently asked one HMO, with whom I have 1500 patients and have never had an increase in the 6 years I have been with them, for a raise. I was offered a 0.5% increase. It was an insult.....................................................................................................................
I just hope and pray that I can keep this up and not be forced by the government to change.

No, they aren't. In particular, Medicare has an administrative overhead of something like 2-5%, compared to the whopping 20-30% seen in the private insurance industry. This is because Medicare doesn't expend time, effort, and money trying to figure out how not to pay claims. It just pays the claim. Granted, it doesn't pay *enough* of the claim, but again, this is related to the fact that it carries the bulk of the high-cost patients while private insurance companies cherry-pick the cheap ones.

No, the insurance business sucks because insurance is inherently a stupid way to handle a service that is needed by everyone. Insurance is based on risk pooling. It makes sense for fires and natural disasters. It does not make sense for health care.

An unregulated insurance industry would simply go even farther in the current direction of improving profits by reducing product quality (i.e., refusing to insure the ill, and refusing to pay legitimate claims).

I've never had problems with insurance payments as a therapist. Medicare/aid I had the worst problems.

When you talk about overhead, what exactly are you including? And do you realize that public programs in theory *should* have lower overheads because of taxpayer money?

I'm also curious where you got your overhead numbers.

And yes, private insurance plans can pick who they insure, to a degree. It's called risk management. The whole idea behind insurance is to prepare you for catastrophe, not to start paying out immediately. That's not insurance.

Health care is not the sole responsibility of the gov't or an insurance company to provide. Your number one health care provider should be yourself with your diet, exercise, etc. Buying a policy for unforeseen illness is very appropriate. Otherwise, going to the doctor for your yearly or every other year checkup costs how much? And how much are people spending on luxury and excess in that year or 2? But that argument comes down to whether one considers healthcare a right or not, and I do not.

However, there are 3 big examples of gov't healthcare programs that are failures: Medicare, Medicaid, Social Security. If they were such successes, we wouldn't be scrambling with meetings about the debt ceiling and having our president threaten our elderly that they're not going to receive their checks next month (while he and Congress would still get paid, of course).

That's fascinating. I've had the exact opposite experience. I find private insurers meddle endlessly in treatment decisions. I've never ever gotten a demand for prior authorization from Medicare.

No, why should they? Usually people make the opposite argument - that governmental administration results in bloated budgets.

Originally from an Op-Ed series by Paul Krugman some years ago, but before I posted I googled around and found corroboration from multiple sources.

So it's okay with you if only healthy people, and not sick people, can get care?

I don't think this is a philosophical matter, but a pragmatic one. It is to the benefit of all of us to live in a society where all members have their basic health care needs taken care of. If laissez-faire, fee-for-service healthcare were in practice to result in sufficiently low costs that everyone could afford basic care, I would be all for it. However if in practice it resulted in lots of people spreading measles and TB on public transport because they couldn't afford preventative care, I'd say we'd need another system.

I am against private insurance because in practice it has resulted in wasted resources, nonprovision of care, and bureaucratic interference with care that is provided by physicians. Not because of any theoretical position on health care as a right or not.

On the fact that it is happening now, and that the government regulation is mostly aimed at preventing it from going even further in that direction. I think you've reversed the causality: the more insurance goes in the natural direction of improving profits at the expense of providing care, the more the government tries to rein in those tendencies. By what reasoning would you expect that getting rid of the regulation would suddenly cause the insurance companies to start implementing strategies that would improve health care at the cost of their own profit margin?

Again, when you try to apply an insurance model to health care, you end up with a lot of people who are too expensive to be profitable to private insurers. Those people end up on the government rolls. Obviously the system that is forced to take all the unprofitable patients is going to end up... unprofitable.

Gov't debt doubled during the Bush years, and I don't once recall most of that being attributable to the costs of sustaining medicare, medicaid, and SS. So unfortunately, it looks like we have another pathetic "Pee Baggers" theory at play here.

TR, you present a d*mn compelling argument that seems pretty useful for prepping for med school interviews. Thanks!

Thank you for that compelling, mature, adult description to your stance at play here . Debt did go up under Bush, and I was quite vocal about him as well, but none moreso than under Obama, a convenient fact you ignore.

Back to the ignore list for you, since you are more about ad hominem than intelligence for topics you disagree with, as evidenced above.

That really doesn't have anything to do with what I stated. As it stands, the really sick have emergent care available despite payor source. The indigent have Medicaid.

I never said I was against public health in general, especially vaccines. I'm absolutely pro-vaccine.

I don't want the gov't telling me how to live my life, taking my income (which is property) and distributing it to others vis a vis telling them how to live their lives.

By this position, you should also be against any past and present gov't healthcare program as well. Nothing is more bloated, more bureaucratic, or wasteful than this.

There would be more competition, especially from smaller companies that have been forced out of existence thanks to regulation.

Medicaid is not a bona fide insurance model.

I appreciate you taking the time to explore the different ideologies with me. I would like to hear more of your views, but I may not be able to check back in until later this week. I start my general surgery service tomorrow and I have no idea when I'm even going to sleep again LOL.

Interesting thread.

I find I am bursting with the desire to respond to some of the comments so excuse me for being rather rambly.

First of all, I am an ED doc in rural TX and see mostly Medicaid and uninsured patients. Believe me, the ED is NOT the place to go with acute suicidality. You will spend the night/day/ hours getting screened medically, then MHMR comes and chats with you, usually to send you home if you sign a no harm agreement. The wait for a follow up appt is weeks to months even if you were in the ED. There is only one truly active State Hospital in TX, in Austin, often having limited beds. Medicaid patients have it a little easier, can get into some private hospitals/facilities, but most of the folks I see needing emergency psych care for suicidality or drug-related/alcohol related problems get sent home with no hope for real counseling, rehab or psych care. They may get put on antidepressants, get some pamphlets, AA literature. They are left with few options but the ER and we have no resources, no social worker or psych nurse, certainly no psychiatrist other than one at a county MHMR clinic.

For other urgent/non-emergent issues, we are hardly adequate for the hundreds of patients that flood our doors. We are often so busy with ear aches and dental infections at 1 am that when the true emergency, the rollover with open fractures or the AMI we have to move patients out to the hallway to get the truly emergent patient in the appropriate room. This with one doc on for 12-24 hrs, one nurse, one LVN for a 12 hour overlap shift that ends at 11pm. The ED is not the place for the uninsured or Medicaid who either can't afford a visit out of pocket to local docs, or whose assigned provider is out of town, has no appointments or is in the next town down the road.

Frankly, this is the most half-baked system imaginable. Care is spotty at best, follow up is poor, specialists are virtually impossible to find who will take uninsured or Medicaid, ambulance providers can refuse transport if patients can't pay, thus forcing the rural hospital to pay, insurance companies deny services so even if you think you are in the free and clear by having employer-paid insurance forget it. You can be denied for something in your record from years back, or you may be stuck with high deductibles that in themselves are prohibitive to obtaining care.

Enough said, the real question for me is this: why is it we are the ONLY developed nation with a fee-for-service system of health care and no public option or universal program? Medicaid and Medicare do not count because they are NOT universal NOR are they an option for all. They compete with private insurers (at the payee level, with us, hospitals, clinics, other providers--there is no comparison with completely public systems). I have practiced under a socialized system, in New Zealand, and it was a blessing to never have to worry about reimbursements. We billed the gov't programs, we were paid electronically within 10 days, no questions asked. Check out the cost per capita in New Zealand. The least expensive country per capita weighed against quality of healthcare and longevity is Switzerland, a country that provides universal healthcare, home health, an affordable prescription program and excellent prenatal and birth care. Universal access is not socialism. It is providing a basic service necessary to maintain the health and well-being, and ultimately the ability of people to contribute to society.

Calling health care an entitlement is an abomination. Entitlement is the 458:1 ratio of CEO salaries to avg worker salaries. Entitlement is the expanding profits of the insurance companies despite the recession and high unemployment and foreclosures and new homelessness these past few years. The number one cause of new homelessness, loss of home to foreclosure, bankruptcy and job loss is loss of health and associated medical/hospital bills. This does not just impact the poor, the working poor and the low-middle class. It impacts the entire middle class which is most of us physicians. It impacts our families, our parents, our kids in college, our grandkids. The chance for achieving the "American Dream" is shrinking daily as we lose our respect for Humanity, blame the disadvantaged for their illness and lack of ability to pay, and refuse to take care of each other.

And for the person who thinks the overweight, bad food eaters, smokers, etc should either not be covered or pay more, that is pretty much also heartless. I've seen folks who run daily, eat perfectly and live a clean and good life yet die from a huge LAD blockage, are permanently damaged from a Berry aneurysm rupture, or develop a rare form of cancer. Lifestyle is only one aspect of health, not the whole picture, and the best way to address that is via education, not denying health care and by providing resources to weight loss specialists, bariatrics, smoking cessation resources and so forth. Addiction, binge eating disorder, alcoholism are all chemical, physical and pscychiatric issues, not simply about "choice" and behavior. Much of it is related to trauma from childhood, habits taught during childhood, lack of breastfeeding and healthy diet, etc. McDonald's is a helluva lot cheaper than Whole Foods, plus have you ever noticed where fast food restaurants tend to pop up? Most are in poor areas, providing a disproportionate amount of meals to the poor, indigent and locally bound (i.e. lack of transportation to grocery store, etc.) Judging lifestyle is as useless as judging someone based on the car they drive. We are here to help, not judge, and if helping isn't part of what you want to do as a physician, maybe it's not the best field for you.

I'm new to this forum and site in general, but am finding it very interesting! Keep up the debates. I look forward to seeing any responses to my ideas.

And for the person who thinks the overweight, bad food eaters, smokers, etc should either not be covered or pay more, that is pretty much also heartless.

Judging lifestyle is as useless as judging someone based on the car they drive. We are here to help, not judge, and if helping isn't part of what you want to do as a physician, maybe it's not the best field for you.