<p>You have it backwards. Since the beginning of medicare, doctors and other health care entities have abused Medicare and Medicaid in every way imaginable. It was an accepted business practice and it cost us billions. </p>
<p>My mom worked for a small group of doctors for 30 years, from the 50s through the 80s. The doctors committed Medicare/Medicaid fraud on a daily basis. Every doctor she knew did. It probably started with charging the equivalent of an office visit for making rounds - see 20 people in an hour but charge the equivalent of an office visit for each - pretty good money. When Medicare/Medicaid never questioned it, they took the next step. They started charging even when they didn’t go to the hospital. One of the doctors was caught and fined, but nothing really came of it. Figuring out how to rip off Medicare/ Medicaid and private insurers became a full time endeavor by the medical profession generally. Throw bigpharma in there too. The insurance companies knew it and turned a blind eye. All they had to raise premiums to make themselves whole - cheaper than ferreting out fraud. Then the corporate world figured out to rip off the system even more - legally. </p>
<p>The politicians knew it and know it but the medical/insurance/pharmaceutical conglomerate owns them in that regard and as long as there was plenty of money for everyone, who cares? </p>
<p>Now that there are some, albeit weak, regulations in place making the government ripoff harder, folks who made their financial beds based on billing abuse are suffering. Isn’t it rich that the people who made billions destroying something are now complaining about its health?</p>
<p>"Isn’t rich that the people who made billions destroying something are now complaining about its health? "</p>
<p>Happy to plead ignorance here…who are you talking about? Who made millions and is now complaining? The eighties was thirty years ago! Medicare and medicaid started in '65, right? I would have been six. My impressions of "managed care " started WAY after that, and seems far more influential. </p>
<p>I will say I did not make millions, but I AM complaining, specifically about the disparity about what we know about, want to pay for, and what we expect from “mental health”.</p>
<p>It is interesting to see how docs will bill for THE SAME thing. I got allergy shots from two different docs offices. One charged me for an office visit every time, even tho all I did was get an injection & never even knew if the doc was in, the other charged me for an injection only at a much lower rate. The shots were twice a week, so they really added up quickly in terms of MY payment & insurers.</p>
<p>Dentists and eye docs manage to stay out of the insurance reimbursement mostly by charging lower rates & mostly not having to do insurance billing at all.</p>
<p>It is alarming to me to see how high medical bills are & how much of it is written off and it’s tough to know what REAL costs are & what is inflated mark-up. I do know that we just had two hospitals in our state go bankrupt for the 2nd time, this time closing its doors, finding new placements for all its patients and laying off nearly 1000 healthcare workers.</p>
<p>That’s a different complaint. I’m talking about the medical industry generally that looked at Medicare/Medicaid and private insurance as brass rings. Millions, heck billions, have been made on the back of insurance - both public and private. The private guys were complicit and the public was too in the sense that the more they paid out, the more they got. As efficient as Medicare/Medicaid is, they have almost been bankrupted by the fraud and greed of those much smarter and better backed.</p>
<p>edited to add - hospital profit is all about number of beds. They get paid by the number of days beds are occupied. Many hospitals banked on that and added a large number of beds. Insurance - public and private - is changing the way they reimburse so those rooms are not necessarily paying for themselves. The way they afforded the additions was to reduce staff. You started seeing more rooms than nurses in the hospital.</p>
<p>Huh? Medicare and Medicaid fraud is punishable with huge fines and jail time. The government has the attitude that you are guilty unless proven innocent. You want to compare that with what is going on with banking and Wall Street?</p>
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<p>Ask any drug abuser how many people abuse drugs and they will also tell you “everyone does it”.</p>
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<p>I also hear that from most of the MDs I know. They will bend if their kid is really, really passionate about it, but that’s all.</p>
<p>I think ophthalmology is a safe choice - an example. </p>
<p>The education of doctors need to change significantly. There is no justification for the years spent - and the expense - to become a doctor that does not involve a scalpel of some kind. The nurse practitioners are proving this. They often do a better job than the docs and many patients prefer to see them. They are often much better diagnosticians. The training should be more vocational in nature - like nursing - starting in undergrad. Then there could be a year of two of a residence/training program. The cost should be cut in half - at least. Same is true for the horrible waste of money on law school. It should be done with an undergrad degree and internship.</p>
<p>"The nurse practitioners are proving this. They often do a better job than the docs and many patients prefer to see them. They are often much better diagnosticians. The training should be more vocational in nature - like nursing - starting in undergrad. "</p>
<p>Could be true. What are you using in terms of outcome? </p>
<p>Where I practice, this does not seem true, at least in mental health, and today, what is NOT “mental health”? But then I am thinking in terms of dollars spent, often in pharmaceuticals, and in outcome. </p>
<p>In mental health it is not hard to label and prescribe. What can you link in terms of outcome?</p>
I think it’s interesting - and a little amusing - that this is an example of the “problem.” You’ve got a doctor who was marking up the drugs he was prescribing and making a lot of dough off the retail business at the expense of the taxpayers - and it wasn’t even “fraud.” Now that option has been foreclosed, and he’s got financial problems. </p>
<p>I don’t see that as a problem of “medical economics.” I see it as an entrepreneur who got caught in a changing retail environment. If the doctor hadn’t gone into the drug selling business in the first place he wouldn’t have lost money.</p>
<p>Many of the MDs we know are actively discouraging their kiddos from going into medicine. The hassles greatly outweigh the money from their perspective. A few of their kids are going into medicine anyway–or at least that is the current plan. One OB/GYN says he gets paid the same $1500 or less caring for a woman for 9 months & delivering the child, no matter what time of day or night he gets calls & has to go & deliver the kid, including all complications, etc. His S went into engineering instead & the other one sells cars. His wife can’t afford to work at his practice & is working as an RN elsewhere so they can have medical benefits.</p>
<p>My H did not encourage our kids to go into medicine–not because of the money, but because of the horrendous hours, stress, and more stress.</p>
<p>I look at the average salaries bandied around on this thread and I gotta laugh. You don’t make the kind of money that buys luxury cars or mansions taking care of poor kids in Newark.</p>
<p>I think if we had gone to a Canada-style single payer system, where he wouldn’t need to spend hours and hours on the phone and filling out forms for scores of different insurance companies bent on denying care any way possible, he might have stayed in medicine. But that not being the case, he’s now an over-worked high school teacher instead of and a tremendously overworked doc–less money, but he has his life back.</p>
<p>I have never seen a PA or NP to date, all MDs. I have heard some NPs say things I KNOW to be totally wrong and dangerous medically in large statewide gatherings. I have heard of healthcare professionals who work with NPs and PAs who say the NPs and PAs are good about billing but not very good about treatment and diagnosis. These healthcare professionals have to undo the mistakes made by the NPs and PAs, so I expect there is CONSIDERABLE variability on quality.</p>
<p>^^ Just to be clear, I do not see mistakes, so much as I see a reliance on superficial knowledge, not unlike the “checklist” sort of stuff that many folks on the internet equate with “knowing” what to demand in a medical setting.</p>
<p>Yeah, patients are satisfied, but does it change outcome? And which is more important in the long run?</p>
<p>It takes a lot of volume, under duress, and with a range of outcomes, to practice the way doctors in the US practice. Not necessary? Okay; I’ll buy that…okay, I won’t BUY that…hopefully costs will reflect that.</p>
<p>Yes, true, I have also fired many docs for that reason (plus making me sicker than when I started seeing them).</p>
<p>One of our relatives is going into podiatry because it supposedly has better hours and less stress than her dad’s job as an MD. The other hopes to be a doc like his parents & is now in the midst of medical school interviews. It’s still a very competitive process, as is podiatry. Another doc’s kid WAS interested until she did some medical research in Europe one summer & got TOTALLY turned off to medicine AND research. Her sister still wants to be a doc & is currently a freshman. Her folks wonder what the older one who is getting her BS in some science field will be doing after she graduates this spring. Yet another doc’s kid is getting a double-degree in health promotion & Japanese and HOPES to get into med school after working for a while. Will see how it goes.</p>
<p>Shrinkrap - you are right, mental health has been underfunded and poorly reimbursed for years. If anyone should be complaining, it’s the mental health professionals. I have had good experience referring to mental health NP’s but I wish we had more mental health professionals and prescribers in particular. </p>
<p>As to S-corp profits- I have had an S corp for 12 years now with my private medical practice. Any profits or losses gets added (or deducted), to my income on my tax returns. It has been, at least for me, a huge negative. If I buy medical equipment with loans, the loan payments show up as profit and I often have to pay taxes on money I never received. Since my practice, like most primary care practices run with such a small profit margin, I was never able to receive a distribution to pay taxes. In effect, it reduces my actual income. </p>
<p>I admit I’ve discouraged my daughter from from being a NP and PA and instead encouraged med school. It makes no sense to be doing the same work for less than half the pay. I’m not complaining as I feel I make a great salary. But I would do things differently if I had to do it over again. </p>
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<p>I would love to know some examples so it can be reported to the proper regulatory agencies who are responsible for licensing NPs. In my case, my practice is regulated by the medical and nursing association. If such mistakes are made, as well as the practice mistakes you are describing, it should be reported.</p>
<p>I’m confused as to how the loan payments toward medical equipment are seen as PROFIT? That just seems odd. Isn’t there something the bookkeeper can do to prevent this?</p>
<p>Interesting blog. My kid is a 2nd year medical student and is still somewhat blind to the issues facing doctors. Unfortunately, the practise of medicine going forwards is not going to be as profitable as in the past. With all the years of going to school (which I believe can be cut back as in other countries), I’m not certain it is worth it - particularly for women.</p>
<p>“It makes no sense to be doing the same work for less than half the pay.”</p>
<p>You really think it is the same work? </p>
<p>I feel both H (primary care) and I do a lot of intellectual work, “supervising”/signing off on, non MD’s.</p>
<p>Some people seem to think an rx is just a piece of paper. I think it represents a lot of intellectual work, not to mention risk.</p>
<p>Here is an example. A few months ago I see a young girl, maybe 10 for “anxiety”. She has presented to an NP working with a pediatrician who had NEVER seen her with weight loss. Father tells NP the weight loss is because grandmother said something to her about chewing food thoroughly and not swallowing to fast. No further work up; kid gets referred to psych. </p>
<p>Now weight loss in a 10 year old is a pretty big deal. Almost NEVER happens for me, with a primary psych diagnosis in a 10 year old. I call NP and aks how did she make dx of anxiety. She says “dad says so”. I’m not saying another MD knows how to dx anxiety,and their is a lot more to it than what I’ve said here, but a pediatrician knows weight loss in a 10 year old is a pretty big flag, even if the “rating scale” points in another direction. Why? Because he probably lost a few kids, just like I did, during residency.</p>
<p>We got some bad accounting advice and such costs can be accounted for (somewhat) with appropriate depreciation of the medical equipment. At one point, and possibly still (we haven’t bought super expensive equipment in the last 5 years), you could deduct the cost of medical equipment. But, if you have to borrow money to pay for it, loan payments are not deducted. We borrowed 60K/year for 3 years for 401K plans for the staff and medical equipment, only to find that my partner and myself had to claim an extra 30K of income for 3 years.</p>
<p>^^^ Sounds like you could benefit from a good CPA providing better advice so you & your partner can plan better and have your taxes more accurately reflect your income.</p>
<p>Yes, prescribing the right medication in the correct amount and tracking whether the patient BENEFITS or has any adverse effects IS very important AND has potential for great rewards and liability. I am glad to have my MDs & am very apprehensive of the day that I am ever told to see a NP or PA instead. I understand the HMOs & other orgs use them quite a bit, as do large practices. My docs all have very small practices and have had very long-term relationships with their patients.</p>
Her sister still wants to be a doc & is currently a freshman. Her folks wonder what the older one who is getting her BS in some science field will be doing after she graduates this spring. Yet another doc’s kid is getting a double-degree in health promotion & Japanese and HOPES to get into med school after working for a while. Will see how it goes.</p>