Probably writing their own version but whatever they pass the House will likely pass pretty quickly imo.

That's helps, I guess, but if renodoc's "We see them" meant what you say it means, that's also confusing. Especially, since I assume renodoc is seeing pretty much nobody "off the street" as you put it.

It's not like people are calling his office with their self-diagnosed retinopathies or whatever it is that he deals with (I've forgotten his specialty and am too lazy to check). I assume he has an essentially 100% referral practice. So you're telling me if someone other than an ER refers a medicaid patient to him, he is going to refuse to see them. And he's going to state on here that his policy is "We see them [i.e., medicaid patients]".

As a practical matter, if no one else in the community is taking medicaid, then there aren't really going to be referral sources for medicaid patients. But that's quite a bit different then saying that renodoc won't see non-ER medicaid patients.

I guess renodoc can settle this for us: Renodoc, what would your office do if your fax machine spits out a referral (not from an ER) for a medicaid patient? Would you see them or do something else?

"That's helps, I guess, but if renodoc's "We see them" meant what you say it means, that's also confusing. Especially, since I assume renodoc is seeing pretty much nobody "off the street" as you put it."

I think we kind of got off track, and it's probably my fault. What I was trying to get at relates mostly to primary care providers, at least in our community - IM, FP, Pediatrics, and OB-GYN - they're not seeing Medicaid patients de novo. GI has been hit and miss. Ortho will see medicaid patients if we refer them, or they'll come to the ER and see them there (they get a stipend on each patient from the hospital to do so) But if you sprain your ankle while visiting in California, and want to be seen here for continued pain/PT/recheck, it's not happening AFAIK - unless you come to our ER, get seen, and get referred.

"So you're telling me if someone other than an ER refers a medicaid patient to him, he is going to refuse to see them."

That's not what I said, or at least not what I meant - but it's complicated

Renodoc is a subspecialist - as I noted, I might consult him or one his colleagues once every couple of years on a patient. I would guess the majority of patients needing his services are Medicare patients. (I could be wrong, but retinopathy/retinal problems are much more common in older patients) Medicare is a different (and much better payer) than Medicaid. As I noted in a previous post, if one of the subsidized clinics has a patient that needs his services they'll make a direct referral. I'd assume they then get seen, but I'm assuming that because I can't recall any patients being turfed to us.

And I'm sorry if I made this stuff less that clear. To be frank, it's confusing to people in the medical profession....

MM MD

https://twitter.com/SenateDems/statu...01941521108992

Its a daily occurrence. We get patients referred by optometrists, general ophthalmologists, and primary care docs. Very few from the ER. We see them and its become close to 20% of my practice. Diabetics mostly, but some detachments etc. Do we not become physicians in order to take care of people?

"Yeah, you guys are ****ed. Gov should veto it, but they passed it as a constitutional amendment also. That will have to get thru again in 2 years, and then to the masses in a POTUS election year. "

Vetoed today. (Re AB 382 in Nv) So I don't have to fly to Arizona to work for the next two years anyway.

I'd like to think that they'd get together a working group to sort this out in some sort of reasonable manner for all, but that would require politicians to act like grownups. So it ain't happening.

MM MD

Actually I believe Sandoval included a working group suggestion in his veto message. Meanwhile, the culinary union is calling the proposed constitutional amendment their "hammer." Nice.

Yeah - as usual, everything ****ty in health care in Nevada comes out of Clark County.

I'll be retired by the time (if) it passes - I kind of feel like the captain of the sinking ship stepping into the lifeboat as the ship slips under the water.....

MM MD

Thanks for clearing things up, but I think the main source of confusion is that you did a horrible job of trying to convey what you meant.

When you say this,

but what you actually meant was this,

then massive confusion is going to be the inevitable result. Especially when there is a specialist on here in your area who is claiming to take all medicaid patients that come his way. When I read your first post the only possibilities I could think of that you were uninformed, calling renodoc a liar, or just not communicating accurately. Looks like it was the latter. But I think the confusion is all cleared up now.

Yeah, as I said, my bad on the specialty issue. Posting after a long shift probably isn't optimal.

Sadly, though, we've managed to set up a system in which if you have a problem that can only be handled by a specialist, we can probably get you seen - but getting basic primary care provided is somehow beyond us. Seems less than desirable.

MM MD

Interesting article about more and more US-born doctors attending foreign medical schools filling the void for practitioners.

https://apple.news/AKQ073CqpQEmpiO-SnnUdgg

I've worked with a fair # of FMG's over the years (one of my partners trained in Mexico) - with a couple of exceptions they all seemed more than competent. (and I'm not implying that they were worse as a whole than US trained docs)

The biggest hurdle for them is getting into a residency program here (AFAIK only Canadian docs get a pass, and I could be wrong about that) which they have to complete before they can get a license in the US. This should probably change, at least for some countries - although to be honest I have no idea how you'd determine which countries should have to do additional training.

Dunno how the future looks for immigrant MD's though, given the current political climate......

MM MD

These guys going overseas is not going to help unless the number of residency slots is increased. In the past there were more quite a bit more residency slots than graduates from US allopathic medical schools. So getting a residency spot as a foreign medical grad was not that difficult for the best ones.

This trend is reversing as more medical schools are being built in the US and class sizes are expanding. The number of medical school slots is rising faster than the number of residency slots. If the trend continues, there may not be enough slots for even the grads of US schools. So it will be extremely hard for any grads from foreign schools to get residency training and practice in the US.

Trump hates foreigners and academics. I assume there won't be any soon regardless of available spots.

Perhaps, but my post was mainly addressing the issue of American citizens getting medical degrees elsewhere and then endeavoring to come back to the US to practice.

A US citizen who graduated from a foreign medical school is still considered a foreign medical graduate in the context I'm talking about.

All things being equal, a US citizen from a foreign school probably has a leg up over a non-citizen from a foreign school (even in the pre-Trump era) when it comes to residency selection. But both have far less opportunity than a graduate from a US school (even if that graduate is not a US citizen).

Let me ask a devil's advocate question. I don't necessarily subscribe to this view right now, but I am wondering if the medical office business model could use some changes if it can't survive on Medicare rates?

In the tech field I gotta imagine there have been and will continue to be advances making healthcare delivery and testing cheaper. so the negative margins on Medicare rates are at least a mild surprise. On the other hand, the doctors offices still appear to be operating by roughly the same business model they did in say 90s or even 80s. For the record, in my field (let's say tech consultancy) if I showed up to a government client and complained that their reimbursement rates are too low for me to make a profit, I'd be laughed out of the room. And rightly so. No one feels bad for failing tech companies who are using the wrong tools, even if those same companies were once selling cutting edge stuff. At the very least, even VCs most of the time only tolerate negative margins from a startup for a short time before they'd be looking at how to modernize.

HobbesMMMD, what are your biggest costs in delivering healthcare?

"HobbesMMMD, what are your biggest costs in delivering healthcare? "

Wrong guy to ask. I'm an ER doc - essentially the only cost I have is med mal. It's higher than I like, but that's not my (or other docs) primary objection to the med mal issue, and not really a topic for this thread.

Renodoc could comment, but we really need an IM/FP type to give us a good answer.

From the hospitals point of view, I have some understanding, as I was on the hospital board for a while - but I dunno if that's very applicable to your question, either.

MM MD

Since you're an ER doc, let me ask you this, and I guess you can put this into whatever quantifiable form you wish (with the understanding you'll be guesstimating from a position of expertise)... How much more are we paying and how often are we paying it to treat people in the ER who a) could have been treated more affordably through a primary care doctor the day they walked into the ER or b) could have avoided a now-necessary ER trip by getting preventative/routine care from a primary doc?

And by "we," I basically mean any/everyone in the country... So whether they're insured or not, publicly or privately, etc. I'm just looking at this from a cost-control point of view.

"How much more are we paying and how often are we paying it to treat people in the ER who a) could have been treated more affordably through a primary care doctor the day they walked into the ER or b) could have avoided a now-necessary ER trip by getting preventative/routine care from a primary doc?"

Two different questions. For a) not as much as you would think, for a bunch of reasons. For a lot of issues that come to an ER a primary is pretty worthless - if you have chest pain/abdominal pain/traumatic injuries, going to your primary is generally just going to delay you getting to where you can be worked up (assuming the chest/abdominal pain isn't a chronic issue with you.) Primary docs can't do the imagining/lab work needed to sort that stuff out, and if they DO find something you end up in the ER anyway.

At a recent ACEP a non-doc economist gave an interesting talk where he argued that most of the "overuse" of ER care represents a completely rational decision by the patient. If you happen to have chest pain at 2pm and call your primary, you're either going to get an appointment for a week from Tuesday, or more likely (and appropriately) be told to go to the ER to make sure you're not having a heart attack/PE/aortic issue, none of which the primary can do anything about anyway. If you come in and see me, within 10 minutes you have an EKG, with 30 lab testing and within 90 minutes CT imaging of your lungs/aorta, if it's needed. Never mind that most docs offices are Mon-Fri 9-5. In the ER you get seen, evaluated and (hopefully) figured out in a few hours (our average patient time in the ER is 3 hours, which is obviously highly dependent on just what you show up with) Add in the option of an urgent care? You can be seen by a PA/NP IF you're insured, and if you need testing get sent to the hospital lab/imaging center and wait for the results, or you can be seen by a boarded ER doc and get the testing done on site.

For b) my scientific wildass guess would be all them money in the ****ing world. It's where an intelligently thought out health care system would make maximum effort - it's cheaper by an assload of money to have someone's hypertension/diabetes/CHF/COPD/psych issues (ESPECIALLY PSYCH ISSUES) followed and managed on an outpatient basis, and MUCH better for the patients as well. I'm very good at what I do - I'm a smart guy and I'm well trained. But I know ****-all about the chronic care aspects of the above, and I shouldn't be doing it.

For what it's worth, the majority of this could be done by NP/PA types with MD supervision. Given the huge move by IM grads to hospitalist work since the pay is much higher, it'll have to be.

Kaiser is probably the best at this stuff, although for reasons you don't care about I'd never work for them. But I'd be happy to have their insurance, if I was living in an area they served. I think the Marshfield system in Wisconsin is similar.

MM MD

What Hobbes said, except that if you live in this (and most) towns and your eye/vision is ****ed up, you don't really want to waste your time going to the ER because they are under equipped and don't know ****.

It doesn't matter if they know nothing. They presumably know enough to call you. Some patient with an acute ophthalmologic emergency (and lets assume they don't have an ophthalmologist they have an established relationship with that they can call) at midnight has no better option than to go to the ER and hope one of the ER docs hooks them up with the appropriate person.

If you have a better plan for someone in this predicament, I'd be interested in hearing it.

It amazes me how many of my established patients go to the ER, wasting valuable time and resources, instead of calling me. Most acute visual problems happen during daylight, and asking Siri or Alexa to find an eye doctor is going to pay dividends

So we agree that in the scenario I posted, going to the ER is not a waste of time?

reno/hobbes, i appreciate your responses, but so far i am still having trouble seeing where medicaid is screwing you over. i understand some stuff about hospitals, but honestly i believe government should be subsidizing both premiums for people as well as hospitals/providers. can you give me a more detailed explanation?

They dont really cover costs. You cant lose $5 per patient and make it up with volume