ikes then i guess we'd have to start debating the merits of the system itself which I wasn't going to get into because I figured everyone here was smart enough to just see what I was getting at with my simple quip, but alas, ikes stepped in with his famous nittery, not even of something I said, but of something that he thought that I meant. Are you suggesting that the general American public would be better off not paying into Medicare and instead responsibly saving that money, as we know everyone would, and then finding their own non-government-aided private insurance plans once they hit 65?

Regardless, sorry for the derail. Carry on ranting a bout doctor shortages and socialism

Pretty simplistic.

There are a lot of aspects of medicare that can be discussed, but lets start with fixed fees for doctors. Oh, there's a veneer of quality out there- check enough boxes on your chart and get 1% more- but don't you pay more for the plumber who fixes your pipes right the first time, on a Sunday, when your house is flooded?

Many of my colleagues have chosen a concierge model where instead of 1000 patients paying $100 medicare dollars each, they have 100 cash patients each paying $1000. Fewer, better paying customers maybe?

Why aren't you doing that?

I really only have heard of primary care docs using the concierge model. Are these colleagues that you are referring to ophthalmologists? I've never heard of an ophthalmology concierge practice? Could you link to some?

Correct, and i realized that was likely mis-spoken.

Retina practices are about 70% or more medicare. I don't know a single one who doesn't take medicare. I'd love to hear about one if it exists.

I'm in one of the most difficult specialities to dump medicare Its the primary care docs that are the coal mine canaries for physicians getting out.

The biggest obstacle I have is the pharmaceuticals that have become standard of care for macular degeneration, which is the most common condition I treat. A 68 year old who presents with disease in both eyes could easily spend over $40,000 a year in drug costs alone.

(The thing is, if medicare decided that these drugs were "not covered" then perhaps some patients would pay for them out of pocket. Wouldn't they cost a lot less, since the pharma companies wouldn't be getting the guaranteed marketplace/customer base of the medicare population?)

Plus, my patients would get really pissed, cause they're "entitled" to see me and they've been trained to think that I have to take medicare.

I don't feel there is a sense of hate for doctors here. Most of the people here who understand where the real cost for healthcare and why it is too much know doctors are way down the list. I think massive cost reductions could take place in the healthcare industry without even getting to doctor compensation.

The reality is some doctors are underpaid. Pcs are probably underpaid.

You mention the concierge practice but I think doctors need to be careful. One doctor in New York just charged his patients $25 a month and they could come in as often as needed. I believe he had a fairly good size practice. Problem is the state decided he was selling insurance without a license. I think that is an issue doctors potentially run up against. Or if they are one of the many being swallowed up by the hospitals , it is unlikely their contracts would even allow for that.

It will be interesting to see the concierge business overlay the ACA in a few years. Most people will have insurance so pretty much every patient will be worth the same. Having a premium tier of service will exist. Although I do not believe most doctors can pull it off. Value will have to be available for that premium price and some of it will have to be tangible. Recruiting patients becomes a bigger issue as well.

There is a bit of a problem with the totality of patients and doctors now. Doctors are far from created equal but there are still not very good ways to identify good doctors other than word of mouth. One of the co-workers of my long time PC filled in for her when she was out and I was really sick. He specifically told me during the exam "At least we know you don't have pneumonia!" I guess he was right. Two days later I went to the ER and had a nine day hospital stay including five days in the ICU for double pneumonia.

So how do people ignore horrible doctors like that? It is not easy and wanna-be healthcare professional yelp sites don't really fit the bill.

My parents had the same doctor for thirty years. Someone they first found at a doc-in-the-box but who went on to have a massively successful practice. She was an amazing doctor and took good care of them for years. However as they got older and their ailments got worse and the doctor neared retirement it was clear to me she was going through the motions and not treating them for the now but just for the status quo. It was a tough decision to leave but she was a victim of success. The only reason my parents could get into see her was because of their long standing relationship. Otherwise you were talking about 7-10 day wait times for basic illnesses.

To turn a long story into a novel, i would love to know what percentage of PC visits are people with colds which the doctor can't do anything about. For decades doctors would over prescribe antibiotics even though they knew it would not help them get over their cold faster. We have talked a lot about PAs and NAs here and it does seem this is going to have to be the standard method of triage with only more serious , concerning or perplexing issues getting to the doctors. As Ike will mention, though, the laws for what assistants can do vary greatly by state. I think some uniformity in that would be helpful. I don't mean federal government oversight but just the states working together.

Ike's,

I know you don't know this, but those old people have contributed to Medicare their whole life. On top of that they pay a monthly premium to get access to it. A premium that just went up for 2014. On top of that there is a small deductible.

People who earn above a certain amount but are on Medicare, pay an even higher premium. Again let us not forget that they paid taxes for Medicare on all or most of their income.

Add in Medicare c and d premiums and you could be looking at a couple/several hundred dollars a month. Above and beyond a lifetime of taxes.

The fact is someone eligible for Medicare who had a decent income and wanted a full value Medicare package could end up paying $500-$600 a month. That is post subsidy.

Fasting test with regular blood panel is probably $100-$150. Flu Shot is probably $20-$30. Not sure about tetanus or pneumonia vaccinations.

So you pay $500-$600 a year plus copay and get two hundred dollars in those benefits alone plus anything else you would manage to address.

On top of that you continue to have coverage if something goes horribly wrong. I know people just want to have insurance kick in the day they get deathly ill but it will never work that way. Just having a proper baseline for blood pressure and weight has value in determining what a future problem might be.

I had periods where I was never really that sick, beyond a head cold. Maybe not see a doctor for years. Seems every time I went though i ended up having a lot to discuss.

The idea that there is no reason or benefit for healthy young people to have insurance is just wrong.

What if you break your arm or leg? That has little to do with being young and healthy and more to do with being young and active. X-rays, cast, change of cast, removal of cast. That is going to end up a pretty penny relative to the premiums a young person has. Obviously deductible comes into play. Ever priced out a sleep study? Even a relatively young and healthy person can have sleep apnea. Between the multiple studies and equipment you would blow any deductible throw the roof and keep on going. Could easily be 6k-10k.

At probably my peak health I got punched in the jaw. Shattered in one side and pushed it out the other. Worse i was on vacation. Not getting into the massive expenses of long term orthodontics, having to have my jaw rebroken again. What do you think it costs for emergency surgery to get my jaw wired shut for six weeks and then follow up care and treatment. I didn't need health insurance, I was healthy, super healthy. Guess how long it took the criminal who assaulted me to pay me back? Never did. I once got a check for $5.42. I sued the company overseeing the property and that case took ten years and it did not even cover my medical expenses. On top of that my insurance company wanted it.

Fact is young and healthy people have a higher risk to be stricken by severe trauma. Be it a fight, car accident or whatever. Sure there overall costs are lower and risk is lower but you act like because you are young and healthy paying insurance premiums is a complete waste of money. That is not the case.

Again I do not get the mindset where people think health insurance should be a zero sum game at WORST. I would rather be the guy who pays $600 a year in premiums and never gets ANY benefit from it then the guy paying $5000 a year in premiums and costing his insurance company $15k a month.

What part of implies don't you understand? Seriously you have some reading comprehension issues.

It's obvious you're having some sort of difficulty with basic English, so I'll try and help you out. I did not imply it. How do I know? Because I ****ing wrote it. You inferred something that you had no reason to infer. I can't help you with that.

In fact, I specifically mention stuff that is quite obviously rare:

I'm not sure how anyone can read that and say that the implication is that one needs insurance because these things are common.

It's obvious you think that you have some sort of awesome argument in your head. Instead of asking silly rhetorical questions, why don't you use your words and spit it out? Perhaps I can be more helpful to you then.

Was that doctor really "horrible?" Or did he make a mistake that day? There's a axiom that "the last doctor is the smartest"- I tell patients this all the time. Often someone comes to me after being seen by an optometrist and a general ophthalmologist-- sometimes on the same day. They are anxious and tired and often grumpy to boot. Some of those are easy, but others I just don't know whats wrong with them or I know its going to take some investigation that isn't going to give them an answer immediately. Still others I realize need to see someone even more specialized (an ocular oncologist, a neuro-ophthalmologist, perhaps someone who sees nothing but hereditary diseases)

Here's a couple pro tips:

1) Word of mouth is the best I think.
2) Online ratings (health grades, yelp-type stuff) not as good- usually you get a disproportionate amount of people who get pissed off cause they had to wait an hour longer than expected and missed getting home for the MNF kickoff or something.
3) Experience matters, to a point. I can tell you that I'm the retina surgeon you want to see right now. I'm 48 years old with over 15 years experience and I'm peaking. I wasn't as good 10 years ago--I was still figuring it out. I probably have the potential to be great for another 7 years or so- then I'm going to have to mix it up. You can't do microsurgery forever at an exceptional level. So maybe more office work, less OR time. Likewise, there's a younger guy in town- fresh out of training- who likes to operate. Sometimes our system is rigged to pay off the cutters, so getting more than one opinion on something truly elective seems prudent.

lol ikes

Words like "necessary" are also apparently "our" words and a bit too complicated for your caste. #StandwithPhil, though, huh? Robertson/Zimmerman 2016!

Fly:

You know his donations are easily searchable, right?

He's given 10K+ to the Pauls but my favorite is the 1k+ to Sharon Angle.

Swift Boat Vets and POWs For Truth probably my second favorite.

You don't even try to understand or debate the issues. You come in blasting snarky one-liners and juvenile stuff like "the savior Obama" then expect to be treated like an adult? Come on son.

We've been down this road 20 times with you. The second the debate turns to - "Well what is your plan for the uninsured and rising health care costs? How do you reconcile that the richest country on earth is the only developed nation not to provide some kind of universal health coverage?" - you mumble something about paying with chickens and disappear for another 6 months like Brigadoon. You've made up your mind on an emotional level a long time ago and have zero interest in legitimate debate - you are the MD version of raradevils.

Either stop suckling at the govt teat or stop whining about how you don't get enough milk. Your shtick is insufferable.

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”
― Upton Sinclair

So this clown is complaining that medicare doesnt pay enough, predicting doctors will flee (note, nothing compels them to accept medicare now!) while also complaining about taxes that pay for medical care? What?

Lets skip ahead. The absolute last thing you want is a free market.

What if he's hourly?

The endgame of every single one of these arguments is that the raras and renodocs of the world would rather have more money for themselves and let poors die than have real reform that works. But since they know how bad that sounds, we get circular logic and concern trolling.

Just own it guys, you think poor people should die instead of having to pay higher taxes.

When they came for the privileged white males (and by "came for" I mean dinged the net amount the govt pays them for treating old people by a few %) I said nothing... because that would be a ridiculous cause to get riled up about.

They take a loss on medicare but accept it anyway for some reason.

Yes that is actually a common argument.

looooooooooooooooooooooooooooooooooool

Again, that's where we see the "libertarian" bona fides of the Tea Party collapse. Man, they don't give a **** about the free market or whatever.

They are just angry things for their kids aren't like they were for them growing up, when any WASP with a work ethic could be a doctor without having to deal with smelly Indian(dot not feather) kids taking their jerbs.

That isn't trolling that's absolutely accurate.

I love it. The entire discussion started with fly asserting that medicare is a handout for doctors. Now people who clearly haven't read a damn thing on the topic are jumping in claiming that cuts for medicare would result in poors dying. Just ****ing love it. Couldn't prove the point better really.

The logic here is probably something like "I get paid less for that Medicare patient than another patient so I take a loss on it!" but then they gloss over that the reason they took that Medicare patient in the first place is because there was no one else to fill that time slot and pay them more monies.

Reno what got you all fired up to donate to the Swift Boat Vets?