Crappy Compensation Just One (Big) Reason Doctors May Spurn Your Obamacare Coverage

DoctorsolgaA recent survey of New York doctors finds them wildly unenthusiastic about the new health plans offered through Affordable Care Act exchanges. The Empire State results follow on those from a much larger national survey of physicians that also showed sparse willingness to participate in health plans offered on the exchanges. Red tape and poor design and implementation had physicians worried even before the October launch of the exchanges provided a train-wreck-y case study of government incompetence. Also acting as doctor-repellent are compensation rates far, far below those offered by existing health plans.

Covering the New York survey, the New York Post's Carl Campanile writes:

A poll conducted by the New York State Medical Society finds that 44 percent of MDs said they are not participating in the nation’s new health-care plan.

Another 33 percent say they’re still not sure whether to become ObamaCare providers.

Only 23 percent of the 409 physicians queried said they’re taking patients who signed up through health exchanges.

Even among physicians who are participating, three out of four say it's only because they're forced to by contractual obligations; just one in four signed up by choice.

Last month, the Medical Group Management Association surveyed a much larger group of doctors around the country. Just 29.2 percent of respondents told the MGMA they planned to participate in exchange plans, while 40.2 percent were considering the matter, and 14.4 percent had already decided against participation. Interestingly, among those participating, 26.8 percent also cited contractual obligations as their reason for accepting exchange patients, and another 21.6 percent pointed to "Inability to select patients based on their insurance." (The question allowed for multiple, overlapping responses).

Why the lack of enthusiasm?

The New York respondents cited low pay, chaotic implementation and administrative hassles as major concerns. The MGMA survey was more specific, with 64 percent citing "administrative and regulatory burdens," 61.9 percent citing "financial burdens from patient collections," and 59 percent pointing to the 90-day grace period during which doctors must continue to offer coverage to patients who don't pay their premiums—and then will have to swallow two months of uncompensated costs if those patients turn out to be true deadbeats. Another 59 percent pointing to "low reimbursement rates."

MGMA Obamacare survey of physiciansMGMA

Red tape and administrative headaches are a growing concern across the board for medical providers dealing with insurers or simply trying to comply with laws including HIPAA. The Affordable Care Act makes them worse, but they aren't new. The terrible compensation offered to doctors for seeing patients who buy plans through the new exchanges is new, however.

Citing a health industry executive, the CT Mirror reported that "national insurers appeared to have a one-size strategy across the country, tying reimbursement rates to Medicare rates. That might work in places where Medicare rates are high, but not in places where they’re low." That strategy is just a bit problematic at a time when Medicare is losing doctors willing to accept its low rates or deal with its bureaucratic hassles.

More specifically, MedPage Today reported last month that providers are being offered bargain-basement compensation well below current rates.

A representative of one primary care provider organization, speaking to MedPage Today on background, said some rates were 70% lower than traditional preferred provider network plans, adding that plans were trying to make provider rates as low as possible to keep premiums equally low.

"Initial hearsay information is that payment rates being offered by [marketplace] plans are quite low in at least some of the states," a federal affairs representative for a second primary care provider group said. "What that means is that fewer providers will sign up."

Read that again: "some rates were 70% lower than traditional preferred provider network plans." Whatever industry you're in, can you imagine having to take a 70 percent haircut to your pay from any customer or group of customers and continuing to work with them? Could you keep your doors open if that was across the board?

Much press coverage so far has focused on the disastrous rollout of the health exchanges and the difficulty patients have had in signing up for plans. Wait until Obamacare enrollees find out that they have an insurance card that isn't worth a damn.

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  • Fist of Etiquette||

    Wait until Obamacare enrollees find out that they have an insurance card that isn't worth a damn.

    No one is going to report a story that suggests health insurance isn't necessarily health care. The reason you're hearing about the website is because it will eventually be fixed or worked around. There is no fix for MD's who refuse to be moved around the chessboard.

  • Ghetto Slovak Goatherder||

    Sure there is. Demote them from knights to pawns. In other words, enslave them, so they're fully subject to the King.

  • Tonio||

    The government could fuck with the licenses of physicians who don't cooperate. The government could pressure the AMA to require members to do a certain number of hours of insurance care.

    Of course, this could backfire by driving doctors out of practice and reducing the supply of doctor hours, which would...

  • ||

    It's already doing that, dude.

  • Free Society||

    yep. fixing procedure prices, artificially limiting the supply of medical schools and doctors. among other things...

  • #||

    ^^ this is the next step. Mandating that doctors take the insurance.

  • Fist of Etiquette||

    They'll decide the only winning move is not to play.

  • Auric Demonocles||

    Bring back Groovus!

  • Cliché Bandit||

    "Remember, only YOU can prevent marriage to hot foreign women."

  • Faceless Commenter||

    Maybe you could get a ton more highly qualified, motivated, ambitious and diligent doctors in the system by amping up affirmative action in med schools.

  • nova3930||

    My wife is an MD and we're actively preparing contigency for just such shenanigans, eliminating debts and cutting our cost of living down to the bone. The minute her license is contingent upon her being a virtual indentured servant to .gov, that's the minute she shuts the doors and stays home. The public at large would be absolutely shocked if they knew just how many doctors are making those contingency plans...

  • nova3930||

    My word of the "contingent" BAH!

  • nova3930||

    Let me try for a third time. My word of the day is "contingent" apparently.

  • Cliché Bandit||

    There's no sugarcoating it, Nova is contingent.

  • Red Rocks Rockin||

    This is a good way to live regardless of long-term occupational uncertainty.

    Debt's nothing more than a form of indentured servitude, especially today with access to so many lines of credit. People with no debt are not owned by anyone.

  • nova3930||

    I disagree to an extent. Debt is a tool, and like any other tool can be hazardous if misused.

    An example is the latest vehicle purchase for my wife. We had enough to pay cash if we wanted, but financing incentives pushed our interest rate to 0%. If someone else wishes to let me use their money to buy things while my money keeps working for me, well who exactly am I to say no.

    Another is we borrowed to help set up my wife's practice. The income stream from the practice is several multiples above the debt service payment. In a sense, not borrowing would have cost us significantly more than borrowing because she would have spent several years saving while working as an employed physician somewhere making much less money.

    Now the flipside is a form of slavery. Borrowing to finance frivolous things like vacations or TVs is nonsense...

  • sasob||

    I, for one, would not blame such doctors even one tiny bit.

  • Faceless Commenter||

    No, they wouldn't be shocked. They've long known that you doctors are acquisitive, extortionist, creatures of endless greed with no interest whatsoever in saving human lives. And the good thing about Obamacare is, if I like my doctor I can keep my doctor!

  • thom||

    The minute her license is contingent upon her being a virtual indentured servant to .gov, that's the minute she shuts the doors and stays home.

    So your wife is planning to deny people their right to health care just because she lost an election? Just because you don't get what you want doesn't mean you can deny people their civil rights. /prog

  • Loki||

    You jest, but I guarantee some proggie fuck will make that exact argument. These schmucks are beyond parody.

  • Major Johnson||

    Are you saying that because someone has a right to health care she has a duty to provide it to them?

    Do you also support the federal government paying for my guns and gun dealers being forced to sell them to me? The right to bear arms is actually a federally guaranteed right, unlike your fairy tale right to health care.

  • Major Johnson||

    I pay cash for my care and have for over 10 years. Occasionally I make payments when the care is more expensive than what's in my bank account but no doctor has ever turned me down yet. I myself was paid for on the installment plan, my parents didn't have maternity coverage.

    I'm hoping this debacle actually turns out good by creating a cash market for health care and getting the employers and insurance companies out of it entirely. If people realized they could pay out of pocket for the vast majority of health care and actually come out ahead they may start dropping insurance like a hot rock and we could return to catastrophic coverage for problem care. To me that's the only solution to our health care cost problem.

    It seems to me that R's are just as adamant that employers should supply health care via 'insurance' as D's are that government should supply it, which is really how we ended up with unaffordable care to begin with (thanks FDR!)

    So maybe your wife should consider going self-pay only. I'd go to a black market doctor before I'd buy Obamacare so I can get condoms with only a 40% copay after paying thousands for premiums and meeting a $6000 deductible.

  • dan'o||

    Sadly I think the conventional wisdom following the inevitable crash and burn of the ACA (as portrayed by the msm) will be the need for a true single payer system.

  • Madisonian||

    Since Blue Cross was dropping our catastrophic coverage, as of Jan 1, I dumped it this month. We have found a practice that will cover all basic tests, physical, urgent care, small surgical procedures, even gynecological, all for $89.00 each per month. I should have done this years ago; we've been paying $421 monthly for hospitalization only.

  • Ted S.||

    The government could fuck with the licenses of physicians who don't cooperate. The government could pressure the AMA to require members to do a certain number of hours of insurance care.

    Why do you think I keep suggesting the same sorts of restrictions around lawyers?

  • Michael Price||

    Why not go the whole hog and just conscript the doctors you need? Happened before in some European country, according to Ayn Rand. Belgium I think.

  • Rasilio||

    The funny thing is if somehow Obamacare does work it will create a bifrucated health care system in which the rich employ concierge doctors which they pay on a retainer and skip "health insurance" so they can be guaranteed access and everyone else is either forced to accept substandard care or go on LONG waiting lists to get in to see a decent doctor.

    I could actually see being able to pass down your spot as a patient for a particular doctor in your will becoming a thing.

  • gaijin||

    I could actually see being able to pass down your spot as a patient for a particular doctor in your will becoming a thing.

    A taxable asset!

  • some guy||

    Black market medical care, dude. It used to be just for pain management and bullet removal. In ten years it might be for everything.

  • AlexInCT||

    Progtards never want to work for free. In fact, most of them have an overinflated opinion of how much the crap they do is worth. Conversely, progtards think that everyone else should work for free though. Especially the people they feel are better off than they are. It's jealousy and greed at its most basest form, masquerading as concern and good intentions. Doctors are amongst the group progtards dislike the most, because they can’t outright kill them off as Stalin, Mao, or Pol Pot would have for being uppity, without suffering the real world consequences for that.

    Everyone wants the best doctor possible when their ass is on the line. Way too many people do not want to pay anymore than they would pay a quack to get the best medical treatment. Government takes that shit to the next level of stupid. I am with the doctors that are telling government to take a long walk off a short pier.

  • ||

    It's jealousy and greed at its most basest form, masquerading as concern and good intentions.

    And once again, TEAM BLUE is entirely projection. It's basically all they are.

  • John||

    Someone on another thread made the point that Obama, being an old style black leftist, hates the typical stuff white people like suburban white liberals' guts and thus is happy to see them get fucked in the name of helping the uninsured under his health care plan. That is probably true. I wonder what your typical gentry liberal is going to say when he realizes that the black Jesus actually hates him?

  • ||

    I don't have a crystal ball and I can't read Obama's mind, and I'm certainly not going to make assumptions such as "Obama hates white suburbanites". That's pointless and stupid. I don't need to make assumptions to know he's an utterly incompetent megalomaniac.

    I don't think Obama suffers from projection. That's for the sheep that bleat after him. He's at the top, and he's a malignant narcissist and megalomaniac, not a projector.

  • John||

    I think Obama meant what he said when he slipped and said he wanted to transform America and "spread the wealth around". What does that stuff mean? It means going after the middle and upper middle class where the money is and giving some of what they have to people who don't have as much. That is what he has always been all about.

    Somehow the millions of upper middle class liberals who voted for him convinced themselves that he either didn't really mean it or more likely he was talking about everyone but them. Ah no, he was talking about them. And they are now starting to figure that out.

  • Harvard||

    LOLZ You really "think" he meant what he said? And how does "This means I'm a sleepy fuckstick" sit with you now?

    I'm curious. And what raced through your brain during the first campaign when he promised to "fundamentally change America"??

  • Scarecrow Repair||

    I'll go with that. It fits with the mindset that sees only results and not opportunities, and equality thereof. All he sees is some people with more money than they need and others with less, as if frozen in stasis. If that really were how society works, with everybody frozen in place, no job changes, no promotions, no layoffs, no inventions, no death, no sickness ... then such redistribution would have some semblance of success. But such a world doesn't make sense except in a weird sci-fi context.

  • Calidissident||

    I don't think Obama is an old style black leftist. I think he fits in better with urbanite white liberals than he does with radical black leftists.

  • Fluffy||

    Well, as debate with MNG used to make clear, to a prog, doctors deserve to be enslaved because they have medical knowledge, and others need that knowledge.

    MNG was safe from enslavement, because he didn't possess any medical knowledge. Therefore enslaving him would be wrong.

    So with the progs in charge, if you want to be safe you better see to it that you don't acquire any medical knowledge.

  • John||

    Everyone works for the state fulffy. Who are doctors to tell the state that it can't employ their talents in ways that best benefit the collective?

    Once you start thinking the state is everything, enslavement is the logical result.

  • Fluffy||

    Well, we saw in the shutdown that the progs don't consider things like "you can't sell beer until we approve your label" as petty tyrannies, they see them as services.

    "The government is providing the critical service of approving your beer label! That service makes it possible for you to sell beer!"

    So I don't doubt they see the medical licensing process as a service, too.

    And you owe the state service in return for that service.

    That's how they see it.

  • Bryan C||

    Healthcare is a word we use for things we all do together.

  • SugarFree||

    MNG|8.12.09 @ 12:48PM|#

    To say that someone has a moral duty to provide immediate help to one imminently in need of what you can provide, and that that duty is so strong that it justifies coercion to mke you obey it is not necessarily to say that the duty exists or at the same strength to justify coercion for every situation which exists in the world of someone in need who could use something you my have.

    In On Liberty Mill talks of how it would be OK to use coercion on a person who knows the bridge is out and could reasonably flag down car approaching the bridge-less chasm. That seems right to me. Like imposing a duty on that guy to share his information with the driver I can see imposing duty on a doctor to share his skills on the dying guy at his feet...
  • SugarFree||

    Also, look for the bonus MNG derp about how keeping someone from stealing from you is NAP-violating coercion.

  • Rasilio||

    Even if this argument is accepted as valid it ignores the fact that the majority of medical care is NOT a guy dying at your feet but either a guy who may at some point in the future die from some condition he is suffering from if it remains untreated or a guy who is going to die in the very near future from one of a number of conditions present and treating him will buy a few extra weeks or months at best.

  • sasob||

    ...either a guy who may at some point in the future die from some condition he is suffering from if it remains untreated or a guy who is going to die in the very near future from one of a number of conditions present and treating him will buy a few extra weeks or months at best.

    Hmm, can't you just see that argument being used to justify forced treatment?

  • Fluffy||

    is not necessarily to say that the duty exists or at the same strength to justify coercion for every situation which exists in the world of someone in need who could use something you my have.

    I also like how he simply asserts this, and doesn't even try to support it.

    Ah...memories...

  • Libertarius||

    "In 'On Liberty' Mill talks of how it would be OK to use coercion..."

    I do wish that libertarians would grasp what this *really* means: utilitarianism is the practical application of the left's hysterical altruism. Utilitarianism is entirely an irrational, collectivistic philosophy from beginning to end, and as such, the coercion of the individual is necessary to its practical enactment.

    In this as in all other matters I have contemplated as an Objectivist, Rand. was. right. Until you are willing to fight for an objective code of non-sacrificial morality, the apostles of human sacrifice will continue to beat you.

  • OneOut||

    I'm not sure that I want a doctor to be forced against his will to try and save my life. I had much rather have one that wanted to, for whatever reason.

  • Free Society||

    The RUC committee, a board of healthcare technocrats, in the American Medical Association price fix the compensation rates to physicians with Medicare. Health insurers the, are obligated under a litany of laws and judicial precedent to base their own reimbursement on Medicare/Medicaid standards. The result: a centrally planned, price fixed healthcare regime.

    Despite the huge inefficiencies and obvious deficiencies of the government's ability to manage their healthcare cartel, political control of the industry only grows.

    The state is literally murdering people in order to grab and keep more power.

  • Free Society||

  • Free Society||

    search on wiki and google: Specialty Society Relative Value Scale Update Committee

  • ||

    "a 70 percent haircut on your pay"

    blame it on autocorrect.

  • The Late P Brooks||

    Willing buyers voluntarily contracting with willing sellers; it's what's for dinner.

    Oh, wait, no it isn't. Have some gruel, and like it.

  • John||

    Read that again: "some rates were 70% lower than traditional preferred provider network plans."

    You mean insurance companies don't print their own money? You mean they don't just pay any price demanded by doctors? They are a third party payer. I thought that vitiated the laws of supply and demand? This is going to come as a shock to a lot of people, left and right.

    Meanwhile back in the reality, if you control how much insurers can charge, make them cover every type of procedure known to man, and make them pay for pre-existing conditions, they are going to make up that lost money by paying doctors less and rationing the available care. I mean who could have seen that coming? They are just evil, greedy capitalist or something.

  • Free Society||

    Actually the ability of insurers to "haggle" or otherwise negotiate about reimbursement is almost non-existent. Prices are fixed by technocrats in the AMA and Medicare and the result is hugely inflated prices for insurance and healthcare in general. So this may come as a surprise to you, but the 3rd party cartel system does grossly distort supply and demand. The market mechanisms that normally regulate prices and cost are nearly non-existent in this industry.

  • John||

    That is an interesting point. But I was under the impression that medicare doesn't pay shit. That most doctors don't want to take medicare because the reimbursements are so low. Is that not true?

    If it is true, how is medicare driving up prices by underpaying for services? Are doctors forced to take it and then just passing the loss on in the form of increased prices to insurance companies?

  • Free Society||

    When medicare isn't underpaying they're overpaying. Their underpayments though, are one reason we have $8,000 ambulance rides and $400 band-aids at the hospital.

    Check out this NPR link:
    http://www.marketplace.org/top.....re-pricing

    It's a transcript of an NPR Marketplace broadcast, but it's actually very informative. It describes the central planning regime in place that fix prices for all sorts of procedures. But since it's NPR, of course they don't find fault with a centrally planned healthcare industry per se, they just sort of lament that we don't have better central planners and declare that there is no alternative pricing system available (which is a funny conclusion for a guy that hosts a show called "Marketplace")

  • John||

    Medical care is never going to be a perfect market because people will always need insurance. And insurance will never be able to be as careful with their money as most people would be with theirs.

    That said, the idea that the government could determine the proper price for the medical care of everyone in America over the age of 65 is to put it mildly insane.

    Paul Ryan has the right idea. Give old people help buying insurance and then let the market determine the price as best it can.

    Ideally, medical insurance should work like life insurance. You should be able to buy in when you are young and your risk is low in return for having reasonably priced coverage when you are old and your risk is high. In some ways, the Progs are sort of right in that for the medical insurance system to work, young and healthy do need to subsidize the old and sick. But the way that should work is each individual pays more when they are young in return for the assurance of reasonably priced coverage when they are old. That way, people basically prepay for their own health care when they are young.

  • Free Society||

    Medical care is never going to be a perfect market because people will always need insurance. And insurance will never be able to be as careful with their money as most people would be with theirs.

    Insurance might be one of the most libertarian economic institutions in existence.
    -It's need to mitigate risk makes it one of the most efficient cost saving organizations in the market.
    -The need for (market based) insurance is a bulwark against the welfare state; it is the most viable and preferable alternative.
    -It prevents all sorts of moral hazards that normally occur in situations where risk is mitigated by political institutions.

    The problem is that the healthcare insurance industry, has been turned into a cartel operating in a hyper-regulated market. Don't blame the free market where the free market doesn't exist is my point, in a nutshell.

    That said, the idea that the government could determine the proper price for the medical care of everyone in America over the age of 65 is to put it mildly insane.

    fixed it ;)

    Ideally, medical insurance should work like life insurance.

    Agreed. It should be able to function like any other type of insurance. But political interference prevents that.

  • John||

    Yes. Insurance is incredibly libertarian. But somehow the idiots at CATO have convinced a lot of people on this board that medical insurance is evil and the problem. It is just insane.

  • Free Society||

    I'm not familiar with CATO's line of argument enough to comment on that specifically. But hating the concept of medical insurance because of the existence of politically created cartels, is indeed insane.

  • John||

    Free Society,

    They hate medical insurance because they think that when insurance companies, rather than individuals, pay for healthcare that the price goes up and insurance companies are more willing to spend money than the individual. Regardless of whether that is true or not, even if it is, it just means medical care is always going to cost a bit more than it should since people are always going to want insurance.

    They are also convinced that the tax break causes people to buy more insurance than they otherwise would and that if we didn't have it everyone would go to the beloved high deductable health plan and all would be great. I think that is fantasy. Demand for health insurance is a lot less elastic than they think. Getting rid of the tax benefit will not cause people to buy less insurance, they will just pay more for what they have now. And high deductible plans do not make sense for a lot of people. CATO is convinced they are the only rational choice and would be universal if only people could buy them and didn't get the tax break. I again think that is a fantasy.

  • Free Society||

    Yeah I won't defend the inherent contradictions of CATO. There is no such thing as a tax break that shouldn't exist.

    And their analyses of why cost is what it is, is remarkably naive. By their logic, car repairs should be unaffordable to the common man because of car insurance markets. Insurance may be willing to spend more because it's able to, but within groups, insurance cuts costs better than any individual could proportionally cut from their own spending.

  • Rhywun||

    I work in (property) insurance. We do more to make sure people keep their places in shape than the state, that's for damn sure. And we weed out fraud, too. Yet - we are the evil ones.

  • Free Society||

    I work in (property) insurance. We do more to make sure people keep their places in shape than the state, that's for damn sure. And we weed out fraud, too. Yet - we are the evil ones.

    I'm a P&C agent too. My agency is in a town that's below the poverty line and highly dependent on government handouts. These people stumble into homeownership and then fail to give a fuck about their own property. Luckily for them, banks and insurance companies care about their property more than they do.

  • Ted S.||

    No; what we (or at least I) believe is that insurance is for catastrophic events.

  • Free Society||

    It's for truly unforeseen liabilities. They need not be catastrophic.

  • Free Society||

    n some ways, the Progs are sort of right in that for the medical insurance system to work, young and healthy do need to subsidize the old and sick.

    That's a necessary component for ANY insurance system to work. Insurance is groups of people pooling resources to mitigate risk. Everyone in a better position is always subsidizing the losses of everyone in a worse position.

  • Fluffy||

    That's a necessary component for ANY insurance system to work. Insurance is groups of people pooling resources to mitigate risk. Everyone in a better position is always subsidizing the losses of everyone in a worse position.

    No.

    This is progressive propaganda, that completely overlooks the entire 700 to 800 year history of the concept of insurance.

    Insurance is not a pool.

    Insurance is a private contract between two parties. One party, with little capital, contracts with someone with more capital. The first party pays a one-time or a regular fee. In exchange, the second party will make payments in case of certain events.

    That's it. That's all insurance is. The second party is gambling that a bird in the hand (the premium) is worth more than the birds in the bush (the chance that they'll have to pay out a claim).

    Insurance was invented to deal with the risks associated with Mediterranean shipping. Pools had nothing to do with it; these were events that were not frequent enough to create any kind of pool.

    The pool effect is an emergent property of the fact that when someone with LOTS of capital aggregates a very large number of small contracts or bets of this kind, the risk of loss on any one bet is spread among a large number of similar bets. But that emergent property of insurance is not the reason insurance exists, and it's not its justification. It's an administrative and statistical side effect.

  • John||

    Insurance is not a pool

    Health insurance most certainly is a pool. An insurance company only makes money because people pool their risk. Without the pool, the company is not insuring, it is gambling. The insurance company has no idea what your health care costs are going to be this year. All they know is what the aggregate of a ten thousand or however many fluffys medical costs will be. So they need the ten thousand so they can get enough premiums from the healthy fluffies to cover the unhealthy ones.

  • Free Society||

    ^this

  • Free Society||

    Insurance is a private contract between two parties. One party, with little capital, contracts with someone with more capital. The first party pays a one-time or a regular fee. In exchange, the second party will make payments in case of certain events.

    You're describing one way that a particular company may interact with a client, not the workings of insurance as an economic institution.

    The second party is gambling that a bird in the hand is worth more than the birds in the bush.


    Insurance is not gambling. Gambling is about random happenings. Insurance is based on empirical data about past events and the likelihood of occurrence.

    Yes a company and an individual are in a contract, but there is this thing called a "market" where these contracts occur. Insurance markets, like all markets, are groups of people arriving at mutually agreed upon prices for goods and services.
    There would be no insurance companies without an insurance market, there would be no insurance market without many individuals buying and selling these contracts.

    Pools had nothing to do with it; these were events that were not frequent enough to create any kind of pool.

    The market is a pool. Storms and shipwrecks were plenty common and their occurrence was frequent enough to gauge that.

    The notable exception, that you're riding is the extremely unlikely circumstance where an insurer has one single client.

  • Free Society||

    But the way that should work is each individual pays more when they are young in return for the assurance of reasonably priced coverage when they are old. That way, people basically prepay for their own health care when they are young.

    Says who? A legislature, a bureaucracy, or a market? If you can find an insurance company in the market that operates that way, more power to you. If you think for a second that that method should be forced into a existence, you're going to create more problems than it solves.

    The market likely wouldn't do that because it's impossible to accurately predict the cost of future medical costs for the whole market.

    The government would fail at doing that because government has even less future predicting powers than the market and they are unable to make honest promises that in the future you'd pay less. For an example, see the difference between a Roth IRA and a regular IRA. You can either pay the tax up front when you initially invest, or wait to pay until you withdraw your funds. Stupid people pay their taxes up front because they mistakenly believe they therefore won't be taxed again later on when they withdraw their money. Government does not have the ability to keep promises.

  • John||

    Why couldn't you do that? All you need is an actuarial table. Sure I don't know your future costs. But I can predict with pretty good accuracy what the aggregate cost of a hundred thousand people like you will be and then charge accordingly.

    When I say should I don't mean to imply a value jusgement. I am just saying that is how it probably would work. That said, it is not quite like life insurance since I have no idea what medical care will cost in 30 years even if I can make a acurate guess on how much of it someone of your risk pattern is likely to need. So that would make it hard to do. But still not impossible. If we didn't have medicare, I bet a whole lot of people would be willing to sign up for very high priced coverage in their 30s in return for a promise of health insurance in their 70s. Even if I can't make a perfect guess, I could always err towards higher premiums on the young and most likely get them because people would really want the assurance of care when they were old.

    Without this system, I don't see how old people ever get care. No premium is high enough to cover the cost of insuring someone in their 80s. You would end up with a system where everyone would have cheap health insurance until they hit a certain age at which time their rates would quickly rise to infinity leaving them without coverage.

  • Free Society||

    Why couldn't you do that? All you need is an actuarial table. Sure I don't know your future costs. But I can predict with pretty good accuracy what the aggregate cost of a hundred thousand people like you will be and then charge accordingly.

    Fair enough. You'd need the most comprehensively insightful actuarial table ever made.

    The insurance premium you pay now reflects what medical procedures and equipment cost currently and to a lesser extent, what it's projected to cost within a a year or two, or maybe within a decade. You're talking about predicting costs 20, 30 or 40 years down the road. Factoring in by necessity, the happenings in politics, finance and industry within that time-span. There is no actuarial table or data in existence that can predict anything that far out with any accuracy.

    More importantly, how could you get a guarantee from that company that they'll take care of you 30 years away? They can't even say for sure they'll still be in business by the time your balls are hanging past your knees.

  • KimInGA||

    That's totally logical, but what do you do with all the people who failed to pay in when they were young? I say screw them. They were dumb and shortsighted and failed to plan. But liberals can't handle the idea that anyone should suffer any consequences of his own irresponsibility. They pick out the rare case that really is a sob story and plaster it all over the news, and ignore the vast majority of cases where people just refused to delay their own gratification and be responsible.

  • Free Society||

    A fair point. If those people truly need help for their consequences, let charities and voluntary charity help them. They aren't owed anything taken by force, that's for damn sure.

  • Floridian||

    Most of your cost for a physician does not go to the physician. Especially surgeons. The bill you get has to pay for the OR cost, equipment, surgical techs, PA, drugs, suture, implants, etc. all this is very expensive. So you might pay 30 grand but the surgeon is getting 100-200 bucks. Cut his reimbursement by 500 out of 30 grand and he can't do business. Family practice has staff and building cost. Most hospitals get by on very thin margins. 1-2%.

  • Free Society||

    You left out regulatory burdens and administrative costs associated with compliance. The number of people employed by the healthcare industry has exploded, yet the number of practitioners has remained fairly constant and dwindling in some fields.

  • Adam330||

    100-200 bucks for a 30k surgery? No way. It's true the surgeon doesn't get the bulk of the money, but the surgeon's fee is typically a few thousand dollars.

  • Floridian||

    Depends on the procedure. That may be an exaggeration but these guys tell me how much they get paid and it is surprising. On some cases the anesthesiologist gets paid more than the surgeon and they aren't even in the room for most of the case.

  • ALP||

    I concur. Last year, I had carpal tunnel surgery on both hands. I was stunned at how little the surgeon made. The biggest chunk of my bill?

    A thing called the "facility fee".

  • Rasilio||

    Hmm, if I perform Medicare procedure 537.k4 which is what this patient needs it will cost me $80 and take 25 minutes of my time but they will only reimburse me $65

    Well I better do 537.k4 but even though I know he doesn't need it I can justify 611.23, 45k.20, and 98.hh so I'm going to throw them on the claim sheet too. They won't pay for them all but I'll get some of them and make more than the $65 they would have paid me for the one procedure this guy needs.

  • OneOut||

    i was under the impression that a large number of Doctors don't belong to the AMA.

  • dan'o||

    My wife is a poster-child for why Medicaid (or some basic safety net should exist.) Cystic Fibrosis and a rare immuno-deficiency disease has wreaked havoc on her organ systems, rendering the need for 8 specialists and a primary care doc. Her annual care is over 7 figures, and has she never been capable of working (or even attending school regularly since jr high.)
    Medicaid pays our her primary care doc a whopping $45 per appt. A saintly (and brilliant) guy, he frankly admitted to taking a loss by providing her care. He further explained that if each doctor was willing to take on a few such patients the system could work. Now that Medicaid enrollment will double and the exchange policies won't pay shit, I fear that there will not be a sufficient ballast (PPO's that actually pay) for practices to be adequately profitable.

  • dan'o||

    Should probably add some anecdotal evidence: her oxygen company (Apria) has stopped accepting new medicaid and under 66 medicare clients. Current clients have had their deliveries cut from every other week to every eight due to cuts in reimbursement from the govmt.
    If I copy/paste this on Huffpo, anyone wanna bet against my prediction that the villain will be Apria?!

  • Adam330||

    Actually, in most markets, the providers have significant leverage over the insurers because the providers, and particularly the hospitals, are controlled by one or a very small number of groups. The insurance market by contrast is generally pretty competitive, and an insurer can't leave off one of the two major provider groups in the market without losing a lot of subscribers. That's a major reason for healthcare inflation.

  • Free Society||

    Competitive? Try to start your own insurance company and tell me how it goes getting around those barriers to market entry. In most states there are only a dozen or so possible health insurers, while the number of car insurance companies may be in the triple digits. Health insurance markets are quite unlike any other insurance markets in that they are highly regulated and highly protected cartels.

  • R C Dean||

    in most markets, the providers have significant leverage over the insurers because the providers, and particularly the hospitals, are controlled by one or a very small number of groups.

    This will come as a surprise to every physician group and hospital administrator I know.

  • Free Society||

    It should certainly come as a surprise to hospital administrators. They're the ever-expanding bureaucratic army that exists thanks to the litany of healthcare regulations.

  • Sevo||

    But what about all those "doctors" Obo had standing around as props? Aren't they thrilled and out spreading the joy?

  • John||

    Even the real dead ender liberal doctors I know think the ACA is horrible. Notice how the media never seems to trot out an actual practicing doctor (as opposed to a paid hack who happens to have an MD) to sing the praises of Obamacare? There is a reason for that.

  • Free Society||

    But they widely publicize a picture of Obama at the podium with a bunch Democratic donors wearing white lab coats.

  • John||

    Just because you are wearing a lab coat doesn't mean you are actually a doctor.

    And even if they were, that was back when no one had any idea what was in this bill.

  • Free Society||

    notice I called them Democratic donors in lab coats.

    Nonetheless, Obama made a pretty strong appeal to authority with those lab coats. Proving that he doesn't need the support of actual doctors, just the support of people who are perceived to be doctory.

  • John||

    Says how stupid he either is and or thinks everyone else is. See a guy in a lab coat thinks this is great. yeah, that is a compelling argument.

  • Free Society||

    Rulers disdain the ignorance the ruled as a rule.

  • sasob||

    So do con artists; they always think they're more clever than everyone else. But they aren't - just more dishonest.

  • Medical Physics Guy||

    That's just it. Every doctor I ever met in the NYC area at some wine and cheese party was quick to voice their support for all things Hillarycare / Obamacare. It showed their proper Manhattan / Westchester credentials. Now it's time to walk the walk and they're fleeing ACA as fast as they can.

  • Faceless Commenter||

    I wonder how many of them will have the guts to take on "single-payer" when Candidate Hillary pushes it in 2016.

    I also wonder if the Party of Stupid is making an approach to MDs in anticipation of the coming troubles.

  • Lady Bertrum||

    I'm starting to feel bad for physicians. I would suggest they go Galt and not take insurance at all, accepting only patients who can pay up front, but I'm sure their student loans prevent many from going that route. With 200-300k in student loans they don't have the time to slowly build a practice; they need to earn immediately.

    Those guys in the pic (alt-text) cannot be docs - too much facial hair.

  • Free Society||

    Not to mention that once the do accept Medicare/MEdicaid, they must be careful not to run afoul of Medicare compliance standards (by setting their own prices outside of the 'codes') lest their government permission to be a doctor gets a revoked.

  • Cytotoxic||

    Black markets in healthcare? Can it happen? Secret underground surgery compounds?

  • Rasilio||

    Why go underground. Just go to India

  • OneOut||

    Just go to Oklahoma instead.

    http://www.surgerycenterok.com/

    Now what would insurance prices for that place cost ?

  • sasob||

    We once had back alley abortions in this country.

  • gaijin||

    Not all physicians are angels, apparently:

    Your doctor views you as an ATM

    When you have a hammer, every problem yadayada.

  • RG||

    Destroying the remnants of a functioning health care market is a feature, not a bug.

    If this isn't repealed in the next 3 years, it's over. Next stop, single payer.

  • Dweebston||

    John makes a good case that single payer is less likely than repeal, given the immense and numerous legal hurdles to overcome and the intense unpopularity such a move promises. The Brits brought about their system in an era before healthcare insurance had taken root, while any politician brainless enough to grab that torch would encounter insuperable inertia from providers.

  • ChrisO||

    We're headed for the same sort of two-tier system you see in Britain in Canada, where there is "government care" that is crappy and insufficiently staffed, and private fee-for-service care for those who can afford it.

    In Britain, that private care is readily available. Canada made it illegal to practice medicine outside their national health system, so people needing timely and decent care head south of the border to get it. If the future U.S. national health system or single-payer regime tries that, you'll see a huge convoy of American doctors headed to Mexico or the Dominican Republic to practice offshore private medicine. Medical tourism will become a huge business. You might see it under Obamacare, anyway.

  • ||

    To be fair, there is really a multi-tier system everywhere. Rich people get better care than poor people in the US, Canada, Britain, everywhere.

    The real difference is that the market preserves incentives to improve service and deliver care more efficiently. Not that we get the latter half of that, since our employer-based system has essentially fucked all the price signals. But at least we're getting the incentives to improve treatments part.

  • Anomalous||

    Asclepius will shrug.

  • GroundTruth||

    A feature, not a bug.

  • OldMexican||

    Crappy Compensation Just One (Big) Reason Doctors May Spurn Your Obamacare Coverage


    No, no, no, they just want Obamacare to fail because those doctors can't stand the idea that the country has a president who is semi-black, or something.

  • sasob||

    Semi-black. Lol.

  • coma44||

    Crappy Compensation Just One (Big) Reason Doctors May Spurn Your Obamacare Coverage

    The rest will realize that they have become slaves to the state once the single payer system kicks in.

  • Faceless Commenter||

    And then, the white doctor will go the way of the white athlete.

    I can't help how racist that looks.

  • NebulousFocus||

    Question- If you don't participate in the ACA plans (as a doctor), what do you do? Who are your customers?

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