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> Sorry, I meant suggest taking less patients, in addition to charging enough to match what you were making before. How? They can't negotiate with public insur

> Sorry, I meant suggest taking less patients, in addition to charging enough to match what you were making before. How? They can't negotiate with public insurers (Medicare and Medicaid), who together control over 40% of the payer market. They can't charge self-paying (uninsured) patients any more, because those patients can't really afford it so they don't actually pay. And they already overcharge private insurers (to account for the below-cost reimbursement rates of public insurers), so there really isn't room to charge them any more. > Is there no doctor's lobby? Not really. The last 40 years have been a massive power shift from doctors to hospitals, and from hospitals to insurance companies. The ACA was probably the single biggest sign of that, but it was as much a symptom as it was a cause. Contrary to popular belief, doctors have less power today than they did 20 or 40 years ago, and they have very little leverage with which to secure any additional power. Almost all the industry power rests in the hands of the insurers. (And the private insurers are themselves beholden to Medicare). The entire narrative is around expanding coverage and reducing costs, which invariably means paying doctors less, not more, for the same work.

lloyd-christmas 11y ago
> Almost all the industry power rests in the hands of the insurers. (And the private insurers are themselves beholden to Medicare). Don't forget Big Pharma who pay for all of their research and sponsor their conferences. Speaking out against them means your research funding disappears. Doctors have a lot of industries surrounding them that are pulling strings. It's arguably the most regulated industry in the world. If you puff your chest out in any direction, it's the Alamo.
hardwaresofton 11y ago
Thanks for the information/sharing the challenges that are present. Forgive my naive thought - but what if doctors just stop... negotiating with public insurers? is there some legislation I don't know about that prevents that?
- chimeracoder 11y ago
  > what if doctors just stop... negotiating with public insurers? is there some legislation I don't know about that prevents that? Doctors aren't negotiating at all with public insurers. Medicare doesn't negotiate, for any meaningful definition of 'negotiate'. They set the rates they are willing to pay, and you can either accept it or.... accept it. As a provider, it's very, very difficult to refuse to treat Medicare/Medicaid patients in practice, for all sorts of legal reasons. (Also, it's usually the hospital that's in this position now, not doctors. Private practice is a dying breed; most doctors in the US are now salaried.)
  - hardwaresofton 11y ago
    OK got it - so there is some law that prevents/makes it prohibitively expensive for hospitals to not serve medicare/medicaid patients?
    - lloyd-christmas 11y ago
      Not specifically law, but the number of patients on Medicare. You're essentially eliminating at least 15% of potential patients(and growing as the population ages) That doesn't even factor in the age of patients. Only 15% of that 15% are under the age of 65. That leaves you with 40m+ people on medicare who are over 65. Who tends to go to the doctor more frequently, a 25 year old or a 70 year old? Dependent upon specialty, you could have 90% of your patients on medicare. If I dropped 90% of my clients, I don't think "comfortable" would be an accurate description of my workload. It's a tough position to be in. Many doctors ARE dropping medicare due to the large amount of paperwork, costs of auditing, deep price discounts, etc. This means that the doctors who DO accept medicare end up getting swamped with patients which increases the patient wait times. So, as a medicare recipient, you either end up paying more out of pocket to see the doctors who dropped medicare or you wait longer to see your doctor. As a doctor, you either lose your patients or gain an unmanageable amount of patients along with drastically more paperwork. Lose-lose. All that being said, it's clearly a lot easier to criticize than contribute meaningful suggestions. The only thing I could suggest is to put much more effort into preventative medicine. Preventing disease is drastically cheaper than managing symptoms. While it comes up a lot, it doesn't seem to be a focal point.
maxerickson 11y ago
The entire narrative is around expanding coverage and reducing costs, which invariably means paying doctors less, not more, for the same work. Or creating new technology. I wonder just how much spending has been headed off by pneumonia vaccines. Not that a single treatment like that will make a noticeable dent in demand, but at least it usually comes with a good improvement in outcomes.

lloyd-christmas 11y ago

> Almost all the industry power rests in the hands of the insurers. (And the private insurers are themselves beholden to Medicare). Don't forget Big Pharma who pay for all of their research and sponsor their conferences. Speaking out against them means your research funding disappears. Doctors have a lot of industries surrounding them that are pulling strings. It's arguably the most regulated industry in the world. If you puff your chest out in any direction, it's the Alamo.

hardwaresofton 11y ago

Thanks for the information/sharing the challenges that are present. Forgive my naive thought - but what if doctors just stop... negotiating with public insurers? is there some legislation I don't know about that prevents that?

chimeracoder 11y ago
> what if doctors just stop... negotiating with public insurers? is there some legislation I don't know about that prevents that? Doctors aren't negotiating at all with public insurers. Medicare doesn't negotiate, for any meaningful definition of 'negotiate'. They set the rates they are willing to pay, and you can either accept it or.... accept it. As a provider, it's very, very difficult to refuse to treat Medicare/Medicaid patients in practice, for all sorts of legal reasons. (Also, it's usually the hospital that's in this position now, not doctors. Private practice is a dying breed; most doctors in the US are now salaried.)
- hardwaresofton 11y ago
  OK got it - so there is some law that prevents/makes it prohibitively expensive for hospitals to not serve medicare/medicaid patients?
  - lloyd-christmas 11y ago
    Not specifically law, but the number of patients on Medicare. You're essentially eliminating at least 15% of potential patients(and growing as the population ages) That doesn't even factor in the age of patients. Only 15% of that 15% are under the age of 65. That leaves you with 40m+ people on medicare who are over 65. Who tends to go to the doctor more frequently, a 25 year old or a 70 year old? Dependent upon specialty, you could have 90% of your patients on medicare. If I dropped 90% of my clients, I don't think "comfortable" would be an accurate description of my workload. It's a tough position to be in. Many doctors ARE dropping medicare due to the large amount of paperwork, costs of auditing, deep price discounts, etc. This means that the doctors who DO accept medicare end up getting swamped with patients which increases the patient wait times. So, as a medicare recipient, you either end up paying more out of pocket to see the doctors who dropped medicare or you wait longer to see your doctor. As a doctor, you either lose your patients or gain an unmanageable amount of patients along with drastically more paperwork. Lose-lose. All that being said, it's clearly a lot easier to criticize than contribute meaningful suggestions. The only thing I could suggest is to put much more effort into preventative medicine. Preventing disease is drastically cheaper than managing symptoms. While it comes up a lot, it doesn't seem to be a focal point.

maxerickson 11y ago

The entire narrative is around expanding coverage and reducing costs, which invariably means paying doctors less, not more, for the same work. Or creating new technology. I wonder just how much spending has been headed off by pneumonia vaccines. Not that a single treatment like that will make a noticeable dent in demand, but at least it usually comes with a good improvement in outcomes.