A quandry involving Medi-Cal, going from paying badly to not at all
 

The state legislature has decided it would save them money to drop podiatry, optometry and dentistry. As of July 1st, they go from 10 cents on the dollar, to nil. Medi-Cal is the state medically indigent program.

For the ER stuff, don't have a choice, gotta go, but if the person has been admitted and it comes across as consult on an inpatient, you can decline. Generally I do the no pay stuff when they call me, but I am a bit torn; doing free stuff for the state of California is particularly distasteful to me. If I don't handle stuff, it ends up in the Chief of Surgery's lap, and I don't like doing that to Mike, I like Mike. I need to do a bit more research on this part. It may well be that if I am the surgeon, they don't pay the anesthesiologist or the hospital either. If this is the case, the orthopedic surgeons will be bummed, because they will end up doing all the crap foot cases at the hospital.

I also have a fair number of Medicare/Medi-Cal patients, where the Medi-Cal pays the 20% Medicare co-pay. With most of them, I figure I bill them, they can't afford to pay and I write off the loss

There are a couple local hospitals that will pay Medicare rates for all non-insured (and let's face it--in your case, MediCal is effectively non-insured) patients. Just bill the hospital medical director directly. Or, at least, that's what I'm told. I haven't gone through with it, yet.

Otherwise, consider all those non-paying patients (which are the majority of ER patients) as your "community service."

In the meantime, I'm still waiting for my California tax refund...

My fear is an ever-widening single provider program will drive away financial incentive for doctors. This is a serious potential problem, and the entire nation is to blame for setting up the environment.
Jurgen

so you work for free..
this must be the new health care plan O is talking about..
amazing plan..

perhaps you can write 'see community service' on your next tax bill...

Rika

I work for free all the time. About 10% of my admissions are "private pay" which usually equates to "no pay".

I keep saying that the gubmint should let docs deduct the cost of their services for indigent patients off their taxes as a charitable contribution.

Hey, stop complaining ...these a politicians are trained professionals. They know BEST how you will spend both your time and your money.

Seriously, we have an epidemic of power-drunk politicians. Can ya triage those folks to the front of the line? ....maybe some electro-shock therapy?

Tobra, are you a podiatrist? I'll bet we know some of the same people.

I don't take MediCal. I end up providing the care for free. Luckily it's not too frequent. Choosing when and to whom we give away our care is far more satisfying.

Soon, California will take the Massachusetts approach; if you want a license to practice, you WILL take MediCal. Yep. We will be indentured servants of the state.

I don't work for free and don't think you should either. Did those folks who want free care help pay for your very expensive, very long, and very difficult education?

I do donate time and money to charity which is what you are doing so that's your call.
If I were in your shoes I'd do what I could to limit that charity to 10 or 15%.

All of the liability, none of the pay...

What a great-sounding deal!

Precisely why I'm not doing architectural work anymore.

I imagine it is difficult being in a Dr's shoes - knowing you can help someone, wanting to do it but knowing that if you don't get paid for it you can't afford to keep doing it. Especially in CA.

I don't have any suggestions really because if I were in those shoes I am sure I would have the same questions Tobra raised in his initial post. Provide care knowing full well you won't get paid or don't.

I can sympathize with your distaste for the way the CA government is handling things and the state of our health care system.

There are a great number of inefficiencies I have witnessed as a patient in the way billing is done in the state run institutions. One example is that it took 10 months for us to receive our first bill on an ER visit for my son. The thing is, they never billed our insurance (which we gave them at the time of service), had they done that they would have been paid immediately. Unreal and just the tip of the iceberg - 10 months!!!

I do plenty of freebies now, probably 50% of the ER calls. Fortunately, they don't call too often, but if I see 9164542222 on the caller ID, I always cringe. I actually lose money on them, because you still have to pay for gas you use to drive to the hospital to provide free care, go figure. Supplies for dressing changes can add up too. This guy I am seeing now probably owes me north of $2500. Only chance I see any of this is if he hits the lottery, and that would be a slim chance. Carl is a nice guy with some bad metabolic disease and no insurance.

Last ER call was a 31 yo IDDM pschyzophrenic who walked a hole in her foot, got a nasty abcess, but surprisingly did not have a bone infection. I get to stick a knife in her and clean it up, which turned out to be a waste of time. I told her every single day for a week and a half that she would get her leg cut off if she did not stay off her foot, and she was up on that MFer ever single time I rounded on her. She was in the hospital for that long because they could not get her blood sugars under control, imagine that. Only way we afford healthcare for everybody is for people like her to expire promptly.

Why stay? I am serious. What is it that is making you stay under these circumstances? The tolerance for the crap you put up with in California amazes me.

I like the climate myself, it is only relatively recently(last few decades) that they have gotten out of hand on spending. When you get established, you don't really want to pull up stakes, which is just what I did coming out here, but had extenuating circumstances.

This latest deal will not last too long, they will figure out relatively quickly how much cheaper it is to go the pay me now, rather than pay me later route. My national association is working on some things that will fix this on the federal level, which will remove this authority from California, because it is federal dough, administered by the states.

I understand. When my sister moved to San Diego in the late 1980's it was a wonderful place. 14 years later when I moved there, it was completely different. The "little towns" along the coast were now one continuos suburb. The only separation between San Diego and LA was/is Pendelton.

No one has the balls to stand up and change things. It will take California going bankrupt to make the necessary changes. But that will only fix the financial issues. Californians have allowed many of yours right to be eroded. Those will be even tougher to get back. No financial bankruptcy is going to remove the stupidly onerous gun laws you have.

I don't know what we all are going to do, if a single payer, Medicare type system is attempted in the US. I do not expect it will be a good thing for doctors.

holy crap you sold your car

Another factor in staying is that it's surprisingly difficult to get up and go. Actually, getting up and going is not too difficult (though you do have to pay tail-end malpractice coverage--You have to pay malpractice for all the lawsuits that might come in after you leave your practice. Effectively, from a purely business standpoint, you can't leave unless you pay to leave.)

But getting set up in a new shop is somewhat difficult. Most doctors have hospital privileges. You can't just walk into a hospital and work, even if you have a license in that state. So, backing up, you have to get a license in the state for which you want to work. That will take (usually) 4-8 months.

Then, you have to get hospital privileges. That will take another 6 months.

Before you can get hospital privileges, you have to have malpractice insurance. If you're in a high-risk specialty like Moses (OB-GYN) in an unfriendly state, that can run in the 6-figures. That's payable up front. No refunds for any unused portion. No pro-rating. So, before you can even start working, you have to pay malpractice while you sit with your thumb up your rear-end, waiting for hospital privileges.

Once you get hospital privileges, then you can essentially start seeing patients (though there are some practitioners who have offices, but no hospital privileges). Then, once you start seeing patients, it'll take usually 3 months or so to get paid for services rendered. So, after you've paid your hefty malpractice premium for the year, it will take at least 9 months before you start seeing any return on investment.

If you join a hospital staff, you usually have to tell them who's going to cover you when you're not on call or on vacation. That other physician has to be on the same hospital staff (or I suppose you can apply with a partner at the same time). Sounds reasonable, but it's a bit odd to go around a medical community, introducing yourself to people who are going to be your competitors, and ask that they back you (a stranger) up.

If you're a surgeon and expect to do procedures in a hospital, you also have to be "proctored" for a certain number of surgeries (by another surgeon of the same specialty, who's in good standing at the hospital) before you're allowed to operate on your own. They have to be there for those first few surgeries that you do. Doesn't have to be the same guy for all x number of cases. But you have to have all those first few cases covered. Again, sounds good and reasonable. But you're again asking a stranger (who's going to be a future competitor) to stand up and vouch for you, and risk his/her reputation and medical license. And you're asking them to come do it for free. It would be like opening up a new McDonalds, and asking the local Burger King to send over a few employees to watch over the McDonalds crew for the first couple weeks of business. I've never heard of anyone saying no to this type of request, but it's an unusual position to be in, nonetheless.

I'm sure every field of business has it's difficulties. These were just a few that I noticed about trying to start up a practice in medicine, however.

Exactly. The barrier to relocation is pretty huge.

The ER stuff goes with the territory, but decline the rest.

In my old digs, this is what our practice group did, and it worked out fine despite the indignation of various administration officials.

The work will always get done, somehow, just not by you. And you'll be happier, with more time to use productively.

When you provide free services, there will be unlimited requests for 'more.' Break the cycle.

Sounds like the MD's in Cali have the State for PROCTOLOGISTS....

Moses you beat me to it..your not indentured servants your SLAVES>...

How much do doctors earn and hospitals make in other countries that have some form of single payor healthcare, e.g. Canada, UK, France, Germany? How do those economic models work, for the providers?

WHY jYL what is wrong with you, your a BAD Pelican you ask intelliegnet questions...

Your question intrigued me so I decided to do a little quick internet research. The findings honestly shocked me. I had no idea it was this bad.

This is from 2006:
http://forums.pelicanparts.com/uploa...1242074870.jpg

I suspect that wasn't the answer you were looking for jyl but there's the truth.

I had thought doctors in other countries made less money, so that doesn't surprise me.

In the US, my guess is that if the avg hospital doc made $100K, there would be a significant doctor shortage, given the cost of medical school and the length of training needed. Is that true? If so, how does it work in those other countries? Is there a doctor shortage, and why or why not?

No shortage. Quality of medical school applicants decreases dramatically, though. After the Iron Curtain fell, this country would not honor medical diplomas from many eastern European nations. In many cases postal workers made more than doctors. Hardly the way to recruit "the best and the brightest".

Oftentimes, in foreign countries the cost of medical school is not borne by the students. Here, in the US, tuition costs will vary widely. Even a state school will cost several thousand dollars (not a big deal), and private med schools will easily run $40K for tuition, alone. Annually. Times four years.

I also wish I made what is depicted in the chart, above. That's significantly more than what I earn.

My niece in Mexico is applying for med-school. For them, you apply to med-school out of high-school, and you do under-grad and med-school over 7 years. It is paid for by the government. And it is not easy to get into ANY medi-school in Mexico, even the crummy ones. So, there is not a huge school debt to pay afterwards.

I don't know how much doctors make in Mexico, but I do know they take bribes, to change the order of when a patient gets care or surgery.

If you live in a country where every other job sucks even worse than being a doctor, you can still attract the best and the brightest.

As above, assuming that everyone's wages don't fall by 50% then obviously the best and brightest will choose to go into other professions.

So, the real question is, do you want cheaper healthcare at the cost of knowing that the guy about to cut you open barely graduated college?

There is another important question that complements this one (and I'm not Trolling).

How much do tort lawyers earn, and how much is malpractice insurance, in these other countries?

While tort reform is an important part of the healthcare puzzle, it doesn't factor in nearly as much as most people think, at least in terms of actual dollars. Now, the discussion of whether fear of malpractice suits encourages doctors to overtest and overprescribe is another topic altogether and may well factor in significantly to the cost of healthcare.

The only docs who would feel direct effects of malpractice insurance are those who are working in smaller practices where their "salary" is what is left over after the practice pays all the bills. Personally, I work for a large physician group and my malpractice insurance is included in the costs to our practice and has nothing at all to do with my personal salary. I might be in a unique situation though.

The other assumption here is that people go into medicine JUST because doctors make big bucks. In fact, most of the doctors I know didn't go into it for that reason.

But, after they get "medicared", the doc's will unionize and we'll start having stikes...

You know, although you jest, but it would be the right thing to do. If public servants (which is what MD's would become under a single payor system, foot on the neck scenario) MD's should be able to do it too. Furthermore, since education is required that is prolonged and frequently not at the cost of the government, it would be interesting to see what sort of retirement benefits etc could be wrangled from the government, especially since the firefighters/police etc are getting 90% of their base salaries + full healthcare in perpetuity in Cali.

Forty six cents of every USD spent this year by BAMA is going to be borrowed....

Are doctors in the UK inferior to doctors in the US? I see from the chart posted that they make 1/2 the money.

No, but they have a shorter and decidedly more affordable pathway to medical practice.

In Germany universities are free and students get stipends from the state for room and board. So, if you graduate with zero debt, you can definitely get by on a smaller salary, confiscatory taxes notwithstanding. I've heard from a few doctor friends in Germany that nurses and even hospital cleaning crews can make more money than the doctors. I don't know why they bother unless it's just out of a sense of great medical curiosity or some hope of making it big many years later. Joeaksa and I had a mutual doctor friend in Germany who was the boss of a large clinic and made very big bucks. But he paid his dues in his youth and was older than my folks.

No they are not inferior, but the entire system in the UK is different. Malpractice systems are different, care systems are different, education costs are different.

Look at what is considered a good standard of living in the UK. People live in much smaller houses and get along with much less than the average US citizen.

I appreciate your attempts to continue to rationalize bringing socialized medicine to the US, but until you change the entire US culture, the result will simply be that the people you want to become doctors (the intelligent, compassionate, hardworking people) will see that they can make much more with much less stress, less legal risk, and an easier schedule in other professions.

I am a solo practioner, so your first scenario describes me; my overhead is about 55-60%, it was less in Texas, go figure. I think the trend is toward multiple doctor practices, multi-disciplinary groups, allows you to capture more market share, spread out expenses and get economies of scale, all that crap they taught me in economics.

Healthcare on this planet is at the level it has attained due in large extent to the US system. If we go to nationallized plan, where will the Canadians go to get their heart bypasses? What new medications will be developed, new surgical devices, wound care products, a lot of progress in medical technology is driven by the profit motive.

One thing is for certain, I have spoken to enough of my colleagues to know that there will be a problem with it.

I am talking to the Emergency Medicine Committee on the 28th about it. Set that up as an improve patient care, diminish length of stay sort of thing. The more i think about it, the more I am convinced that if they don't call while the prospective patient is in the ED, they won't be getting treated by a podiatrist.

Are there aspects of the US healthcare system that could be changed to permit US doctors to have the same take-home/net income and the same schedule/stress/life quality as they do today, while receiving substantially lower gross revenue? Put another way, what can be done to substantially lower US doctors' costs of doing business?