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In My Opinion
Healthcare Reform: What’s really going to happen when Capitol Hill runs emergency medicine
 
By now most people believe that some kind of comprehensive healthcare reform is going to happen this year.  Although I’m sure that there are some real idealists in Washington who believe in the concept of some “nirvana-like” healthcare system, keep in mind that everything that happens in DC is ultimately about money, power, and votes for re-election.  While the final version of comprehensive healthcare reform is still taking shape, what is clear is that there are few key players in Congress who are going to drive the healthcare reform ship…and that there are clearly going to be winners and losers when the dust finally settles. What is also clear is that unless Congress or the White House somehow develops some intestinal fortitude, no one is going to fix the ultimate problem with healthcare spending. There are going to be more Americans, older Americans, who all will want everything when it comes to their own healthcare…and we are going to get stuck with the bill.

Given that the Democrats control the White House and both houses of Congress, they are clearly going to be “in charge” of healthcare reform. There is no doubt that the Democrats, especially the President, have learned from the mistakes of the Clinton administration, and are making every effort to at least give the appearance of being more inclusive with input from providers, insurers, and the business community as the future of healthcare, and your career, is defined. However, will Senator Kennedy (who sponsored a single payer, government run, universal healthcare plan in the early 70’s) and the rest of the Dems play nice and allow real Republican input or will they take their majorities and do what they will?

So how will this promised legislation play out? After the many healthcare bills and amendments are sponsored by various members of Congress, it is likely that a single bill, supported by the Senate leadership, will be introduced in the Senate sometime in June. A companion bill will follow closely in the House. These bills will be “debated” with each body passing a bill before the August recess. During the recess and the fall, there will be a conference committee established between the House and Senate to work out differences in their respective bills and a “compromise” bill will be sent to the President’s desk before the end of 2009.

Sounds easy, right? Sure, except for one small detail. The President and Congress have no way to pay for this more than $1 trillion (that’s right, trillion with a “t”) ten-year healthcare plan. In the upcoming budget year (2009), the United States of America will actually have to borrow more than 50% of the money needed to fund the federal budget. That’s right, pretty soon China may just end up owning a majority stake in our little piece of the world.


5 Ways You’re Going to Pay
 . . . And Not Get Paid

Increase in the federal income tax rate
Sure, be a team player. Pick up that extra uncovered shift on the schedule. But don’t pick up too many, because the max federal tax rate is going to go up…probably to 39%. Especially for you really hardworking stiffs making more than $250K per year, it’s time to start doing the math before you work too hard and end up giving most of that extra shift to Uncle Sam.

Decrease in the reduction for charitable contributions
Better think twice about buying those Thin Mints from the next door neighbor’s kid, or giving to the YMCA, United Way or any other charity. Why, because the amount of that contribution that you could deduct from your federal income taxes is going to go down, probably from 42 to 29 cents on the dollar. So much for give until it hurts, now it’s give until you bleed.

Bundling
“What the heck is bundling?” you ask. Bundling is going to be one of the key strategies to reduce federal expenditures on healthcare in the upcoming years. Here’s how this special trick is going to work. Instead of the government paying for each portion of a patient’s care (i.e. Hospital charge, radiologist charge, emergency physician charge during a single ED visit) the feds are going to come up with a single payment for an “episode of care”. They are then going to come up with a single payment (which you can bet is going to be less than the current sum of the parts), and then they are going to give it to one entity (probably the hospital). It will then be up to all of the participants to somehow divide the total payment. Gee, I wonder if the hospitals will just be nice and treat the ED docs as well as their radiologists, surgeons, cardiologists, hospitalists and every other specialty that will stake a claim for the money the hospital receives. This is where those years of schmoozing your hospital CEO and CFO will pay off. Oh, you haven’t been doing that? Too bad! Back of the line for you.

The AMA looks the other way 
After 30 years of letting the insurers, hospitals, and pharmaceutical companies skim all the profits in healthcare while physicians were getting, at best 0-1% updates from Medicare, I’m not convinced that the AMA is really who I want representing me in the big healthcare debate. And now we’re supposed to believe that because the insurers, hospitals, big pharma and the AMA sent some flowery, Kumbaya, “we’re all in this together” letter to the President, docs aren’t still going to get the short end of the stick (or dollar in this case)? Haven’t those same for-profit groups been shafting docs all along? Why should they play nice now?

Tort Reform?
Don’t hold your breath

Haven’t heard much talk about that in the healthcare reform debate, now have you? Probably not going to either. No, tort reform won’t be a big player in the healthcare debate, due in no small part to the historically friendly relationship between the powerful trial lawyer lobby and the democratic party. What we’ll get instead of a discussion of tort reform is a discussion about “more effective medicine.” That’s right, the federal government is going to do effectiveness research and tell us doctors what the “right” thing to do is, or at least what they will pay you for. But don’t worry, you probably won’t be immune from being sued even if you follow that standard.

Well, now that I’ve been a little ray of sunshine in your day, I’ll just leave you with a little quote so that you can go cry into your N95 mask when you go see the next patient with Swine/Avian/Gorilla Flu. In the words of the immortal Jack Nicholson as Marine Colonel Jessep: “You can’t handle the truth!” The truth is that emergency physicians do stand their post 24/7/365. We stand tall every day, night, weekend and holiday despite being puked on, spit on, and sworn at. And yet, the future of our specialty now rests in the hands of a few Washington bureaucrats who believe they know how to run the entire healthcare system from the Capitol steps. God help us all.
 
 

Comments   

# bonofides=20 years as a blue collar ER docDr Sourbutt 2009-06-18 20:33
Immanuel,Guethn er,Bern"yank"me and now Sebelius...the Four Horsemen of the Apocalypse complete. Re: Health reform..."Let's Get 'er Done" (We will "work out" the details later...Washing tonSpeak for "Pay no attention to that man behind the Curtain")...How 'bout POTUS, MOC and all Federal workers try out the "public option" for a year and let doctors analyze the outcomes data before we spend/lose another $1,000,000,000, 000
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# Time for Atlas to ShrugMaria L Martins, MD 2009-08-21 08:02
The day the government thinks they own my mind and the output of my work, by telling us how to practice medicine by formula and how much we will be paid to save someone's life, is the day I quit medicine. There may be a pocket of freedom in another country. I won't be the only well trained, experienced physician to leave the cesspool they are making of this country. I won't help them pretend what is left is real health care. I won't lie to my patients.
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